Recent trends in sexually transmitted infections among adolescents, Catalonia, Spain, 2012-2017.

Monitoring sexually transmitted infections (STIs) in adolescents is essential to inform STI prevention strategies at primary and secondary levels in this key population. We aim to describe recent trends in STIs among adolescents and to analyse their socio-demographic and behavioural characteristics in Catalonia, Spain between 2012 and 2017. Data on Chlamydia trachomatis (CT) infection, gonorrhoea and syphilis cases aged from 13 to 19 years reported to the Catalan Mandatory Notifiable System from 2012 to 2017 were analysed. Diagnosis rates were calculated and a descriptive analysis was performed. Between 2012 and 2017, CT infection, gonorrhoea and syphilis cases reported among adolescents aged 13-19 years accounted for more than one-eleventh of all reported cases in Catalonia. The rate of the three nationally-notifiable STIs increased dramatically among adolescents. CT infection rates rose from 13 to 144.1 per 100,000 adolescents between 2012 and 2017, an increase of 1007%; gonorrhoea cases increased by 246% (from 13.4 to 45.4/100,000) and syphilis cases increased by 247% (from 1.7 to 5.9/100,000). Gonorrhoea and syphilis cases affected mainly males while CT infection cases were mostly in females (84%). Adolescents are being increasingly affected by CT infection, gonorrhoea and syphilis. A broader array of intervention strategies aimed at adolescents should be reinforced through strong prevention campaigns, improved sexual health information, as well as encouragement of regular offers of STI screening by healthcare providers.

Barriers to health care services for migrants living with HIV in Spain.

Background: In Spain, migrants are disproportionately affected by HIV and experience high rates of late diagnosis. We investigated barriers to health care access among migrants living with HIV (MLWH) in Spain. Methods: Cross sectional electronic survey of 765 adult HIV-positive migrants recruited within 18 health care settings between July 2013 and July 2015. We collected epidemiological, demographic, behavioral and clinical data. We estimated the prevalence and risk factors of self-reported barriers to health care using multivariable logistic regression. Results: Of those surveyed, 672 (88%) had information on health care access barriers: 23% were women, 63% from Latin America and Caribbean, 14% from Sub-Saharan Africa and 15% had an irregular immigration status. Men were more likely to report barriers than women (24% vs. 14%, P = 0.009). The main barriers were: lengthy waiting times for an appointment (9%) or in the clinic (7%) and lack of a health card (7%). Having an irregular immigration status was a risk factor for experiencing barriers for both men (OR: (4.0 [95%CI: 2.2-7.2]) and women (OR: 10.5 [95%CI: 3.1-34.8]). Men who experienced racial stigma (OR: 3.1 [95%CI: 1.9-5.1]) or food insecurity (OR: 2.1 [95%CI: 1.2-3.4]) were more likely to report barriers. Women who delayed treatment due to medication costs (6.3 [95%CI: 1.3-30.8]) or had a university degree (OR: 5.8 [95%CI: 1.3-25.1]) were more likely to report barriers. Conclusion: Health care barriers were present in one in five5 MLWH, were more common in men and were associated to legal entitlement to access care, perceived stigma and financial constraints.

Infecciones de transmisión sexual: experiencia de una consulta multidisciplinar en un hospital terciario (2010-2013) / Sexually Transmitted Infections: Experience in a Multidisciplinary Clinic in a Tertiary Hospital (2010-2013)

INTRODUCCIÓN: Las infecciones de transmisión sexual son un motivo de consulta creciente en nuestro medio. El objetivo de este trabajo es describir y analizar las características epidemiológicas, conductuales, clínicas y microbiológicas de los pacientes registrados en una unidad de infecciones de transmisión sexual de un hospital terciario. MÉTODOS: Estudio descriptivo, retrospectivo y unicéntrico realizado en una unidad multidisciplinar especializada en infecciones de transmisión sexual de un hospital terciario entre 2010 y 2013. Se recogieron datos epidemiológicos, clínicos y conductuales mediante entrevista oral abierta y cuestionario estandarizado, y se llevó a cabo la obtención de muestras para estudio microbiológico. RESULTADOS: Se estudiaron 546 pacientes, de los cuales fueron 96% varones, 41% infectados por el VIH, 56% hombres que tienen sexo con hombres. Los motivos de consulta más prevalentes fueron: uretritis, úlceras genitales y/o anales/perianales, proctitis, úlceras orales, contacto sexual de persona con ITS conocida y contacto sexual de riesgo. Los diagnósticos microbiológicos más frecuentes fueron: Neisseria gonorrhoeae en uretritis, Treponema pallidum en úlceras genitales y/o anales/perianales y Chlamydia trachomatis serovares de linfogranuloma venéreo en proctitis. Las principales ITS estudiadas fueron más prevalentes en varones homosexuales e infectados por el VIH. CONCLUSIÓN: Se confirma el incremento en la incidencia de las infecciones de transmisión sexual en los últimos años y las características epidemiológicas de la epidemia VIH/ITS de nuestro entorno

INTRODUCTION: The number of consultations for sexually transmitted infections (STIs) is increasing in Spain. The aim of this study was to describe and analyze the epidemiological, behavioral, clinical, and microbiological characteristics of patients registered at the STI unit of a tertiary hospital. METHODS: This was a retrospective, single-center descriptive study carried out between 2010 and 2013 in a multidisciplinary unit specialized in STIs, situated in a tertiary hospital. Epidemiological, clinical, and behavioral data were gathered using a face-to-face interview and a standardized questionnaire. Samples were collected for microbiology analysis. RESULTS: The study included 546 patients: 96% were men, 41% had human immunodeficiency virus (HIV) infection, and 56% were men who have sex with men. The reasons for consultation were the following: urethritis; genital, anal, or perianal ulcers; proctitis; oral ulcers; sexual contact with a person with a known STI; and high-risk sexual contact. The most common microbiological diagnoses were Neisseria gonorrhoeae in urethritis, Treponema pallidum in genital and anal or perianal ulcers, and Chlamydia trachomatis lymphogranuloma venereum serovars in proctitis. The highest prevalences of the main STIs studied occurred in homosexual men with HIV infection. CONCLUSION: This study confirms the increase in the incidence of STIs in recent years and the epidemiological characteristics of the HIV/STI epidemic in Spain

Sexually Transmitted Infections: Experience in a Multidisciplinary Clinic in a Tertiary Hospital (2010-2013).

INTRODUCTION: The number of consultations for sexually transmitted infections (STIs) is increasing in Spain. The aim of this study was to describe and analyze the epidemiological, behavioral, clinical, and microbiological characteristics of patients registered at the STI unit of a tertiary hospital. METHODS: This was a retrospective, single-center descriptive study carried out between 2010 and 2013 in a multidisciplinary unit specialized in STIs, situated in a tertiary hospital. Epidemiological, clinical, and behavioral data were gathered using a face-to-face interview and a standardized questionnaire. Samples were collected for microbiology analysis. RESULTS: The study included 546 patients: 96% were men, 41% had human immunodeficiency virus (HIV) infection, and 56% were men who have sex with men. The reasons for consultation were the following: urethritis; genital, anal, or perianal ulcers; proctitis; oral ulcers; sexual contact with a person with a known STI; and high-risk sexual contact. The most common microbiological diagnoses were Neisseria gonorrhoeae in urethritis, Treponema pallidum in genital and anal or perianal ulcers, and Chlamydia trachomatis lymphogranuloma venereum serovars in proctitis. The highest prevalences of the main STIs studied occurred in homosexual men with HIV infection. CONCLUSION: This study confirms the increase in the incidence of STIs in recent years and the epidemiological characteristics of the HIV/STI epidemic in Spain.

Lymphogranuloma venereum in Barcelona, 2007-2012: the role of seroadaptation in men who have sex with men.

This study describes the incidence rate of reported lymphogranuloma venereum (LGV) in men who have sex with men (MSM) in Barcelona from 2007 to 2012. Epidemiological, clinical and sexual behaviour characteristics of LGV cases are described. Seroadaptive behaviours as a transmission risk factor were assessed by a telephone questionnaire during 2012. Data were handled on a strictly confidential basis. LGV annual rate ratios in MSM were compared with cases from 2007. Differences were statistically analysed with a Poisson test. The incidence rate of LGV in MSM aged 15-69 years ranged from 32·1/105 MSM per year in 2007 to 182·7/105 MSM per year in 2012. In 2012, 31/51 LGV cases (61%) answered the telephone questionnaire, of which 84% (26/31) were HIV positive, 39% (12/31) reported having sex according to their partners' serostatus and 7% (2/31) used strategic positioning. The incidence of LGV has increased since 2007 and mainly affects HIV-positive MSM. It is probable that seroadaptation has facilitated LGV transmission.

Increase in gonorrhoea among very young adolescents, Catalonia, Spain, January 2012 to June 2013.

Between January 2012 and June 2013, 27 sexually transmitted infections were reported in adolescents aged 13-15 years in Catalonia, Spain. In the first half of 2013, there were nine cases of gonorrhoea, while in the same period of 2012, there was one. In June 2013, two gonorrhoea cases aged 13-14 years, linked to a common source through a social network, were reported. The public health response should be adapted to this vulnerable population.

Factors associated with late presentation of HIV infection in Catalonia, Spain.

We sought to describe the prevalence, trends and factors associated with late diagnosis of HIV infection between 2001 and 2008 in Catalonia, Spain. Adults over 13 years of age with available CD4 cell counts, who were notified to the Catalonia Voluntary HIV Surveillance System between January 2001 and December 2008, were included in the study. Late presentation for HIV infection was defined as a CD4 cell count <350 cells/µL or with an AIDS-defining condition at presentation. Multivariable logistic regression was used to identify factors independently associated with late diagnosis of HIV. Of the 4651 newly diagnosed HIV-infected individuals with available CD4 counts, 2598 (55.9%) were diagnosed late. The proportion of people with a late diagnosis decreased from 60.4% in 2001 to 50% in 2008, a significant trend (P < 0.001). Older age, male gender, foreign birth, heterosexuality and injecting drug use were independent risk factors for late diagnosis. Strategies to actively promote HIV testing to populations at risk of late diagnosis of HIV or those never attending health systems should be implemented.

[Delay in diagnosis of HIV infection]. / Retraso diagnóstico de la infección por VIH.

Late presentation of HIV is common. It has been associated with greater risk of AIDS, death, lower immunological response, greater toxicity and a higher probability of transmission. In this study we review the impact of different definitions in terms of mortality and morbidity, associated factors, economic implications, as well as strategies for increasing diagnosis.

Lymphogranuloma venereum: a hidden emerging problem, Barcelona, 2011.

From the beginning of 2007 until the end of 2011, 146 cases of lymphogranuloma venereum (LGV) were notified to the Barcelona Public Health Agency. Some 49% of them were diagnosed and reported in 2011, mainly in men who have sex with men. Almost half of them, 32 cases, were reported between July and September. This cluster represents the largest since 2004. This article presents the ongoing outbreak of LGV in Barcelona.

Retraso diagnóstico de la infección por VIH / Delay in diagnosis of HIV Iifection

El retraso en el diagnóstico de la infección por el VIH es frecuente en nuestro medio y se asocia a un mayor riesgo de progresión, a una menor recuperación inmunológica, mayor toxicidad y mayor probabilidad de transmisión. En este estudio revisamos el impacto de las diferentes definiciones, el impacto en términos de mortalidad y morbilidad, los factores asociados y las implicaciones económicas. Así como las estrategias para incrementar el diagnóstico(AU)

Late presentation of HIV is common. It has been associated with greater risk of AIDS, death, lower immunological response, greater toxicity and a higher probability of transmission. In this study we review the impact of different definitions in terms of mortality and morbidity, associated factors, economic implications, as well as strategies for increasing diagnosis(AU)

Survival of a large cohort of HIV-infected tuberculosis patients in the era of highly active antiretroviral treatment.

OBJECTIVES: To determine the survival rate, predictive factors and causes of death in a cohort of human immunodeficiency virus (HIV) infected tuberculosis (TB) patients in the era of highly active antiretroviral treatment (HAART). DESIGN: This retrospective cohort study included all HIV-infected TB patients reported in Barcelona between 1996 and 2006. A survival analysis was conducted based on the Kaplan-Meier estimator and Cox proportional hazards; hazard ratios (HRs) and their 95% confidence intervals (CIs) were calculated. Causes of death were classified using the International Classification of Diseases (ICD) 9 and ICD-10, and defined as acquired immune-deficiency syndrome (AIDS) related, non-AIDS-related or unknown. RESULTS: Of the 792 patients included, 341 (43.1%) died. Survival at 10 years was 47.4% (95%CI 45.2-49.6). Poorer survival was observed in patients aged >30 years (HR 1.6, 95%CI 1.1-2.1), inner-city residents (HR 1.3, 95%CI 1.1-1.7), injecting drug users (HR 1.4, 95%CI 1.1-1.8), those with a non-cavitary radiological pattern (HR 1.5, 95%CI 1.0-2.2), those with <200 CD4/microl (HR 1.8, 95%CI 1.2-2.7) and those diagnosed with AIDS prior to their TB episode (HR 1.85, 95%CI 1.4-2.2). No differences were found for TB treatment (6 vs. 9 months) or for anti-tuberculosis drug resistance; 64.8% of the deaths were non-AIDS-related. CONCLUSIONS: Poor survival was observed despite the availability of HAART, and non-AIDS-related mortality was high. Earlier HAART could help address AIDS and non-AIDS-related mortality.

Evaluating the impact of methadone maintenance programmes on mortality due to overdose and aids in a cohort of heroin users in Spain.

AIMS: To assess the relationship between methadone treatment (MT) and overdose and HIV/AIDS mortality among heroin users resident in Barcelona city. DESIGN: All patients who started treatment in any treatment centre between 1992 and 1997 were included in a cohort the first time they were admitted for heroin addiction treatment. Follow-up controls were carried out every 9 months, on average, until 31 December 1999. Variables, both constant and varying over time, were fitted into Cox regression models. FINDINGS: The study recruited 5049 patients, which provided 23,048.2 person-years. Fifty per cent were in MT during the study period; of the total cohort 1005 patients died: 38.4% due to AIDS, 34.7% to overdose and 27% to other causes. Overall mortality decreased from 5.9 deaths per 100 person-years in 1992 to 1.6 in 1999. Globally, life expectancy at birth was 39 years, 38 years lower than that of the general population. The main factor for overdose mortality was not being in MT at the time of death [relative ratio (RR) = 7.1]; other factors were being a current injector at baseline and being HIV positive. For AIDS mortality, the main factor was the calendar year (RR for 1996 versus 1999 = 4.6), the next major factor was more than 10 years of heroin consumption, followed by not being in MT, being unemployed, then having a prison record. CONCLUSIONS: The observed mortality decline could be linked to the effectiveness of low-threshold MT. The life expectancy of heroin users increased by 21 years during the study period.

[Imputation of the date of HIV seroconversion in cohorts of haemophiliacs]. / Imputación del instante de seroconversión al VIH en cohortes de hemofílicos.

OBJECTIVES: To describe the methods used to impute HIV seroconversion date in the haemophiliac cohorts from GEMES project and to validate its use. METHOD: 632 haemophiliacs coming from three hemophilia units identified as HIV+ and 1.092 individuals coming from 5 project GEMES cohorts with a seroconversion window (time among test HIV and HIV+) less than 3 years where mid point (PM) was assumed as seroconversion date. For both groups, seroconversion date was imputed after estimating the probability distribution of seroconversion by means of the EM algorithm. Two imputation methods are used: one obtained from the expected value and the other from the geometric mean of 5 random samples. from the estimated distribution. Imputations have been validated in the non haemophiliacs cohorts comparing with the PM seroconversion date. Also AIDS free time and survival from the different seroconversion imputed dates were compared. RESULTS: Median seroconversion date is located in May of 1993 for the non haemophiliacs and in 1982 for the haemophiliacs. Not big differences are observed among the imputed seroconversion dates and the mid-point seroconversion date in the non-haemophiliac cohorts. Similar results are found for the haemophiliac cohorts. Also no differences are observed in the estimated AIDS-free time for both groups of cohorts. CONCLUSIONS: Geometric mean imputation from several random samples provides a good estimate of the HIV seroconversion date that can be used to estimate AIDS-free time and survival in haemophiliac cohorts where seroconversion date is ignored.

Tuberculosis screening among immigrants holding a hunger strike in churches.

SETTING: In January 2001, approximately 600 immigrants held a sit-down and hunger strike in several churches in Barcelona to force the Spanish government to comply with demands to regulate their immigration status. Following the diagnosis of a case of smear-positive pulmonary tuberculosis (TB) in one of the immigrants, we performed a large contact investigation. OBJECTIVES: To describe contact investigation procedures used in this setting and to evaluate contact investigation results. METHODS: Demographic variables were collected, and tuberculin skin tests (TST) and chest radiograph examinations were performed. Odds ratios (OR) with 95% confidence intervals (CI) were calculated and logistic regression was used for multivariate analyses. RESULTS: A total of 541 TSTs were performed. Of these, 86% were read and 40.5% yielded a positive reaction with an induration >14 mm. In a multivariate analysis, the risk of presenting a TST induration >14 mm was found to be three times higher among those aged >35 years compared to those <24 years (OR 3.40; 95%CI 1.76-6.59), and for immigrants from Bangladesh (OR 3.14; 95%CI 1.16-6.10) and Pakistan (OR 2.04; 95%CI 1.11-3.73) compared to those from India. A total of 314 chest radiographs examinations were performed and three additional cases of TB were identified, yielding a TB prevalence of 0.7%. CONCLUSIONS: By focusing efforts and conducting targeted TB screening in this high-risk population, it was possible to complete the intervention in only 3 days. A high prevalence of TB infection and TB disease was found.

Influence of highly active anti-retroviral therapy (HAART) on the natural history of extra-pulmonary tuberculosis in HIV patients.

OBJECTIVE: To determine factors related to survival in acquired immune-deficiency syndrome (AIDS) patients with extra-pulmonary tuberculosis (EPTB), when this condition is the first AIDS-defining disease. DESIGN: A retrospective cohort-study of 549 AIDS patients with EPTB as the first AIDS-defining disease. Potential candidates to predict survival were sex, human immunodeficiency virus (HIV) exposure, the coexistence of pulmonary and EPTB at diagnosis, tuberculin skin test, directly observed therapy for tuberculosis (DOT), and highly active anti-retroviral therapy (HAART). The Kaplan-Meier method and Cox regression models were used to assess factors associated with survival. RESULTS: Estimated 3-year survival was 47.0% for those diagnosed before 1993, 72.6% for patients with first AIDS diagnosis during 1995-1996 and 84.6% for those diagnosed after 1996. A negative tuberculin test (hazard ratio [HR] = 1.6, 95% CI 1.1-2.3), not being on DOT (HR 2.2; 95% CI 1.3-3.7) and having pulmonary tuberculosis involvement also (HR 1.3; 95% CI 1.1-1.7) were independently associated with poorer survival. The survival of patients significantly improved after the introduction of HAART (HR 0.4; 95% CI 0.2-0.6). CONCLUSION: The survival of HIV patients with EPTB as their first AIDS-defining disease has substantially improved during the last decade. A negative tuberculin skin test and not receiving DOT are associated with poorer survival among HIV-infected patients whose first AIDS-defining disease is EPTB.

Effectiveness of tuberculosis control programmes in prisons, Barcelona 1987-2000.

SETTING: Different bodies have emphasised the need for prisons to implement and evaluate their own tuberculosis prevention and control programmes (TPCP), with the aims of evaluating TPCP in Barcelona prisons and obtaining conclusions that would allow any necessary modifications to be introduced to improve their effectiveness. METHODS: An assessment was carried out for the period 1987-2000, using the exhaustive retrospective method. The quantitative indicators used were defined in the same way as those employed by the Barcelona TPCP, which were taken as the gold standard. The assessment studied trends in the indicators and evaluated the impact by comparing the results with the gold standard. RESULTS: Statistically significant trends (P < 0.0001) were found for incidence rates, infection prevalence, treatment adherence rates among smear-positive cases and percentage of cases on directly observed treatment (DOT). When impact was assessed, only the decline in the average annual incidence rate (25.2%) and desired rates of adherence among smear-positives (> or = 95% since 1993) achieved the proposed objectives. CONCLUSIONS: The observed decline in incidence shows that when programmes are based on reducing diagnostic delay, controlling adherence using DOT and tracing contacts, tuberculosis control among the prisons is effective.

[Health intervention in an Albanian-Kosovar refugees camp]. / Intervención sanitaria en un campo de refugiados albanokosovares.

This paper focuses on the health intervention developed in a camp of Albanian-Kosovar refugees, displaced as a consequence of the Balcans war in Kosova. Between May and June 1999, the camp of Kavajë in Albania, received 1,700 refugees, with an average age of 24 years old. During this period, 1904 cases were registered at the primary health care centre settled in the camp. The most frequent causes of consultation were respiratory infections (22%), external causes (21%), skin infections and intestinal diseases (12%). A part of the psychological damage, the population attended didn't present with relevant health problems. Most of the visits to the doctor, related to the difficulties suffered on their way to the camp and to the conditions they were living on.

Proposing indicators for evaluation of tuberculosis control programmes in large cities based on the experience of Barcelona.

OBJECTIVE: To evaluate the effectiveness of the Barcelona Tuberculosis (TB) Control Programme and to propose evaluation indicators. MATERIALS AND METHODS: Using quantitative indicators, the results and impact of the programme over the period 1987 to 1999 were evaluated. Statistical analysis was based on a description of indicators, including tests for trends, and on the evolution of the incidence. RESULTS: The incidence of tuberculosis rose between 1987 and 1991 (P = 0.10), and fell between 1991 and 1999 (P < 0.001). During the study period statistically significant improvements were observed in the percentage of cases notified by the medical profession, adherence to treatment and the percentage of cases on directly observed treatment (DOT), and meningitis among children aged 0 to 4 years fell notably. However, diagnostic delay in smear-positive cases and the percentage of cases whose contacts were examined did not vary significantly. The evaluation indicated an average annual decline in tuberculosis incidence of 6.7%, and rates of adherence to treatment (94.5% among smear-positive cases) achieved their objectives. The average median diagnostic delay (36 days) and the percentage of cases with contacts examined (mean 59.8%) were rather less optimistic. CONCLUSIONS: The results of the evaluation were in general positive. Decline in incidence, meningitis in children, treatment adherence rates, diagnostic delay and percentage of cases with studied contacts were considered the best indicators for evaluation of TB programmes.

Intervención sanitaria en un campo de refugiados albanokosovares / Health intervention in an Albanian-Kosovar refugees camp

El objetivo de este estudio se centra en la intervención sanitaria llevada a cabo en un campo de refugiados albanokosovares, desplazados a consecuencia de la guerra de los Balcanes en Kosovo. Entre mayo y junio de 1999, el campo de Kavajë, en Albania, acogió a 1.700 refugiados, con una media de edad de 24 años. Durante este período, se registraron un total de 1.904 visitas, siendo las enfermedades más frecuentes: las infecciones respiratorias (22%), las debidas a causas externas(21%), las afecciones dermatológicas (13%) y los procesos digestivos (12%). Al margen del daño psicológico, la población atendida no padecía graves problemas de salud y la mayoría de las alteraciones que sufrían eran debidas a las duras condiciones en que realizaron la marcha y a las que se encontraron en el campo (AU)

This paper focuses on the health intervention developed in a camp of Albanian-Kosovar refugees, displaced as a consequence of the Balcans war in Kosova. Between May and June 1999, the camp of Kavajë in Albania, received 1,700 refugees, with an average age of 24 years old. During this period,1904 cases were registered at the primary health care centre settled in the camp. The most frequent causes of consultation were respiratory infections (22%), external causes(21%), skin infections and intestinal diseases (12%). A part of the psychological damage, the population attended didn’t present with relevant health problems. Most of the visits to the doctor, related to the difficulties suffered on their way to the camp and to the conditions they were living on (AU)