Socio-economic factors associated with loss to follow-up among individuals with HCV: A Dutch nationwide cross-sectional study.

BACKGROUND AND AIMS: The path to hepatitis C virus (HCV) elimination is complicated by individuals who become lost to follow-up (LTFU) during care, particularly before receiving effective HCV treatment. We aimed to determine factors contributing to LTFU and whether LTFU is associated with mortality. METHODS: In this secondary analysis, we constructed a database including individuals with HCV who were either LTFU (data from the nationwide HCV retrieval project, CELINE) or treated with directly acting antivirals (DAA) (data from Statistics Netherlands) between 2012 and 2019. This database was linked to mortality data from Statistics Netherlands. Determinants associated with being LTFU versus DAA-treated were assessed using logistic regression, and mortality rates were compared between groups using exponential survival models. These analyses were additionally stratified on calendar periods: 2012-2014, 2015-2017 and 2018-2019. RESULTS: About 254 individuals, LTFU and 5547 DAA-treated were included. Being institutionalized (OR = 5.02, 95% confidence interval (CI) = 3.29-7.65), household income below the social minimum (OR = 1.96, 95% CI = 1.25-3.06), receiving benefits (OR = 1.74, 95% CI = 1.20-2.52) and psychiatric comorbidity (OR = 1.51, 95% CI = 1.09-2.10) were associated with LTFU. Mortality rates were significantly higher in individuals LTFU compared to those DAA-treated (2.99 vs. 1.15/100 person-years (PY), p < .0001), while in those DAA-treated, mortality rates slowly increased between 2012-2014 (.22/100PY) and 2018-2019 (2.25/100PY). CONCLUSION: In the Netherlands, individuals who are incarcerated/institutionalized, with low household income, or with psychiatric comorbidities are prone to being LTFU, which is associated with higher mortality. HCV care needs to be adapted for these vulnerable individuals.

Long-term evolution of comorbidities and their disease burden in individuals with and without HIV as they age: analysis of the prospective AGEhIV cohort study.

BACKGROUND: People with HIV generally have more ageing-associated comorbidities than those without HIV. We aimed to establish whether the difference in comorbidities and their disease burden changes with ageing. METHODS: In this prospective, longitudinal cohort study, we assessed comorbidities commonly associated with ageing every 2 years in 596 HIV-positive and 550 HIV-negative participants. HIV-positive participants were recruited from the HIV outpatient clinic of the Amsterdam University Medical Centres (Amsterdam, Netherlands). HIV-negative participants were recruited from the sexual health clinic and the Amsterdam Cohort Studies at the Public Health Service of Amsterdam (Amsterdam, Netherlands). Inclusion criteria were participants aged 45 years or older and, for HIV-negative participants, a documented HIV-negative antibody test. The mean number of comorbidities present over time was compared between groups by use of Poisson regression, accounting for dropout and death through joint survival models. Mean disability-adjusted life-years (DALYs) accrued during 2-year intervals were compared between groups by use of an exponential hurdle model. FINDINGS: Between Oct 29, 2010, and Oct 9, 2012, participants were enrolled and then prospectively followed up until their last visit before Oct 1, 2018. 1146 participants were followed up for a median 5·9 years (IQR 5·7-6·0), during which 231 participants (20·2%) dropped out: 145 (24·3%) of 596 HIV-positive and 86 (15·6%) of 550 HIV-negative. 38 (3·3%) of 1146 participants died: 31 (5·2%) of 596 HIV-positive and seven (1·3%) of 550 HIV-negative. 24 HIV-positive and two HIV-negative participants died from ageing-associated comorbidities. 15 HIV-positive participants versus one HIV-negative participant died from non-AIDS malignancies. At inclusion, mean number of comorbidities was higher in HIV-positive participants (0·65) than in HIV-negative participants (0·32; p<0·0001). Mean number of comorbidities increased at similar rates over time: rate ratio (RR) per year for HIV-positive participants 1·04 (95% CI 1·00-1·08), RR per year for HIV-negative participants 1·05 (1·01-1·08; pinteraction=0·78). Number of comorbidities was associated with an increased risk of death (hazard ratio 3·33 per additional comorbidity, 95% CI 2·27-4·88; p<0·0001). HIV-positive participants had higher increases in mean DALYs than HIV-negative participants (0·209 per year, 95% CI 0·162-0·256 vs 0·091 per year, 0·025-0·157; pinteraction=0·0045). This difference was reduced when deaths were excluded in establishing DALYs (0·127, 0·083-0·171 vs 0·066, 0·005-0·127; pinteraction =0·11). INTERPRETATION: The larger comorbidity prevalence in HIV-positive participants aged 50-55 years on effective antiretroviral treatment than in HIV-negative participants increased similarly as participants aged and was associated with an increased risk of death, particularly of non-AIDS malignancies. Our findings reinforce the need for strategies to optimise prevention, screening, and early intervention. FUNDING: Netherlands Organization for Health Research and Development, Aidsfonds, Gilead Sciences, ViiV Healthcare, Janssen Pharmaceuticals, and Merck & Co. TRANSLATION: For the Dutch translation of the abstract see Supplementary Materials section.

Time for change: Transitions between HIV risk levels and determinants of behavior change in men who have sex with men.

As individual sexual behavior is variable over time, the timing of interventions might be vital to reducing HIV transmission. We aimed to investigate transitions between HIV risk levels among men who have sex with men (MSM), and identify determinants associated with behavior change. Participants in a longitudinal cohort study among HIV-negative MSM (Amsterdam Cohort Studies) completed questionnaires about their sexual behavior during biannual visits (2008-2017). Visits were assigned to different HIV risk levels, based on latent classes of behavior. We modelled transitions between risk levels, and identified determinants associated with these transitions at the visit preceding the transition using multi-state Markov models. Based on 7,865 visits of 767 participants, we classified three risk levels: low (73% of visits), medium (22%), and high risk (5%). For MSM at low risk, the six-month probability of increasing risk was 0.11. For MSM at medium risk, the probability of increasing to high risk was 0.08, while the probability of decreasing to low risk was 0.33. For MSM at high risk, the probability of decreasing risk was 0.43. Chemsex, erection stimulants and poppers, high HIV risk perception, and recent STI diagnosis were associated with increased risk at the next visit. High HIV risk perception and young age were associated with decreasing risk. Although the majority of MSM showed no behavior change, a considerable proportion increased HIV risk. Determinants associated with behavior change may help to identify MSM who are likely to increase risk in the near future and target interventions at these individuals, thereby reducing HIV transmission.

Burden of living with HIV among men who have sex with men: a mixed-methods study.

BACKGROUND: With biomedical developments in treatment and prevention of HIV, the implications of living with HIV are considerably more manageable. Within this context, we aimed to describe and quantify the present-day burden of living with HIV among men who have sex with men (MSM) in the Netherlands. METHODS: In this mixed-methods study, we did in-depth interviews on HIV-related burden with MSM diagnosed with HIV between 2014 and 2018. Interviewees were recruited at three HIV treatment centres and the Public Health Service of Amsterdam in the Netherlands. Using the transcripts from all interviewees, the qualitative analysis was done by two independent researchers applying an open-coding process. Results were used to generate a questionnaire measuring HIV-related burden, which was distributed via gay dating apps or sites and social media. MSM diagnosed with HIV before 2019 who completed the questionnaire were included in the quantitative analyses. Descriptive analyses were used to report burden prevalence and to explore differences in burden among MSM diagnosed at different antiretroviral therapy periods. Sociodemographic determinants of burden were explored using multinomial logistic regression. FINDINGS: Between May, 2018, and March, 2019, 18 of 25 MSM who consented for further contact were interviewed, after which thematic saturation was reached. The interviewees revealed that aspects related to medicalisation and emotional consequences were burdensome temporarily after diagnosis, whereas aspects related to HIV status disclosure, stigma, and the sexual and social life were mentioned to be burdensome more persistently. Between April and July, 2019, 613 MSM with HIV started the quantitative survey, of whom 438 (71%) completed the questionnaire and were included in the analyses. These 438 MSM were diagnosed with HIV between 1984 and 2018. The median time since HIV diagnosis was 8 years (IQR 4-13). In total, 135 (31%) of 438 online respondents reported that living with HIV was generally experienced as burdensome and 361 (82%) would be relieved if HIV could be cured. Compared with a low level of burden, a moderate level of burden was associated with having another chronic condition (p=0·0030), and a high level of burden was associated with a more recent diagnosis (p=0·0060) and not knowing other individuals with HIV (p=0·0020). Disclosure dilemmas were reported to be the most burdensome, resulting in difficulties initiating sex (122 [32%] of 378 respondents) and establishing relationships (85 [41%] of 207 respondents). The most prevalent emotional consequences were shame (112 [26%] of 438 respondents) and stress (80 [18%] of 438 respondents). Disclosure and taking antiretroviral therapy in the presence of others were experienced as more burdensome among those diagnosed after 2005 than among those diagnosed in or before 2005. INTERPRETATION: Our findings highlight that despite medical advancements, further stigma reduction programmes and adapted psychosocial support for specific profiles of MSM living with HIV are needed. FUNDING: HIV Transmission Elimination Amsterdam Initiative.

Knowledge and use of antibiotics in six ethnic groups: the HELIUS study.

Background: The increase of antimicrobial resistance, mainly due to increased antibiotic use, is worrying. Preliminary evidence suggests that antibiotic use differs across ethnic groups in the Netherlands, with higher use in people of non-Dutch origin. We aimed to determine whether appropriate knowledge and use of antibiotics differ by ethnicity and whether knowledge on antibiotics is associated with antibiotic use. Methods: We performed a cross-sectional study analyzing baseline data (2011-2015) from a population-based cohort (HELIUS study), which were linked to data from a health insurance register. We included 21,617 HELIUS participants of South-Asian Surinamese, African-Surinamese, Turkish, Moroccan, Ghanaian, and Dutch origin. Fifteen thousand seven participants had available prescription data from the Achmea Health Data-base (AHD) in the year prior to their HELIUS study visit. Participants were asked five questions on antibiotic treatment during influenza-like illness, pneumonia, fever, sore throat and bronchitis, from which higher versus lower antibiotic knowledge level was determined. Number of antibiotic prescriptions in the year prior to the HELIUS study visit was used to determine antibiotic use. Results: The percentage of individuals with a higher level of antibiotic knowledge was lower among all ethnic minority groups (range 57 to 70%) compared to Dutch (80%). After correcting for baseline characteristics, including medical conditions, first-generation African Surinamese and Turkish migrants received a significantly lower number of antibiotic prescriptions compared to individuals of Dutch origin. Only second-generation Ghanaian participants received more prescriptions compared to Dutch participants (aIRR 2.09, 95%CI 1.06 to 4.12). Higher level of antibiotic knowledge was not significantly associated with the number of prescriptions (IRR 0.92, 95%CI 0.85 to 1.00). Conclusions: Levels of antibiotic knowledge varied between ethnic groups, but a lower level of antibiotic knowledge did not correspond with a higher number of antibiotic prescriptions.

Progression of liver fibrosis following acute hepatitis C virus infection in HIV-positive MSM.

BACKGROUND: Whether continued, accelerated liver fibrosis progression occurs following acute hepatitis C virus infection (AHCVI) in HIV-positive MSM is unknown. DESIGN AND METHODS: HIV-positive MSM from the AIDS Therapy Evaluation in the Netherlands and MSM Observational Study for Acute Infection with Hepatitis C-cohorts with primary AHCVI and at least one fibrosis-4 (FIB-4) measurement less than 2 years before and 1 year after estimated AHCVI were included. Mixed-effect linear models were used to evaluate (time-updated) determinants of FIB-4 levels over time. Determinants of transitioning to and from FIB-4 ≤ 1.45 and > 1.45 were examined using multistate Markov models. RESULTS: Of 313 MSM, median FIB-4 measurements per individual was 12 (interquartile range  = 8-18) and median follow-up following AHCVI was 3.5 years (interquartile range = 1.9-5.6). FIB-4 measurements averaged at 1.00 [95% confidence interval (CI) = 0.95-1.05] before AHCVI, 1.31 (95% CI = 1.25-1.38) during the first year of AHCVI and 1.10 (95% CI = 1.05-1.15) more than 1 year after AHCVI. Mean FIB-4 more than 1 year after AHCVI was higher for chronically infected patients compared with those successfully treated (P = 0.007). Overall FIB-4 scores were significantly higher with older age, lower CD4 cell count, longer duration from HIV-diagnosis or AHCVI, and nonresponse to HCV-treatment. At the end of follow-up, 60 (19.2%) and eight MSM (2.6%) had FIB-4 between 1.45-3.25 and ≥ 3.25, respectively. Older age, lower CD4 cell count and detectable HIV-RNA were significantly associated with higher rates of progression to FIB-4 > 1.45, whereas older age, longer duration from HIV-diagnosis and nonresponse to HCV-treatment were significantly associated with lower rates of regression to FIB-4 ≤ 1.45. CONCLUSION: In this population of HIV-positive MSM, FIB-4 scores were higher during the first year of AHCVI, but FIB-4 ≥ 3.25 was uncommon by the end of follow-up. Well controlled HIV-infection appears to attenuate FIB-4 progression.

Gender differences in common mental disorders: a comparison of social risk factors across four European welfare regimes.

BACKGROUND: Decreasing gender differences in mental health are found largely in countries in which the roles of men and women have improved in terms of opportunities for employment, education, child care and other indicators of increasing gender equality. In this study, we examine how European welfare regimes influence this association between mental health and the social roles that men and women occupy. METHODS: The EU-World Mental Health data are used, which covers the general population in 10 European countries (n = 37 289); Countries were grouped into four welfare regions: Liberal regime (Northern Ireland), Bismarckian regime (Belgium, Germany, the Netherlands and France), Southern regime (Spain, Italy, Portugal) and Central-Eastern regime (Romania and Bulgaria). The lifetime prevalence of mood, anxiety and alcohol disorders was determined by using the Composite International Diagnostic Interview 3.0. Overall prevalence rates along with odds ratios by means of bivariate logistic regression models are calculated to compare the presence of common mental disorders in women versus men per welfare regime. RESULTS: Overall prevalence of common mental disorders is highest in the Liberal regime and lowest in the Central/Eastern regime. The gender gap in mental disorders is largest in the Southern regime and smallest in the Liberal regime. Marital status and certain employment positions help to explain variation in mental disorders across and within welfare regimes. CONCLUSION: Most prominent pathways linking gender to mental ill-health being are related to marital status and certain employment positions. However, these pathways also show substantial variation across welfare regimes.

Current state of and needs for hepatitis B screening: results of a large screening study in a low-prevalent, metropolitan region.

BACKGROUND: In low hepatitis B virus (HBV)-prevalent countries, most HBV-infected persons are unaware of their status. We aimed to evaluate whether (i) previous HBV-testing, (ii) physicians decision to screen, and (iii) CDC's recommendations identified infected individuals and which risk-factor groups needing testing. METHODS: During a mass, multi-center HBV-screening study from September 2010-August 2011, 3929 participants were screened for hepatitis B surface antigen (HBsAg), anti-HBs and anti-Hepatitis B core antibodies (anti-HBcAb). Questions on HBV risk-factors and testing practices were asked to participants, while participants' eligibility for HBV-testing was asked to study medical professionals. RESULTS: 85 (2.2%) participants were HBsAg-positive, while 659 (16.8%) had either resolved HBV infection or isolated anti-HBcAb. When comparing practices, HBV-testing was more likely to occur in HBV-infected participants if Centers for Disease Control and Prevention (CDC) recommendations were used (Sensitivity = 100%, 95%CI: 95.8-100) than physicians' discretion (Sensitivity = 87.1%, 95%CI: 78.0-93.4) or previous HBV-test (Sensitivity = 36.5%, 95%CI: 26.3-47.6) (p<0.0001). Nevertheless, many non-infected individuals would still have been screened using CDC-recommendations (Specificity = 31.1%, 95%CI: 29.6-32.6). Using multivariable logistic regression, HBsAg-positive status was significantly associated with the following: males, originating from high HBV-endemic region, contact with HBV-infected individual, without national healthcare, and intravenous-drug user (IDU). Of these risk-factors, physician's discretion for testing HBV was not significantly associated with participants' geographical origin or IDU. CONCLUSIONS: Missed opportunities of HBV-screening are largely due to underestimating country of origin as a risk-factor. Applying CDC-recommendations could improve HBV-screening, but with the disadvantage of many tests. Further development of HBV-testing strategies is necessary, especially before severe disease occurs.