Mapping HIV-related behavioural surveillance among injecting drug users in Europe, 2008.

The systematic collection of behavioural information is an important component of second-generation HIV surveillance. The extent of behavioural surveillance among injecting drug users (IDUs) in Europe was examined using data collected through a questionnaire sent to all 31 countries of the European Union and European Free Trade Association as part of a European-wide behavioural surveillance mapping study on HIV and other sexually transmitted infections. The questionnaire was returned by 28 countries during August to September 2008: 16 reported behavioural surveillance studies (two provided no further details). A total of 12 countries used repeated surveys for behavioural surveillance and five used their Treatment Demand Indicator system (three used both approaches). The data collected focused on drug use, injecting practices, testing for HIV and hepatitis C virus and access to healthcare. Eight countries had set national indicators: three indicators were each reported by five countries: the sharing any injecting equipment, uptake of HIV testing and uptake of hepatitis C virus testing. The recall periods used varied. Seven countries reported conducting one-off behavioural surveys (in one country without a repeated survey, these resulted an informal surveillance structure). All countries used convenience sampling, with service-based recruitment being the most common approach. Four countries had used respondent-driven sampling. Three fifths of the countries responding (18/28) reported behavioural surveillance activities among IDUs; however, harmonisation of behavioural surveillance indicators is needed.

HIV and STI behavioural surveillance among men who have sex with men in Europe.

This paper describes behavioural surveillance for HIV and sexually transmitted infections (STI) among men who have sex with men (MSM) in Europe, focusing on the methods and indicators used. In August 2008, questionnaires were sent to European Union Member States and European Free Trade Association countries seeking information on behavioural surveillance activities among eight population groups including MSM. Thirty-one countries were invited to take part in the survey and 27 returned a questionnaire on MSM. Of these 27 countries, 14 reported that there was a system of behavioural surveillance among MSM in their country while another four countries had conducted behavioural surveys of some kind in this subpopulation. In the absence of a sampling frame, all European countries used convenience samples for behavioural surveillance among MSM. Most European countries used the Internet for recruiting and surveying MSM for behavioural surveillance reflecting increasing use of the Internet by MSM for meeting sexual partners. While there was a general consensus about the main behavioural indicators (unprotected anal intercourse, condom use, number of partners, HIV testing), there was considerable diversity between countries in the specific indicators used. We suggest that European countries reach an agreement on a core set of indicators. In addition we recommend that the process of harmonising HIV and STI behavioural surveillance among MSM in Europe continues.

Patterns of sex work contact among men in the general population of Switzerland, 1987-2000.

OBJECTIVES: To analyse the prevalence of lifetime recourse to prostitution (LRP) among men in the general population of Switzerland from a trend and cohort perspective. METHODS: Using nine repeated representative cross-sectional surveys from 1987 to 2000, age-specific estimates of LRP were computed. Trends and period effect were analysed as the evolution of cross-sectional population estimates within age groups and overall. Cohort analysis relied on cohorts constructed from the 1989 survey and followed in subsequent waves. Age and cohort effects were modelled using logistic regression and non-parametric monotone regression. RESULTS: Whereas prevalence for the younger groups was found to be logically lower, there was no consistent increasing or decreasing trend over the years; there was no significant period effect. For the 17-30 year age group, the mean estimate over 1987-2000 was 11.5% (range 8.3 to 12.7%); for the 31-45 year group, the mean was 21.5% (range over 1989-2000 20.3 to 23.0%). Regarding cohort analysis, the prevalence of LRP was found to increase steeply in the youngest ages before reaching a plateau near the age of 40 years. At the age of 43 years, the prevalence was estimated to be 22.6% (95% CI 21.1% to 24.1%). CONCLUSIONS: The steep increase in the cohort-wise prevalence of LRP in younger ages calls for a concentration of prevention activities in young people. If the plateauing at approximately 40 years of age is not followed by a further increase later in life, which is not known, then consumers of paid sex would be repeat buyers only, a fact that should be taken into account by prevention.

Trends in drug consumption and risk of transmission of HIV and hepatitis C virus among injecting drug users in Switzerland, 1993-2006.

As a part of the HIV behavioural surveillance system in Switzerland, repeated cross-sectional surveys were conducted in 1993, 1994, 1996, 2000 and 2006 among attenders of all low threshold facilities (LTFs) with needle exchange programmes and/or supervised drug consumption rooms for injection or inhalation in Switzerland. Data were collected in each LTF over five consecutive days, using a questionnaire that was partly completed by an interviewer and partly self administered. The questionnaire was structured around three topics: socio-demographic characteristics, drug consumption, health and risk/preventive behaviour. Analysis was restricted to attenders who had injected drugs during their lifetime (IDUs). Between 1993 and 2006, the median age of IDUs rose by 10 years. IDUs are severely marginalised and their social situation has improved little. The borrowing of used injection equipment (syringe or needle already used by other person) in the last six months decreased (16.5% in 1993, 8.9% in 2006) but stayed stable at around 10% over the past three surveys. Other risk behaviour, such as sharing spoons, cotton or water, was reported more frequently, although also showed a decreasing trend. The reported prevalence of HIV remained fairly stable at around 10% between 1993 and 2006; reported levels of hepatitis C virus (HCV) prevalence were high (56.4% in 2006). In conclusion, the overall decrease in the practice of injection has reduced the potential for transmission of infections. However as HCV prevalence is high this is of particular concern, as the current behaviour of IDUs indicates a potential for further spreading of the infection. Another noteworthy trend is the significant decrease in condom use in the case of paid sex.

[HIV epidemiology]. / Epidémiologie du VIH.

Twenty-five years after the description of the first cases of AIDS, the HIV pandemic remains a major public health problem. Although often described as a single epidemic, there are many distinct epidemiological situations. Individual-level risks are at the center of this evolution and influenced by social, economic and political contexts. The overall situation in Europe and the Americas seems stable in recent years. However, the generalized epidemics in sub-Saharan Africa continue to spread and new hidden epidemic foci involving specific risk populations are emerging throughout the rest of the world. A multidimensional approach, tailored to the particular socio-cultural context, is essential to control these complex and diversified epidemics.

[Hyperactivity and prescription of Ritalin in the canton of Vaud (Switzerland), 2002]. / Hyperactivité et prescription de Ritaline dans le canton de Vaud (Suisse), 2002.

BACKGROUND: The estimated prevalence of Attention Deficit Hyperactivity Disorder (ADHD) reported in European countries is 2 to 5% of school age children. Political concern has been expressed in Switzerland about possible over treatment with methylphenidate. The purpose of this research, commissioned by the regional public health authority, was to assess the prescription of methylphenidate (Ritalin) for children as a treatment of ADHD. METHODS: The regional health authority collected all prescriptions of Ritalin delivered in pharmacies during 2002. Data available from prescriptions and analyzed were: age, sex and place of residence of the patient, dosage prescribed, date of prescription, place of practice and medical specialization of doctors. Only patients living in the canton of Vaud and aged less than 20 years were included in the analysis. RESULTS: Six hundred and ninety-seven patients, aged less than 20 years, received Ritalin in 2002. The mean age was 12.1 years (median: 12 years; range: 3-19), 15% were female. These patients represented 0.74% of the 5-14 years old population living in the canton of Vaud. Eighty percent of patients had a prescription from a specialist (pediatrician or psychiatrist) during the year. CONCLUSIONS: Less than 1% of the young population receives methylphenidate in the canton of Vaud. Dosage complies with the recommendations of the Swiss Medic Compendium. The large majority of patients receive prescriptions for methylphenidate from specialists. A new study based on the 2005 data will be conducted to follow changes in the prescription of Ritalin.

[Prevention practices of primary health care physicians in Switzerland in the context of the HIV/Aids epidemic: changes between 1990 and 2002]. / Evolution, entre 1990 et 2002, des activités préventives des médecins de premier recours en Suisse dans le cadre de l'épidémie de VIH/sida.

BACKGROUND: Individual preventive counseling offered to the general public by private doctors working in primary health care is an essential component of the Swiss National Aids Prevention strategy. Surveys were conducted to assess to what extent they fulfill this role and how this may have changed over time. METHODS: Three cross-sectional surveys were conducted in 1990, 1995, and 2002 by anonymous mailed questionnaire in a random sample of primary health care physicians. Dimensions of the physicians HIV prevention practices investigated were: practice of HIV risk assessment, content and frequency of HIV pretest counseling, and, in 2002 only, care of patients living with HIV/AIDS. Trends over the 12-year period were calculated; logistic regressions were performed to investigate factors associated with the frequency of counseling given to HIV positive patients. RESULTS: Risk assessment has increased dramatically over the period for certain groups of patients (patients requesting contraception, young people and new patients). In 2002, routine screening is often or always performed by 93% of physicians for intravenous drug patients or patients with a sexually transmitted infection; 77% for homosexuals; 76% for patients requesting contraception; 63% for young people. It is less frequent in other groups (migrants: 40%; separated/divorced patients: 29%). More than half of physicians care for patients with HIV. Around two-thirds of physicians regularly discuss with their HIV positive patients issues related to patients' professional, social and private life. There are few differences among specialties regarding the propensity to discuss these topics. CONCLUSION: Prevention activities by primary care physicians have increased in the last decade. Nonetheless, potential for increased prevention still exists in some areas of risk assessment and counseling.

HIV testing in Switzerland.

OBJECTIVES: To obtain information about the prevalence of, reasons for, and adequacy of HIV testing in the general population in Switzerland in 1992. DESIGN: Telephone survey (n = 2800). RESULTS: Some 47% of the sample underwent one HIV test performed through blood donation (24%), voluntary testing (17%) or both (6%). Of the sample, 46% considered themselves well or very well informed about the HIV test. Patients reported unsystematic pre-test screening by doctors for the main HIV risks. People having been in situations of potential exposure to risk were more likely to have had the test than others. Overall, 85% of those HIV-tested had a relevant, generally risk-related reason for having it performed. CONCLUSIONS: HIV testing is widespread in Switzerland. Testing is mostly performed for relevant reasons. Pre-test counselling is poor and an opportunity for prevention is thus lost.

Long term global evaluation of a national AIDS prevention strategy: the case of Switzerland.

OBJECTIVES: The Swiss Aids prevention strategy has been subject to a continuous process of evaluation for the past 12 years. This paper describes the conceptual approach, methodology, results obtained and contribution to policy-making of that evaluation. DESIGN: The evaluation is on-going, global with respect to all components of the strategy, and utilization-focused. Each successive phase of the evaluation has included 10-20 studies centred either on aspects of process, of outcome or of environmental context. Findings are synthesized at the end of each phase. METHODS: Both quantitative and qualitative methods are used. Studies generally have one of three functions within the overall evaluation: assessment of trends through surveys or other types of repeated studies; evaluation of specific areas through a series of studies from different viewpoints; in-depth investigation or rapid assessment through one-off studies. Various methods of triangulation are used to validate findings. RESULTS: The evaluation has allowed for: the observation of behavioural change in different populations; the availability of scientific data in controversial fields such as drug-use policy; an understanding of the diversity of public appropriation of prevention messages. Recommendations are regularly formulated and have been used by policy-makers and field workers for strategy development. CONCLUSIONS: The global approach adopted corresponds well to the evaluation requirements of an integrated long-term prevention strategy. Cost is low relative to the extent of information provided. Such an evaluation cannot however address the question of causal relationship between the strategy and observed changes. The evaluation has contributed to the development of a culture of evaluation in Swiss AIDS prevention more generally.

Management of the risk of HIV infection in male homosexual couples.

OBJECTIVES: To study the ways of managing HIV risk within male homosexual steady relationships (gay couples), including factors associated with consistent condom use during anal sex with the steady partner. METHOD: An anonymous and standardized questionnaire completed by a convenience sample of homosexuals in Switzerland in 1997 (n = 1097). Information on the couple was provided by the 74% (n = 786) of male respondents who reported having a steady partner in the past 12 months. Data were analysed by contingency tables and logistic regression. RESULTS: Different ways of managing HIV risk were reported: negotiated safety (both HIV negative, condoms abandoned) was chosen by one quarter of the couples, but the most frequent solution was reliance on condoms for anal sex, chosen by more than four in 10. Altogether 84% of couples exhibited safe management of HIV risk within their partnership. The 16% of couples showing inadequate management of HIV risk within the couple mostly relied on questionable assumptions about past or present risks. A total of 74% of couples had spoken about managing HIV risk with possible casual partners. Reported behaviour with the steady partner and with casual partners was highly consistent with claimed strategies chosen to manage HIV risk. Consistent condom use with the steady partner was mostly associated with variables characterizing the relationship: initial 2 years of the relationship, discordant or unknown serological HIV status, non-exclusivity. CONCLUSION: Gay couples manage HIV risk in a variety of ways. Most strategies provide adequate protection with casual partners, but leave gaps in protection between the steady partners themselves.

HIV/AIDS institutional discrimination in Switzerland.

A UNAIDS protocol designed to identify discrimination against people living with HIV/AIDS was applied in Switzerland, a country where policies against such discrimination had been actively promoted since the beginning of the HIV epidemic. Discrimination, in its strict legal definition, was examined in nine areas of everyday life, and at three levels: legislation, written regulations, and actual practices. Data concerning both expert opinion and subjective experience of discrimination was gathered by members of an interdisciplinary work group by means of: (1) interviews with over 200 key informants and experts, covering each of the areas investigated, and (2) actively seeking testimonies as to experiences of discrimination through local AIDS groups and through informal contacts of work group members. The study revealed little institutional discrimination in the region investigated, attesting to the efficacy of clear and actively promoted anti-discrimination policies. Individual discrimination and stigmatisation persist, however. It is in combating individual discrimination and stigmatisation that efforts must now concentrate. The UNAIDS protocol was found to be a valuable tool for tracking the sorts of discrimination that can most easily be influenced by policy measures.

HIV/AIDS prevention for migrants and ethnic minorities: three phases of evaluation.

There are now a number of HIV/AIDS prevention programmes for migrant and ethnic minority communities throughout the world, both 'top down' programmes organised, for example, by governments and large NGOs, and 'bottom up' programmes, organised by migrant groups themselves. Evaluation of such programmes, however, is in most cases sorely lacking. The Swiss 'Migrants Project' is, to the authors' knowledge, the only such programme to have been systematically accompanied by evaluation throughout. This paper describes three phases of evaluation of the Migrants Project (exploratory studies, process, and outcome evaluations). The evaluations have highlighted the need for culturally and linguistically appropriate prevention efforts which use already-existing community structures, as well as the need to identify and train people from within communities to carry out local prevention efforts. Outcome evaluation has shown that: a government sponsored HIV/AIDS prevention programme can meet with acceptance by migrant communities; considerable engagement in prevention activities can be mobilised; and AIDS prevention among such communities can be effective. Such efforts can create levels of sensitivity to HIV issues and of protective behaviour that are equal to those of the host country population. The strategy adopted by the programme is thus supported. Key elements are to avoid potential for stigmatising by: (1) placing HIV/AIDS prevention efforts for migrant populations within an overall national HIV/AIDS prevention strategy; (2) informing and sensitising general populations within migrant communities before initiating more targeted prevention with migrant IDUs, MSM, and CSWs; (3) encouraging, facilitating and guiding health promotion efforts which emerge from within migrant communities themselves.

Evaluation of AIDS prevention among homosexual and bisexual men in Switzerland.

Attitudinal and behavioural change among gay men in Switzerland was measured between 1987 and 1990 to evaluate the effectiveness of AIDS prevention activities. The methodology used included a self-administered questionnaire published in Swiss gay magazines and distributed by gay organizations (N = 795 in 1987, N = 720 in 1990) and in-depth interviews with men recruited through advertisements and through the questionnaire (N = 42 in 1987, N = 24 in 1990). The two independent sampling procedures yielded similar samples with regard to socio-demographic characteristics, allowing comparisons to be made between the 1987 and 1990 data. Personal confrontation with AIDS (knowing someone who is HIV-positive, or who is ill or dead from AIDS) increased significantly during the period but more adequate ways of coping developed. Behavioural change towards safer sex began well before the first study. The majority of responding homosexuals have adapted their sexual behaviour to the new situation created by AIDS and generally maintain a protective behaviour. However, "exceptions" (condom rupture or episodes of non-protection) are not infrequent and should deserve more attention. Three indicators of sexual behaviour (number of sexual partners, anal sex and use of condom and oral sex with ejaculation), reported for the last 3 months before each study, exhibit few changes between 1987 and 1990: number of partners remained stable, unprotected oral sex decreased. Anal sex slightly increased, the use of condoms remaining stable. Sixty-seven percent of the sample knew their serostatus in 1990 (57% in 1987), and 13% of these stated that they were HIV+ (14% in 1987).

The normalization of AIDS in Western European countries.

The occurrence of AIDS led in every Western European country to exceptional innovations in prevention, patient care, health policy and questions of civil rights. This exception can be explained above all by the fact that not only was a health catastrophe feared but also civilizational harm in the field of civil rights. Despite national differences, this brought about similar exceptionalist alliances consisting of health professionals, social movements and those affected. With the failure of a catastrophe to arise, signs of fatigue in the exceptionalist alliance and increasing possibilities of medical treatment, exceptionalism in Europe is drawing to a close. Four phases are distinguished between in this process, given nationally different patterns of development: Approx. 1981-1985: emergence of exceptionalism. The reasons underlying exceptionalism are investigated. Approx. 1986-1991: consolidation and performance of exceptionalism. The investigation centers on the exceptionalist policy model. Approx. 1991-1996: exceptionalism crumbling, steps toward normalization. The forces driving the process of normalization are investigated. Since 1996: normalization, normality. The forms and perspectives of the changes made in the management of HIV and AIDS are elucidated using examples from the fields of health care, primary prevention and drug policies. AIDS health-policy innovations, their risks and opportunities in the course of normalization are investigated. Three possible paths of development are identified: stabilization, generalization and retreat. The chances of utilizing innovations developed in connection with AIDS for the modernization of health policy in other fields of prevention and patient care vary from country to country with the degree to which AIDS exceptionalism has been institutionalized and the distance of these innovations from medical, therapeutic events.

Anxiety in a cohort of Swiss women participating in a mammographic screening programme.

OBJECTIVES: To follow up anxiety in a cohort of women screened for breast cancer. METHODS: Within the framework of a pilot screening programme for breast cancer in the Canton of Vaud (Switzerland), a cohort of 924 participants aged 50-70 years were invited to answer questions on anxiety related to mammography screening. Anxiety was measured using a specific tool, the psychological consequences questionnaire (PCQ), and a new single item, direct question, breast cancer anxiety indicator (BCA). Participants were asked to fill in the questionnaire at four different phases: at screening, before the result, and 2 and 8 weeks after the result. The final response rate was 93.7%. Predictors of anxiety at each phase were assessed using multiple regression. RESULTS: Among those screening negative (94.7%), anxiety at screening was very low and remained so during the screening process. Among those screening false positive, anxiety was significantly higher 8 weeks after having received a negative diagnosis. Predictors of anxiety before screening were lower education and higher age, with a strong exogenous anxiety component. For subsequent phases, the initial anxiety score and education were the main determinants. Furthermore, a false positive result at screening was the most important predictor of anxiety 2 months after negative diagnosis. Anxiety measured with the BCA was strongly correlated with the PCQ. CONCLUSION: Anxiety was very low at screening and remained so during the process for negative women. Initial anxiety level was a strong predictor of anxiety during the entire process, up to 8 weeks after a negative result, and could be easily assessed using the BCA. The sustained higher anxiety level among those screening false positive is an undesirable side effect of the programme.

Identifying adolescent drug users: results of a national survey on adolescent health in Switzerland.

OBJECTIVE: To explore the proportion and characteristics of adolescents who use illicit drugs and contrast them with adolescents who do not use such drugs in Switzerland. To facilitate the detection of adolescents with drug related difficulties. METHODS: We used data from a national survey on adolescent health in Switzerland (N = 9,273) conducted in 1992 and 1993. The survey is based on self-administered questionnaires among a representative sample of adolescents enrolled in schools and apprenticeship programs. We used exploratory analysis for identifying characteristics which set the drug user apart from non-users and performed confirmatory multivariate logistic regression analysis to examine which variables remain independently associated with heroin or cocaine use. RESULTS: In Switzerland, 3.1% of adolescents have taken heroin or cocaine at least once in their life, and 27.7% have already used cannabis. Analysis of lifestyles and health of adolescents show that young drug users present difficulties in integrating in society, have health problems and difficulties in relationships, situations which tend to be less common among other adolescents. Yet, they also display marked similarities, most notably in that over 70% had seen a physician in the past year. However, while 40% of the drug users expressed a need for help with drug related problems, only 6% had actually talked about them with a physician. Characteristics that remained independently associated with heroin and cocaine use after controlling for confounding factors were age, sex, nationality, type of education, feelings of suicide, past and present smoking, and use of cannabis. CONCLUSION: The level of illicit drug use among Swiss adolescents is high compared to other European countries but lower than the United States. Drug-using adolescents display a constellation of characteristics which should make it possible to identify them and offer help. Yet, even though they may have frequent contact with the health services, their drug problems are generally not recognized by the gatekeepers of the health services and no specific aid is available to them. Drug prevention must be intensified and medical doctors sensitized to the drug problems which adolescents may face.

Men having sex with men and HIV/AIDS prevention in Switzerland: 1987-2000.

Although the latest survey on prevention behaviours of men having sex with men (MSMs) in Switzerland shows a decreasing number of HIV cases since 1992, a decrease in the protection level has also been observed. This could lead to a higher rate of HIV notifications in 2001 compared to 2000.

[Evaluation of campaigns for the prevention of AIDS in Switzerland in 1987]. / Evaluation des campagnes de prévention du SIDA en Suisse en 1987.

Since 1985 the Swiss Federal Office of Public Health and the Swiss AIDS Foundation have been promoting AIDS prevention campaigns. A multi-media information campaign with the main slogan "STOP-AIDS" began in February 1987 and is still underway. Multiplying effects are stimulated. The evaluation of that strategy, based on 13 complementary studies, confirms its efficiency and feasibility. The evaluation process will continue in 1988. The campaign and its objectives reached the general population and the target groups. Noticeable changes in attitudes and behaviours are taking place in the way of better protection in various observed groups, moderately or strongly exposed to HIV infection. Condom sales have increased by nearly 60% in 1987 compared with 1986.

[Characteristics of attenders of low threshold syringe-exchange centers providing sterile syringes in Switzerland]. / Caractéristiques de la clientèle des structures à bas seuil d'accès pour toxicomanes mettant à disposition du matériel d'injection stérile en Suisse.

BACKGROUND: The objectives of the present study were to evaluate Aids prevention in drug users attending low threshold centres providing sterile injection equipment in Switzerland, to identify the characteristics of these users, and to monitor the progress of indicators of drug-related harm. METHODS: This paper presents results from a cross-sectional survey carried out in 1994. RESULTS: The mean age of attenders was 28 years, and women represented 27% of the sample. 75% of attenders used a combination of hard drugs (heroin and cocaine). Mean duration of heroin consumption was 8 years, and of cocaine 7 years; 76% of attenders had a fixed abode, but only 34% had stable employment; 45% were being treated with methadone; 9% had shared their injection material in the last 6 months; 24% always used condoms in the case of a stable relationship, and 71% in casual relationships. In a cluster analysis constructed on the basis of multiple correspondence analysis, two distinct profiles of users emerge: highly marginalised users with a high level of consumption (21%); irregular users, better integrated socially, of which the majority are under methadone treatment (79%). CONCLUSION: Theses centres play a major role in Aids prevention. Nevertheless, efforts to improve the hygiene conditions of drug injection in Switzerland should be pursued and extended. At the same time, prevention of HIV sexual transmissions should be reinforced.

Assessing AIDS/HIV prevention: what do we know in Europe?

An EC concerted action on the assessment of AIDS/HIV prevention strategies was conducted between 1989 and 1992. The aim of this concerted action (CA) was to bring together researchers who are active in this assessment field, make an initial appraisal of the results of AIDS prevention efforts, in various population groups in Europe and develop an assessment methodology. Five areas of study were selected for the CA: the population as a whole ("general population"), men who have sexual relations with other men, intravenous drug users, migrant populations, monitoring of sexually transmitted diseases (STDs) to determine changes in behaviour. For each of these areas, a working group composed of the leading researchers in the field in Europe was constituted and commissioned by the project administration and coordination team to collate and analyse data on prevention efforts and their assessment in different countries of Europe. This review presents the main results from the groups responsible in each area in the concerted action. A number of general conclusions from the results of this concerted action are drawn.