Sleep disorders in a naturalistic cohort of Dutch psychiatric outpatients: prevalence rates and associations with psychopathology symptom severity and well-being.

Sleep problems are very common in individuals with a mental disorder. Given the abundant evidence indicating the negative impact of disturbed sleep on mental health outcome, insight into the prevalence of all types of sleep disorders in specific mental disorders and neurodevelopmental conditions is of practical importance. Therefore, we estimated the prevalence of six types of sleep disorders with the Holland Sleep Disorders Questionnaire in an overall mental health sample (n = 1082) and separately for different mental and neurodevelopmental conditions. Furthermore, associations between specific sleep disorders, psychopathology and well-being were studied. The impact of the total number of sleep disorders on these associations was examined. Overall, 46.2% of all participants scored above the cut-off for having a sleep disorder. Specifically, 26.8% scored on insomnia, 12.1% on sleep breathing disorders, 9.7% on hypersomnia, 13.7% on circadian rhythm sleep-wake disorders, 11.2% on parasomnia, and 17.9% on sleep-related movement disorders. Most sleep disorders were associated with greater severity of psychopathology and lower well-being. These associations got stronger with an increasing number of sleep disorders. Our study revealed higher suspected prevalence of most sleep disorders in a mental disorder sample compared to the general population. Moreover, the presence of sleep disorder(s) was strongly associated with symptom severity and reduced well-being. These findings extend the notion that early detection and treatment of sleep disorders in mental health populations is essential for psychiatric outcome.

Young people's choice and voice concerning sex and relationships: effects of the multicomponent Get Up Speak Out! Programme in Iganga, Uganda.

BACKGROUND: Young people in Uganda face challenges in achieving their sexual and reproductive health and rights (SRHR), such as lack of information, limited access to services, teenage pregnancy and sexually transmitted infections. To address this, their empowerment - including their ability to express themselves and make decisions, is a key strategy. This study assessed how young people's voice and choice concerning sex and relationships changed over the period of 3 years of implementation of the Get Up Speak Out! programme. METHODS: Data were collected through a household survey with young people (15-24 years) and through focus group discussions, in-depth interviews and key informant interviews with youth and community stakeholders in 2017 for the baseline and 2020 for the end-line. Using the difference-in-difference technique and thematic analysis, changes in key outcomes were assessed over time between intervention and control area. RESULTS: There were limited changes over time in the intervention area, which did not differ from changes in the control area. Young people were able to express themselves and expand their decision-making space on sex and relationships, in particular if they were older, male and in a relationship. Young women negotiated their agency, often by engaging in transactional sex. However, youth were still restricted in their self-expression and their choices as speaking about sexuality was taboo, particularly with adults. This was influenced by the political and religious climate around SRHR in Uganda, which emphasised abstinence as the best option for young people to prevent SRHR-related problems. CONCLUSIONS: Young people's SRHR remains a challenge in Uganda in the context of a conservative political and religious environment that reinforces social and gender norms around youth and young women's sexuality. The limited effect of the programme on increasing young people's voice and choice concerning relationships in Uganda can be understood in the context of a ban on comprehensive sexuality education (CSE) and the COVID-19 pandemic. These structural and emerging contextual factors enforce the taboo around youth sexuality and hinder their access to SRHR information and services. Multi-component and targeted programmes are needed to influence changes at the structural, community and individual level.

Disturbed Sleep in PTSD: Thinking Beyond Nightmares.

Sleep disturbances frequently co-occur with posttraumatic stress disorder (PTSD). Insomnia and nightmares are viewed as core symptoms of PTSD. Yet, relations between disturbed sleep and PTSD are far more complex: PTSD is linked to a broad range of sleep disorders and disturbed sleep markedly affects PTSD-outcome. This article provides a concise overview of the literature on prevalent comorbid sleep disorders, their reciprocal relation with PTSD and possible underlying neurophysiological mechanisms. Furthermore, diagnostic procedures, standard interventions-particularly first choice non-pharmacological therapies-and practical problems that often arise in the assessment and treatment of sleep disturbances in PTSD are described. Finally, we will present some perspectives on future multidisciplinary clinical and experimental research to develop new, more effective sleep therapies to improve both sleep and PTSD.

Sleep disorders in people with type 2 diabetes and associated health outcomes: a review of the literature.

Sleep disorders are linked to development of type 2 diabetes and increase the risk of developing diabetes complications. Treating sleep disorders might therefore play an important role in the prevention of diabetes progression. However, the detection and treatment of sleep disorders are not part of standardised care for people with type 2 diabetes. To highlight the importance of sleep disorders in people with type 2 diabetes, we provide a review of the literature on the prevalence of sleep disorders in type 2 diabetes and the association between sleep disorders and health outcomes, such as glycaemic control, microvascular and macrovascular complications, depression, mortality and quality of life. Additionally, we examine the extent to which treating sleep disorders in people with type 2 diabetes improves these health outcomes. We performed a literature search in PubMed from inception until January 2021, using search terms for sleep disorders, type 2 diabetes, prevalence, treatment and health outcomes. Both observational and experimental studies were included in the review. We found that insomnia (39% [95% CI 34, 44]), obstructive sleep apnoea (55-86%) and restless legs syndrome (8-45%) were more prevalent in people with type 2 diabetes, compared with the general population. No studies reported prevalence rates for circadian rhythm sleep-wake disorders, central disorders of hypersomnolence or parasomnias. Additionally, several cross-sectional and prospective studies showed that sleep disorders negatively affect health outcomes in at least one diabetes domain, especially glycaemic control. For example, insomnia is associated with increased HbA1c levels (2.51 mmol/mol [95% CI 1.1, 4.4]; 0.23% [95% CI 0.1, 0.4]). Finally, randomised controlled trials that investigate the effect of treating sleep disorders in people with type 2 diabetes are scarce, based on a small number of participants and sometimes inconclusive. Conventional therapies such as weight loss, sleep education and cognitive behavioural therapy seem to be effective in improving sleep and health outcomes in people with type 2 diabetes. We conclude that sleep disorders are highly prevalent in people with type 2 diabetes, negatively affecting health outcomes. Since treatment of the sleep disorder could prevent diabetes progression, efforts should be made to diagnose and treat sleep disorders in type 2 diabetes in order to ultimately improve health and therefore quality of life.

The association of sleep quality and aggression: A systematic review and meta-analysis of observational studies.

Poor sleep quality is closely related to aggression, but despite the promise of new therapeutic possibilities, a systematic synthesis of observational research on the association between sleep quality and aggression is lacking. This systematic review and meta-analysis examined the association between sleep quality and aggression, using the academic databases PubMed and PsycINFO. Subjective and objective measures of sleep quality were included, as well as multiple measures of aggression, assessing aggressive and externalizing behavior, anger, hostility and irritability. Ninety-two observational articles, containing 96 studies, encompassing a total of 58.154 children, adolescents and adults were sourced out of 7161 references identified. Methodological quality was moderate or strong in 76% of studies. Data for meta-analysis was available from 74 studies. Poorer sleep quality was associated with higher aggression in 80.8% of studies. Pooled results showed a correlation of 0.28 (95%CI 0.25-0.31; I2 = 90.1%) and odds ratio of 3.61 (95%CI 1.13-11.51; I2 = 88.3%). Effect estimates and heterogeneity varied according to population type and measurement instruments, but not according to article quality or age group. Our findings confirm that poor sleep quality is consistently associated with higher aggression. As most evidence is cross-sectional, more prospective and high-quality experimental evidence is required to elucidate cause-effect and optimize prevention and treatment of aggression.

The clinical relevance of early identification and treatment of sleep disorders in mental health care: protocol of a randomized control trial.

BACKGROUND: Sleep disorders are a risk factor for developing a variety of mental disorders, have a negative impact on their remission rates and increase the risk of relapse. Early identification and treatment of sleep disorders is therefore of paramount importance. Unfortunately, in mental health care sleep disorders are often poorly recognized and specific treatment frequently occurs late or not at all. This protocol-paper presents a randomized controlled trial investigating the clinical relevance of early detection and treatment of sleep disorders in mental health care. The two aims of this project are 1) to determine the prevalence of sleep disorders in different mental disorders, and 2) to investigate the contribution of early identification and adequate treatment of sleep disorders in individuals with mental disorders to their sleep, mental disorder symptoms, general functioning, and quality of life. METHODS: Patients newly referred to a Dutch mental health institute for psychiatric treatment will be screened for sleep disorders with the self-assessment Holland Sleep Disorders Questionnaire (HSDQ). Patients scoring above the cut-off criteria will be invited for additional diagnostic evaluation and, treatment of the respective sleep disorder. Participants will be randomly assigned to two groups: Immediate sleep diagnostics and intervention (TAU+SI-T0), or delayed start of sleep intervention (TAU+SI-T1; 6 months after inclusion). The effect of sleep treatment as add-on to treatment as usual (TAU) will be tested with regard to sleep disorder symptoms, general functioning, and quality of life (in collaboration with a psychiatric sleep centre). DISCUSSION: This trial will examine the prevalence of different sleep disorders in a broad range of mental disorders, providing information on the co-occurrence of specific sleep and mental disorders. Further, this study is the first to investigate the impact of early treatment of sleep disorders on the outcome of many mental disorders. Moreover, standard sleep interventions will be tailored to specific mental disorders, to increase their efficacy. The results of this trial may contribute considerably to the improvement of mental health care. TRIAL REGISTRATION: This clinical trial has been retrospectively registered in the Netherlands Trial Register (NL8389; https://www.trialregister.nl/trial/8389) on February 2th, 2020.

Sender and Receiver Acceptability and Usability of an Online Partner Notification Tool for Sexually Transmitted Infection in the Netherlands.

Users (index patients with a verified sexually transmitted infection and notified partners) rated the health care provider-initiated Internet-based partner notification application Suggestatest.nl acceptable and usable. Both groups were less positive about Suggestatest.nl to notify/get notified of HIV than other sexually transmitted infection. An anonymous notification was perceived less acceptable.

Young Low-Risk Heterosexual Clients Prefer a Chlamydia Home Collection Test to a Sexually Transmitted Infection Clinic Visit in Amsterdam, the Netherlands, A Cross-Sectional Study.

BACKGROUND: Home-based self-collection of specimens for urogenital and anorectal chlamydia testing has been proven feasible and acceptable. We studied the efficiency of chlamydia home collection kits for young low-risk persons to optimize care at the Amsterdam sexually transmitted infection (STI) clinic. METHODS: Low-risk heterosexual persons under 25 years submitting an appointment request online were offered 3 different ways of chlamydia testing: (1) receiving a home collection kit, (2) coming to the clinic without, or (3) with sexual health counseling. The collection kit was sent to the client by surface mail and was used to self-collect a vaginal swab or urine sample (men). This sample was sent back to the laboratory for testing and the results could be retrieved online. Testing for gonorrhea, syphilis, and human immunodeficiency virus was indicated after testing chlamydia-positive. RESULTS: Between September 2012 until July 2013, from 1804 online requests, 1451 (80%) opted for the home collection kit, 321 (18%) preferred an appointment at the clinic without, and 32 (2%) with sexual health counseling. Of the requested home collection kits, 88% were returned. Chlamydia was diagnosed in 6.0% of the clients receiving a home collection kit, and none of the chlamydia-positive clients tested positive for other STI. CONCLUSIONS: Home collection is the preferred method for most young low-risk heterosexual clients who seek STI care. With a high compliance to collect and return the samples, home collection can be used as a tool to increase efficiency and dedicate STI clinic workers efforts to those at highest risk.

Sexually transmitted infections among female sex workers tested at STI clinics in the Netherlands, 2006-2013.

BACKGROUND: Specialised sexually transmitted infection (STI) clinics in the Netherlands provide STI care for high-risk groups, including female sex workers (FSW), at the clinic and by outreach visiting commercial sex workplaces with a permit. The objective was to investigate the STI positivity rate and determinants of an STI diagnosis among FSW tested by STI clinics in the Netherlands. METHODS: Sexually transmitted infection clinics report demographic, behavioural and diagnostic information of every consultation to the National Institute for Public Health and the Environment. We analysed all consultations of FSW between 2006 and 2013. Trends in STI positivity rate (chlamydia, gonorrhoea, infectious syphilis, HIV and hepatitis B) were analysed using χ(2) for trend and logistic regression was used to analyse determinants associated with an STI diagnosis. Differences between consultations at the STI clinic and consultations during outreach were analysed using χ(2) tests. RESULTS: The positivity rate for any STI (overall 9.5 %) was stable from 2006 to 2013. Chlamydia positivity rate (overall 7.1 %) decreased (p < 0.001) and gonorrhoea positivity rate (overall 2.6 %) increased (p < 0.001). For gonorrhoea, the highest positivity rate was found oropharyngeal (2.0 %). Characteristics associated with STI were a younger age [adjusted odds ratio (aOR) 0.96, 95 % confidence interval (CI) 0.95-0.97 per year], a previous STI diagnosis (aOR 1.63, 95 % CI 1.38-1.92) and being notified for an STI by partner notification (aOR 2.61, 95 % CI 2.0-3.40). The STI positivity rate was significantly lower among FSW tested at outreach locations (8.6 %) compared to FSW tested at the STI clinic (11.7 %, p < 0.001). CONCLUSIONS: The STI positivity rate among FSW remained stable, but underlying this was a decreasing chlamydia trend and an increasing gonorrhoea trend, suggesting a shift in STI risks among FSW over time. Condom use during oral sex should be promoted since oropharyngeal gonorrhoea was frequently diagnosed and because of the potential spread of antimicrobial resistant gonococci.

Changing Patterns of Undiagnosed HIV Infection in the Netherlands: Who Benefits Most from Intensified HIV Test and Treat Policies?

OBJECTIVES: To estimate HIV prevalence, the number of people living with HIV/AIDS (PLWHA) and the undiagnosed proportion in the Netherlands for 2012, and to compare these with published 2007 estimates. DESIGN: Synthesis of all available data sources. METHODS: Multi-Parameter Evidence Synthesis (MPES) was used to obtain estimates in mutually exclusive key populations at higher risk in three geographical regions (Amsterdam, Rotterdam, rest of the Netherlands). Data sources included HIV prevalence surveys, diagnoses at STI clinics, and registered cases in HIV care. Group specific estimates were reported as Bayesian posterior medians and 95% credible intervals (CrI). RESULTS: The 2012 model estimated 24,350 PLWHA (95% CrI 20,420-31,280) aged 15-70 years; 2,906 (+14%) more than in 2007. The estimated population HIV prevalence was 0.20% (95% CrI 0.17-0.26%). The overall proportion of undiagnosed HIV was lower in 2012 (34%, 95% CrI 22-49%) compared to 2007 (40%, 95% CrI 25-55%). After MSM, migrants from sub-Saharan Africa and the Caribbean formed the largest groups of PLWHA, but proportions of undiagnosed HIV remained high in these groups, 48% and 44% respectively. Amsterdam had lowest proportions undiagnosed for most key populations at higher risk, including MSM and migrants. CONCLUSIONS: In 2012, the number of PLWHA was higher compared to 2007, while the proportion of undiagnosed HIV was lower, especially among MSM. Higher HIV testing rates, earlier treatment, and an improved life expectancy may explain these differences. HIV interventions need to be expanded in all key populations at higher risk, with special focus on migrants and key populationsliving outside of Amsterdam.

Self-reported testing, HIV status and associated risk behaviours among people who inject drugs in Europe: important differences between East and West.

AIMS: To describe HIV-related risk behaviours, HIV testing and HIV status among people who inject drugs (PWIDs) in the 2000 in European countries with high-prevalence HIV epidemics among PWID. METHODS: Data from 12 cross-sectional studies among PWID from seven countries were used. Meta-analysis was used to synthesize the data and meta-regression to explain heterogeneity [in addition to deriving adjusted odds ratios (AORmeta)]. RESULTS: Data on 1791 PWID from western (the West) and 3537 from central and eastern (the East) European countries were available. The mean age of participating PWIDs was 30.6 years (SD 7.9), 75% were men, and 36% [95% confidence interval 34-37%) were HIV-infected (30% West, 38% East); 22% had not previously been tested for HIV. The prevalence of reported high-risk behaviour was significantly higher among PWID from the East. Comparison of HIV-infected and uninfected PWID within countries yielded similar results across all countries: HIV-infected PWID were less likely to be sexually active [AORmeta 0.69 (0.58-0.81)], reported less unprotected sex [AORmeta 0.59 (0.40-0.83)], but reported more syringe sharing [AORmeta 1.70 (1.30-2.00)] and more frequent injecting [AORmeta 1.40 (1.20-1.70)] than their HIV-uninfected counterparts. CONCLUSION: Despite the absolute differences in reported risk behaviours among PWID in western and eastern Europe, the associations of risk behaviours with HIV status were similar across the sites and regions. There is a substantial potential for further HIV transmission and acquisition based on the continuous risk behaviours reported. HIV prevention and harm reduction interventions targeting PWID should be evaluated.

Neurosyphilis in the mixed urban-rural community of the Netherlands.

OBJECTIVE: Neurosyphilis is caused by dissemination into the central nervous system of Treponema pallidum. Although the incidence of syphilis in the Netherlands has declined since the mid-1980s, syphilis has re-emerged, mainly in the urban centres. It is not known whether this also holds true for neurosyphilis. METHODS: The epidemiology of neurosyphilis in Dutch general hospitals in the period 1999-2010 was studied in a retrospective cohort study. Data from the Dutch sexually transmitted infection (STI) clinics were used to analyse the number of patients diagnosed with syphilis in this period. RESULTS: An incidence of neurosyphilis of 0.47 per 100 000 adults was calculated, corresponding with about 60 new cases per year. This incidence was higher in the western (urbanised) part of the Netherlands, as compared with the more rural areas (0.6 and 0.4, respectively). The number of patients diagnosed with syphilis in STI clinics increased from 150 to 700 cases in 2004 and decreased to 500 new cases in 2010. The sex ratio was in favour of men, yielding a percentage of 90% of the syphilis cases and of 75% of the neurosyphilitic cases. The incidence of neurosyphilis was highest in men aged 35-65 years, and in women aged 75 years and above. The most frequently reported clinical manifestation of neurosyphilis was tabes dorsalis. In this study, 15% of the patients were HIV seropositive. CONCLUSION: The incidence of neurosyphilis in a mixed urban-rural community such as the Netherlands is comparable to that in other European countries. Most patients are young, urban and men, and given the frequent atypical manifestations of the disease reintroduction of screening for neurosyphilis has to be considered.

Identifying recently acquired HIV infections among newly diagnosed men who have sex with men attending STI clinics in The Netherlands.

OBJECTIVES: The current surveillance system in The Netherlands cannot differentiate recent HIV infections from established infections, which is crucial for estimating the HIV incidence; this information is needed for assessing trends of the HIV epidemic and the impact of prevention interventions. We determined the proportion of recent HIV infections (RI) and estimated HIV incidence using a recent infection testing algorithm (RITA) among men who have sex with men (MSM) newly diagnosed as having HIV attending sexually transmitted infection (STI) clinics. METHODS: Plasma samples collected between 2009 and 2011 were tested for RI with the Architect HIV Ag/Ab Combo immunoassay. Data on viral load, CD4 count and previous HIV testing were incorporated into the RITA. HIV incidence and 95% CIs were estimated. Logistic regression was used to identify factors associated with RI. RESULTS: Of the 251 samples tested for RI, 78/251 (31%) infections were determined as recent by the RITA. No significant change over time was observed. The estimated HIV incidence in this high-risk MSM population was 3.3 per 100 person-years (95% CI 2.5 to 4.1). The only factor associated with RI in the multivariable model was being tested for HIV ≥ 3 times in the past (aOR=7.4; 95% CI 2.0 to 27.8). CONCLUSIONS: The proportion of RIs was comparable to studies in similar settings in Europe. Implementation of the RITA for routine surveillance in The Netherlands to assess trends in RIs over time, to study the infections in other groups and to inform public health actions, is being planned.

Do sexual risk behaviour, risk perception and testing behaviour differ across generations of migrants?

BACKGROUND: Behaviour and related health outcomes of migrants have been suggested to shift towards the practices of the indigenous population of the host country. To investigate this, we studied generational differences in sexual behaviour between first- and second-generation migrants (FGMs and SGMs) in The Netherlands. METHODS: In 2003-05, persons aged 16-70 years with origins in Surinam, the Antilles and Aruba were interviewed on their sexual behaviour in The Netherlands and their country of origin. The relationship of generation, age at migration and sexual behaviour was studied by multinomial logistic regression analyses. RESULTS: Generational differences were observed regarding concurrent partnerships, anal sex and history of sexually transmitted infection. Compared with FGMs who migrated at an age >25 years, those who migrated between 10 and 25 years of age were more likely to report concurrency [odds ratio (OR): 1.52, 95% confidence interval (CI): 1.14-2.04], whereas SGMs were less likely to report concurrency (OR: 0.65, 95% CI: 0.43-0.98). FGMs who migrated before the age of 10 were more likely to have had anal sex (OR: 1.90, 95% CI: 1.34-2.71) or a sexually transmitted infection diagnosis (OR: 1.80, 95% CI: 1.20-2.71) than those who had migrated at >25 years of age. CONCLUSION: Our study shows that not only SGMs but also FGMs who migrated at an early age tend to differ from the sexual patterns of FGMs who migrated at an older age. Generational differences in sexual behaviour could be explained by acculturation and increased identity with the values of the host country.

Modelling the impact of chlamydia screening on the transmission of HIV among men who have sex with men.

BACKGROUND: Recent studies have found high prevalences of asymptomatic rectal chlamydia among HIV-infected men who have sex with men (MSM). Chlamydia could increase the infectivity of HIV and the susceptibility to HIV infection. We investigate the role of chlamydia in the spread of HIV among MSM and the possible impact of routine chlamydia screening among HIV-infected MSM at HIV treatment centres on the incidence of chlamydia and HIV in the overall MSM population. METHODS: A mathematical model was developed to describe the transmission of HIV and chlamydia among MSM. Parameters relating to sexual behaviour were estimated from data from the Amsterdam Cohort Study among MSM. Uncertainty analysis was carried out for model parameters without confident estimates. The effects of different screening strategies for chlamydia were investigated. RESULTS: Among all new HIV infections in MSM, 15% can be attributed to chlamydia infection. Introduction of routine chlamydia screening every six months among HIV-infected MSM during regular HIV consultations can reduce the incidence of both infections among MSM: after 10 years, the relative percentage reduction in chlamydia incidence would be 15% and in HIV incidence 4%, compared to the current situation. Chlamydia screening is more effective in reducing HIV incidence with more frequent screening and with higher participation of the most risky MSM in the screening program. CONCLUSIONS: Chlamydia infection could contribute to the transmission of HIV among MSM. Preventive measures reducing chlamydia prevalence, such as routine chlamydia screening of HIV-infected MSM, can result in a decline in the incidence of chlamydia and HIV.

Sexually transmitted infections screening at HIV treatment centers for MSM can be cost-effective.

OBJECTIVE: To estimate the cost-effectiveness of anorectal chlamydia screening among men who have sex with men (MSM) in care at HIV treatment centers. DESIGN: Transmission model combined with economic analysis over a 20-year period. SETTING AND PARTICIPANTS: MSM in care at HIV treatment centers. INTERVENTION: Once-yearly or twice-yearly screening for anorectal chlamydia among MSM in care at HIV treatment centers. MAIN OUTCOME MEASURES: Averted HIV and chlamydia infections; discounted quality-adjusted life-years and costs; incremental cost-effectiveness ratio (ICER). RESULTS: Costs will be saved by routine chlamydia screening of MSM in care at HIV treatment centers if these patients seek little or no screening elsewhere. Nonroutine screening is considerably more expensive than routine screening offered within a scheduled visit. Adding once-yearly chlamydia screening for MSM in care at HIV treatment centers is cost saving when 30% or fewer of those men seek once-yearly screening elsewhere (1.5 to 8.1 million euro saved). Twice-yearly routine screening at HIV treatment centers is cost-effective only when routine screening takes place without additional nonroutine screening (1.9 million euro saved). CONCLUSIONS: Adding annual chlamydia screening to the HIV consultation will be cost saving as long as only a limited proportion of men are nonroutinely screened. The ICER was most sensitive to the percentage of MSM that continue to be screened elsewhere.

Hepatitis C among injecting drug users is two times higher in Stockholm, Sweden than in Rotterdam, the Netherlands.

This study assessed risk behavior and preventive measures for hepatitis C among injecting drug users in Rotterdam, the Netherlands (452 participants, 2002-2003) and Stockholm, Sweden (310 participants, 2004-2006), two cities with contrasting drug policies. Uni- and multivariate logistic regression models were used. We found that the prevalence of hepatitis C was almost two times higher in participants from Stockholm than in participants from Rotterdam, even after adjustment for sex sharing paraphernalia (adjusted relative risk: 1.92, 95% confidence interval: 1.60-2.29). Follow-up comparative studies are needed to determine if policies with structured health programs can decrease transmission of hepatitis C.

Higher Chlamydia trachomatis prevalence in ethnic minorities does not always reflect higher sexual risk behaviour.

BACKGROUND: In affluent countries, the prevalence of Chlamydia trachomatis (CT) is often higher in certain ethnic minorities than in the majority population. In The Netherlands, we examined why CT prevalence is higher in Surinamese/Antilleans, the largest minority in the country. METHODS: Heterosexuals were recruited for a cross-sectional survey from May through August 2010 at the sexually transmitted infections (STI) clinic in Amsterdam. Participants completed a questionnaire and were tested for STI. A causal directed acyclic graph was assumed to investigate whether the association between ethnicity and CT could be explained by differences in sexual risk behaviour and socio-economic status. RESULTS: Subjects included 1044 with Dutch background and 335 with Surinamese/Antillean background. Median age for the combined population was 25 (IQR 22-30) years, and 55.4% was female. Sexual risk behaviour did not differ significantly between the two groups. CT was diagnosed in 17.9% of Surinamese/Antilleans and in 11.4% of Dutch. Surinamese/Antilleans were significantly more likely to have CT (OR 1.70; 95% CI 1.21-2.38). The association between ethnicity and CT remained statistically significant after adjusting for sexual risk behaviour, age, sex, and ethnic mixing (aOR 1.48; 95% CI 1.00-2.18), but not after adjusting for education and neighbourhood, markers of socio-economic status (aOR 1.08; 95% CI 0.71-1.64). CONCLUSION: The difference in CT prevalence between the minority and majority groups was not explained by differences in sexual risk behaviour. The higher CT prevalence found among Surinamese/Antilleans appeared to reflect their lower educational level and neighbourhood, two markers of lower socio-economic status. We hypothesise that the effect results from lower health-seeking behaviour.

How patterns of migration can influence the heterosexual transmission of HIV in The Netherlands.

OBJECTIVES: Migrants originating from countries with a high HIV prevalence account for a large number of heterosexually acquired HIV infections in western European countries. These migrants may be infected before migrating and they may engage in unsafe sexual practices both in the country of residence and in their country of origin. This report investigates how patterns of migration may affect the heterosexual HIV epidemic in The Netherlands. METHODS: A mathematical model was used that describes the transmission of HIV in heterosexual partnerships between African migrants, Caribbean migrants and the local Dutch population. Infection of migrants before migrating to The Netherlands and during trips to their country of origin was also accounted for. RESULTS: The incidence of HIV infection among adult heterosexuals in 2010 was 1.50 new infections per 100,000 individuals per year. If the number of migrants entering the country increases, then the incidence of HIV will increase, although this change among Dutch individuals will be negligible. Moreover, if HIV prevalence among those migrating to The Netherlands (at the time of entry to the country) is higher, then incidence in the respective ethnic group will increase; among other ethnic groups, the increase will be very small. CONCLUSIONS: Heterosexual transmission of HIV in The Netherlands occurs mostly within migrant communities. Limiting migration and introducing travel restrictions would probably have no effect on HIV incidence in countries with low HIV prevalence among heterosexuals. Policy making should focus on targeted interventions, to reduce the burden of disease in migrant communities in Europe.

National estimate of HIV prevalence in the Netherlands: comparison and applicability of different estimation tools.

OBJECTIVES: to determine limitations and strengths of three methodologies developed to estimate HIV prevalence and the number of people living with HIV/AIDS (PLWHA). METHODS: the UNAIDS/WHO Workbook method; the Multiparameter Evidence Synthesis (MPES) adopted by the Health Protection Agency; and the UNAIDS/WHO Estimation and Projection Package (EPP) and Spectrum method were used and their applicability and feasibility were assessed. All methods estimate the number infected in mutually exclusive risk groups among 15-70-year-olds. RESULTS: using data from the Netherlands, the Workbook method estimated 23 969 PLWHA as of January 2008. MPES estimated 21 444 PLWHA, with a 95% credible interval (CrI) of 17 204-28 694. Adult HIV prevalence was estimated at 0.2% (95% CrI 0.15-0.24%) and 40% (95% CrI 25-55%) were undiagnosed. Spectrum applied gender-specific mortality, resulting in a projected estimate of 19 115 PLWHA. CONCLUSION: although outcomes differed between the methods, they broadly concurred. An advantage of MPES is that the proportion diagnosed can be estimated by risk group, which is important for policy guidance. However, before MPES can be used on a larger scale, it should be made more easily applicable. If the aim is not only to obtain annual estimates, but also short-term projections, then EPP and Spectrum are more suitable. Research into developing and refining analytical tools, which make use of all available information, is recommended, especially HIV diagnosed cases, as this information is becoming routinely collected in most countries with concentrated HIV epidemics.