Determinants of Repeating an HIV Test Among Gay, Bisexual, and Other Men Who have Sex with Men, and Transgender People Who Use an Online-Requested Self-Sampling Program and Attending Community-Based Testing Venues in Spain (2018-2021).

Our aims were: (1) to characterize gay, bisexual and other men who have sex with men (GBMSM) and transgender (TG) populations using internet-based self-sampling services in the TESTATE project or attending community-based STI/HIV voluntary counselling and testing (CBVCT) services as alternative strategies to formal HIV testing within the Spanish national health system, and (2) to identify factors associated with repeat use of the same screening strategy from November 2018 to December 2021. Demographic, health, and behavioral characteristics of users using complementary strategies were analyzed. We developed a cross-sectional study, with descriptive analysis, HIV cascade, and a multivariate logistic model to identify factors associated with participants' repeated use of the same screening strategy. We included 9939 users, of whom 94.1% were GBMSM (n = 9348) and 5.9% TG (n = 580), with a high representation of migrants. Reactive results were 3.4% (n = 340), with 3.0% in GBMSM (n = 277/9348) and 10.7% in TG (n = 63/591). 73.8% (n = 251) were confirmed HIV positive and 76.7% (n = 194) were linked to health services. Users repeated the online screening strategy more than CBVCT (44.3% vs. 31.8%), but TG population used face-to-face community services more (8.4% vs. 0.6%). Factors influencing the repetition of the online self-sampling strategy included older age, non-migrant status, and recent HIV testing. In the CBVCT strategy, factors included older age, TG identity, non-migrant status, condom use during the last sexual encounter, and recent HIV testing. In conclusion, both CBVCT and online-requested self-sampling at home are important alternatives to the health system for the provision of HIV testing to GBMSM and TG.

An Online HIV Self-Sampling Strategy for Gay, Bisexual and Other Men Who Have Sex with Men and Trans Women in Spain.

We aimed to evaluate the feasibility of an online self-sampling pilot intervention for HIV testing addressed to gay, bisexual, and other men who have sex with men (GBMSM) and trans women (TW) users of dating apps in Spain. The website https://www.testate.org/ was designed to offer self-sampling kits for HIV testing and online consultation of the results. It was advertised on gay dating apps. Participants requested the delivery of a saliva self-sampling kit by mail and a postage-paid envelope to send the sample to the reference laboratory. An anonymous acceptability survey was conducted. The cascade of care was estimated. From November 2018 to December 2021, 4623 individual users ordered self-sampling kits, 3097 returned an oral fluid sample to the reference laboratory (67.5% return rate). 87 reactive results were detected. 76 were confirmed to be HIV-positive, we estimated an HIV prevalence of 2.45% (95% CI 1.9-3.0%). 100% of those referred to specialized care are in treatment. 45.8% of participants took more than one test. 23 incident cases were detected among repeat testers, of which 20 were confirmed. The estimated incidence was 1.00 confirmed case per 100 individual-years of follow-up. 98.01% of participants would recommend it to a friend. The most identified advantages were convenience and privacy. We demonstrated that the online offer of oral self-sampling kits for HIV detection and reporting results online among GBMSM and TW users of dating apps is feasible. The intervention counted with a high acceptability and high efficacy (in terms of reactivity, confirmation and linkage to care rates).

Who is lost to follow-up in HIV care? Assessment of care retention over time and the impact of COVID-19. Longitudinal analysis of the PISCIS cohort.

INTRODUCTION: People living with HIV who are lost to follow-up have a greater risk of health deterioration, mortality, and community transmission. OBJECTIVE: Our aim was to analyse both how rates of loss to follow-up (LTFU) changed between 2006 and 2020 and how the COVID-19 pandemic affected these rates in the PISCIS cohort study of Catalonia and the Balearic Islands. METHODS: We analysed socio-demographic and clinical characteristics of LTFU yearly and with adjusted odds ratios to assess the impact of these determinants on LTFU in 2020 (the year of COVID-19). We used latent class analysis to categorize classes of LTFU based on their socio-demographic and clinical characteristics at each year. RESULTS: In total, 16.7% of the cohort were lost to follow-up at any time in the 15 years (n = 19 417). Of people living with HIV who were receiving follow-up, 81.5% were male and 19.5% were female; of those who were lost to follow-up, 79.6% and 20.4% were male and female, respectively (p < 0.001). Although rates of LTFU increased during COVID-19 (1.11% vs. 0.86%, p = 0.024), socio-demographic and clinical factors were similar. Eight classes of people living with HIV who were lost to follow-up were identified: six for men and two for women. Classes of men (n = 3) differed in terms of their country of birth, viral load (VL), and antiretroviral therapy (ART); classes of people who inject drugs (n = 2) differed in terms of VL, AIDS diagnosis, and ART. Changes in rates of LTFU included higher CD4 cell count and undetectable VL. CONCLUSIONS: The socio-demographic and clinical characteristics of people living with HIV changed over time. Although the circumstances of the COVID-19 pandemic increased the rates of LTFU, the characteristics of these people were similar. Epidemiological trends among people who were lost to follow-up can be used to prevent new losses of care and to reduce barriers to achieve Joint United Nations Programme on HIV/AIDS 95-95-95 targets.

Egocentric sexual network analysis among gay and bisexual men who have sex with men with and without mpox infection.

OBJECTIVES: Recent outbreaks of the mpox (monkeypox) virus have been detected in dense sexual networks of gay and bisexual men who have sex with men (GBMSM). The objective of this study is to describe and compare the epidemiological and behavioural characteristics, as well as the sexual networks, of GBMSM diagnosed with mild mpox in Spain. METHODS: A prospective case-control study was conducted in Spain from July 2022 to February 2023. The study targeted a key population of GBMSM aged 18 years or older. Study participants were categorised into cases, those who were diagnosed with mpox virus infection; and controls, those who were not diagnosed. We examined and compared the sexual network characteristics of the two groups-mpox-positive (mpox-P) and mpox-negative (mpox-N) egos-using χ2, t-test and Wilcoxon test to examine the differences between the two groups in each section. Finally, we conducted univariable and multivariable logistic regressions to determine the factors associated with mpox infection. RESULTS: Among the 105 participants, 35 (33.3%) were mpox-P. Compared with mpox-N, mpox-P respondents more frequently reported syphilis (mpox-P: 31.4%; mpox-N: 12.9%) and HIV (mpox-P: 45.7%; mpox-N: 18.6%), and mpox-P individuals to have had at least one sexual contact with a confirmed mpox case (mpox-P: 62.5%; mpox-N: 8.3%). In the egocentric network analysis, mpox-P respondents had a higher prevalence of group sex with alters (mpox-P: 18.5%; mpox-N: 8.9%) and one-time sexual partners (mpox-P: 46.1%; mpox-N: 31.7%). Multivariable logistic regressions showed that reporting stranger/client ties (adjusted OR (aOR)=10.3, 95% CI 1.39 to 76.6) with alters, being vaccinated for mpox (aOR=0.07, 95% CI 0.02 to 0.24) and tie strength heterogeneity (aOR=0.01, 95% CI 0.00 to 0.42) were associated with mpox infection. CONCLUSIONS: Our findings highlight the role of demographic, epidemiological and sexual network characteristics in the transmission of mpox virus during the outbreak in Spain. These findings have important implications for future prevention efforts.

Syndemic conditions and quality of life in the PISCIS Cohort of people living with HIV in Catalonia and the Balearic Islands: a cross sectional study.

BACKGROUND: People living with HIV (PLWH) face structural and psychosocial factors that affect health-related quality of life (HRQoL). We aimed to evaluate how syndemic conditions affected HRQoL in PLWH. METHODS: A cross-sectional survey was conducted among 861 PLWH, to determine whether syndemic conditions (monthly income; sexual satisfaction; depressive symptoms; social role satisfaction; social isolation; cognitive function; nicotine dependence; perception of stigma) have an effect on HRQoL. A linear regression model and measures of Additive Interaction (AI) were used to determine the effects of syndemic conditions on HRQoL, controlling for other risk factors. RESULTS: Overall, the most frequently observed were stigma perception (56.9%), poor cognitive function (50.6%) and the perception of social isolation (51.6%). The presence of depressive symptoms was the risk factor most associated with worse Physical Health (PH) (B 3.93, 2.71-5.15) and Mental Health (MH) (B 5.08, 3.81-6.34) in linear regression model. Specifically, an interaction was observed between poor cognitive function and poor satisfaction with social role on worse PH and MH (AI 2.08, 0.14-4.02; AI 2.69, 0.15-5.22, respectively); and low income and perception of stigma (AI 2.98, 0.26-5.71), low income and perception of social isolation (AI 2.79, 0.27-5.32), and low income and poor satisfaction with social role (AI 3.45, 0.99-5.91) on MH. CONCLUSION: These findings provide evidence that syndemic factors impact HRQoL. HIV prevention programs should screen and address co-occurring health problems to improve patient-centered health care and outcomes.

Population-based assessment of SARS-CoV-2 infection among people living with HIV and the general population of Catalonia (March-December, 2020).

Introduction: It is unclear if SARS-CoV-2 has affected people living with HIV (PLWH) more. Methods: We compared SARS-CoV-2 testing, test positivity, hospitalisation, intensive care unit (ICU) admission, and mortality between PLWH and the general HIV-negative population of Catalonia, Spain from March 1 to December 15, 2020. Results: SARS-CoV-2 testing was lower among PLWH 3556/13,142 (27.06%) compared to the general HIV-negative population 1,954,902/6,446,672 (30.32%) (p < 0.001) but test positivity was higher among PLWH (21.06% vs. 15.82%, p < 0.001). We observed no significant differences between PLWH and the general population in terms of hospitalisation (13.75% vs. 14.97%, p = 0.174) and ICU admission (0.93% vs. 1.66%, p = 0.059). Among positive cases, we found a lower mortality rate among PLWH compared to the general population (1.74% vs 3.64%, p = 0.002). Conclusion: PLWH tested less frequently for SARS-CoV-2, had a higher test positivity, similar ICU admission and hospitalisation rates, and lower SARS-CoV-2-associated mortality compared to the general HIV-negative population.

Introducción: No está claro si el SARS-CoV-2 ha afectado más a las personas que viven con VIH (PVV). Métodos: Se compararon los test realizados de SARS-CoV-2, la positividad de la prueba, la hospitalización, los ingresos en la unidad de cuidados intensivos (UCI), las tasas de mortalidad entre PVV y la población general de Cataluña desde el 1 de marzo hasta el 15 de diciembre de 2020. Resultados: Los test realizados de SARS-CoV-2 fueron menos entre PVV 3.556/13.142 (27.06%) comparado con la población general de Cataluña 1.954.902/6.446.672 (30,32%) (p < 0,001), pero la positividad de la prueba de SARS-CoV-2 fue mayor entre las PVV (21,06 vs. 15,82%; p < 0,001). No se observaron diferencias estadísticamente significativas entre PVV y la población general en cuanto a hospitalizaciones (13,75 vs. 14,97%; p = 0,174) e ingresos en la UCI (0,93 vs. 1,66%; p = 0,059). Entre los casos positivos, se encontró una menor tasa de mortalidad entre las PVV en comparación con la población general (1,74 vs. 3,64%; p = 0,002). Conclusiones: Las PVV fueron testadas menos frecuentemente por SARS-CoV-2 que la población general, tuvieron una tasa de positividad más elevada, tasas similares de hospitalización e ingresos en la UCI, y menos mortalidad asociada al SARS-CoV-2.

Impact of tenofovir on SARS-CoV-2 infection and severe outcomes among people living with HIV: a propensity score-matched study.

BACKGROUND: Reports on the impact of some antiretrovirals against SARS-CoV-2 infection and disease severity are conflicting. OBJECTIVES: We evaluated the effect of tenofovir as either tenofovir alafenamide/emtricitabine (TAF/FTC) or tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) against SARS-CoV-2 infection and associated clinical outcomes among people living with HIV (PLWH). METHODS: We conducted a propensity score-matched analysis in the prospective PISCIS cohort of PLWH (n = 14 978) in Catalonia, Spain. We used adjusted Cox regression models to assess the association between tenofovir and SARS-CoV-2 outcomes. RESULTS: After propensity score-matching, SARS-CoV-2 diagnosis rates were similar in TAF/FTC versus ABC/3TC recipients (11.6% versus 12.5%, P = 0.256); lower among TDF/FTC versus ABC/3TC recipients (9.6% versus 12.8%, P = 0.021); and lower among TDF/FTC versus TAF/FTC recipients (9.6% versus 12.1%, P = 0.012). In well-adjusted logistic regression models, TAF/FTC was no longer associated with reduced SARS-CoV-2 diagnosis [adjusted odds ratio (aOR) 0.90; 95% confidence interval (CI), 0.78-1.04] or hospitalization (aOR 0.93; 95% CI, 0.60-1.43). When compared with ABC/3TC, TDF/FTC was not associated with reduced SARS-CoV-2 diagnosis (aOR 0.79; 95% CI, 0.60-1.04) or hospitalization (aOR 0.51; 95% CI, 0.15-1.70). TDF/FTC was not associated with reduced SARS-CoV-2 diagnosis (aOR 0.79; 95% CI, 0.60-1.04) or associated hospitalization (aOR 0.33; 95% CI, 0.10-1.07) compared with TAF/FTC. CONCLUSIONS: TAF/FTC or TDF/FTC were not associated with reduced SARS-CoV-2 diagnosis rates or associated hospitalizations among PLWH. TDF/FTC users had baseline characteristics intrinsically associated with more benign SARS-CoV-2 infection outcomes. Tenofovir exposure should not modify any preventive or therapeutic SARS-CoV-2 infection management.

Knee and hip osteoarthritis and risk of nine cancers in a large real-world matched cohort study.

OBJECTIVES: Joint replacement due to end-stage OA has been linked to incidence of several cancers. We aimed to estimate the association between newly diagnosed knee and hip OA and incidence of nine common cancer types. METHODS: We identified persons with incident knee or hip OA, aged ≥40 years, between 2009 and 2015 in the SIDIAP database in Catalonia, Spain. We matched up to three OA-free controls on age, sex and general practitioner. We followed participants from 1 year after OA diagnosis until migration, death, end of study at 31 December 2017 or incident cancer of: stomach, colorectal, liver, pancreas, lung, skin, breast, prostate and bladder. We used flexible parametric survival models, adjusted for confounders. Estimates were corrected for misclassification using probabilistic bias analysis. RESULTS: We included 117 750 persons with knee OA and matched 309 913 persons without, with mean (s.d.) age of 67.5 (11.1) years and 63% women. The hip cohort consisted of 39 133 persons with hip OA and 116 713 controls. For most of the included cancers, the hazard ratios (HRs) were close to 1. The HR of lung cancer for knee OA exposure was 0.80 (95% CI: 0.71, 0.89) and attenuated to 0.98 (0.76, 1.27) in non-smokers. The hazard of colorectal cancer was lower in persons with both knee and hip OA by 10-20%. CONCLUSIONS: Knee and hip OA are not associated with studied incident cancers, apart from lower risk of colorectal cancer. The often-reported protective association of knee OA with lung cancer is explained by residual confounding.

Air pollution and green spaces in relation to breast cancer risk among pre and postmenopausal women: A mega cohort from Catalonia.

BACKGROUND: The association between air pollution and green spaces with breast cancer risk stratified by menopausal status has not been frequently investigated despite its importance given the different impact of risk factors on breast cancer risk depending on menopausal status. OBJECTIVES: To study the association between air pollution, green spaces and pre and postmenopausal breast cancer risk. METHODS: We conducted a population-based cohort study using electronic primary care records in Catalonia. We included women aged 17-85 years free of cancer at study entry between 2009 and 2017. Our exposures were particulate matter <2.5 µm (PM2.5) & <10 µm (PM10), nitrogen dioxide (NO2), normalized difference vegetation index (NDVI), and percentage of green spaces estimated at the census tract level. Breast cancer was identified with ICD-10 code C50. We estimated cause-specific hazard ratios (HR) for the relationship between each individual exposure and pre and postmenopausal breast cancer risk, using linear and non-linear models. RESULTS: Of the 1,054,180 pre and 744,658 postmenopausal women followed for a median of 10 years, 6,126 and 17,858 developed breast cancer, respectively. Among premenopausal women, only very high levels of PM10 (≥46 µg/m3) were associated with increased cancer risk (compared to lower levels) in non-linear models. Among postmenopausal women, an interquartile range increase in PM2.5 (HR:1.03; 95%CI:1.01-1.04), PM10 (1.03; 1.01-1.05), and NO2 (1.05; 1.02-1.08) were associated with higher cancer risk. NDVI was negatively associated with decreased cancer risk only among postmenopausal women who did not change residence during follow-up (0.84; 0.71-0.99) or who were followed for at least three years (0.82; 0.69-0.98). DISCUSSION: Living in areas with high concentrations of PM2.5, PM10, and NO2 increases breast cancer risk in postmenopausal women while long-term exposure to green spaces may decrease this risk. Only very high concentrations of PM10 increase breast cancer risk in premenopausal women.

Household Severe Acute Respiratory Syndrome Coronavirus 2 Transmission and Children: A Network Prospective Study.

BACKGROUND: The role of children in household transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) remains unclear. We describe the epidemiological and clinical characteristics of children with coronavirus disease 2019 (COVID-19) in Catalonia, Spain, and investigate the household transmission dynamics. METHODS: A prospective, observational, multicenter study was performed during summer and school periods (1 July 2020-31 October 2020) to analyze epidemiological and clinical features and viral household transmission dynamics in COVID-19 patients aged <16 years. A pediatric index case was established when a child was the first individual infected. Secondary cases were defined when another household member tested positive for SARS-CoV-2 before the child. The secondary attack rate (SAR) was calculated, and logistic regression was used to assess associations between transmission risk factors and SARS-CoV-2 infection. RESULTS: The study included 1040 COVID-19 patients. Almost half (47.2%) were asymptomatic, 10.8% had comorbidities, and 2.6% required hospitalization. No deaths were reported. Viral transmission was common among household members (62.3%). More than 70% (756/1040) of pediatric cases were secondary to an adult, whereas 7.7% (80/1040) were index cases. The SAR was significantly lower in households with COVID-19 pediatric index cases during the school period relative to summer (P = .02) and compared to adults (P = .006). No individual or environmental risk factors associated with the SAR. CONCLUSIONS: Children are unlikely to cause household COVID-19 clusters or be major drivers of the pandemic, even if attending school. Interventions aimed at children are expected to have a small impact on reducing SARS-CoV-2 transmission.

Body mass index and waist circumference in relation to the risk of 26 types of cancer: a prospective cohort study of 3.5 million adults in Spain.

BACKGROUND: A high body mass index (BMI) has been associated with increased risk of several cancers; however, whether BMI is related to a larger number of cancers than currently recognized is unclear. Moreover, whether waist circumference (WC) is more strongly associated with specific cancers than BMI is not well established. We aimed to investigate the associations between BMI and 26 cancers accounting for non-linearity and residual confounding by smoking status as well as to compare cancer risk estimates between BMI and WC. METHODS: Prospective cohort study with population-based electronic health records from Catalonia, Spain. We included 3,658,417 adults aged ≥ 18 years and free of cancer at baseline between 2006 and 2017. Our main outcome measures were cause-specific hazard ratios (HRs) with 99% confidence intervals (CIs) for incident cancer at 26 anatomical sites. RESULTS: After a median follow-up time of 8.3 years, 202,837 participants were diagnosed with cancer. A higher BMI was positively associated with risk of nine cancers (corpus uteri, kidney, gallbladder, thyroid, colorectal, breast post-menopausal, multiple myeloma, leukemia, non-Hodgkin lymphoma) and was positively associated with three additional cancers among never smokers (head and neck, brain and central nervous system, Hodgkin lymphoma). The respective HRs (per 5 kg/m2 increment) ranged from 1.04 (99%CI 1.01 to 1.08) for non-Hodgkin lymphoma to 1.49 (1.45 to 1.53) for corpus uteri cancer. While BMI was negatively associated to five cancer types in the linear analyses of the overall population, accounting for non-linearity revealed that BMI was associated to prostate cancer in a U-shaped manner and to head and neck, esophagus, larynx, and trachea, bronchus and lung cancers in an L-shaped fashion, suggesting that low BMIs are an approximation of heavy smoking. Of the 291,305 participants with a WC measurement, 27,837 were diagnosed with cancer. The 99%CIs of the BMI and WC point estimates (per 1 standard deviation increment) overlapped for all cancers. CONCLUSIONS: In this large Southern European study, a higher BMI was associated with increased risk of twelve cancers, including four hematological and head and neck (only among never smokers) cancers. Furthermore, BMI and WC showed comparable estimates of cancer risk associated with adiposity.

Ambient air pollution and the development of overweight and obesity in children: a large longitudinal study.

BACKGROUND: Ambient air pollution may play a role in childhood obesity development, but evidence is scarce, and the modifying role of socioeconomic status (SES) is unclear. We aimed to examine the association between exposure to air pollution during early childhood and subsequent risk of developing overweight and obesity, and to evaluate whether SES is a modifier of this association. METHODS: This longitudinal study included 416,955 children identified as normal weight between 2-5 years old and registered in an electronic primary healthcare record between 2006 and 2016 in Catalonia (Spain). Children were followed-up until they developed overweight or obesity, reached 15 years of age, died, transferred out, or end of study period (31/12/2018). Overweight and obesity were defined following the WHO reference obtained from height and weight measures. We estimated annual residential census levels of nitrogen dioxide (NO2) and particulate matter <10 µm (PM10), <2.5 µm (PM2.5), and 2.5-10 µm (PMcoarse) at study entry. We estimated the risk of developing overweight and obesity per interquartile range increase in air pollution exposure with Cox proportional hazard models. RESULTS: A total of 142,590 (34.2%) children developed overweight or obesity. Increased exposure to NO2, PM10, and PMcoarse was associated with a 2-3% increased risk of developing overweight and obesity (hazard ratio [HR] per 21.8 µg/m3 NO2 = 1.03 [95% CI: 1.02-1.04]; HR per 6.4 µg/m3 PM10 = 1.02 [95% CI: 1.02-1.03]; HR per 4.6 µg/m3 PMcoarse = 1.02, [95% CI: 1.01-1.02]). For all air pollutants, associations were stronger among children living in most compared to least deprived areas. CONCLUSIONS: This study suggests that early life exposure to air pollution may be associated with a small increase in the risk of developing overweight and obesity in childhood, and that this association may be exacerbated in the most deprived areas. Even these small associations are of potential global health importance because air pollution exposure is widespread and the long-term health consequences of childhood obesity are clear.

Use of hydrochlorothiazide and risk of skin cancer in a large nested case-control study in Spain.

PURPOSE: Hydrochlorothiazide (HCTZ) use has been linked to skin cancer in northern European countries. We assessed the association between HCTZ exposure and risk of malignant melanoma (MM) and keratinocyte carcinoma (KC) in a European Mediterranean population. METHODS: Two parallel nested case-control studies were conducted in Spain using two electronic primary healthcare databases, each one providing data on both exposure and outcomes: SIDIAP and BIFAP. Cancer cases were matched to 10 controls by age and gender through risk-set sampling. The ORs and 95% CI for MM and KC associated with previous HCTZ use were estimated using conditional logistic regression. In BIFAP, KC cases were further identified as basal cell carcinoma (BCC) or squamous cell carcinoma (SCC). RESULTS: In adjusted analyses, both ever and cumulative high (≥50,000 mg) use of HCTZ were associated with an increased risk of KC. The risk estimates for high use were 1.30 (1.26-1.34) in SIDIAP and 1.20 (1.12-1.30) in BIFAP, with a lower risk for BCC (1.11 [1.02-1.21]) than for SCC (1.71 [1.45-2.02]). A dose-response relationship was observed between cumulative doses of HCTZ and KC risk. Inconsistent results were found for high use of HCTZ and risk of MM: 1.25 (1.09-1.43) in SIDIAP and 0.85 (0.64-1.13) in BIFAP. CONCLUSIONS: In this European Mediterranean population, a high cumulative use of HCTZ was related to an increased risk of KC with a clear dose-response pattern.

The relationship between residential proximity to outdoor play spaces and children's mental and behavioral health: The importance of neighborhood socio-economic characteristics.

Urban outdoor play spaces are reported to improve children's health. However, there is little empirical evidence on the impact of outdoor play spaces on childhood mental and behavioral health. To fill this gap, we investigated the associations between residential proximity to outdoor play spaces and the prevalence of diagnosed mental and behavioral disorders. We explored whether these associations differ by individual and area-level socio-economic status (SES). This cross-sectional study included 151 110 children who were 0-12 years old in 2014 and were visited in public primary health care centers in Barcelona (Spain). Each child's demographic and mental and behavioral disorders information was extracted for 2005-2014, including diagnoses on disorders of psychological development together with other four types of mental and behavioral disorders. The pediatrician diagnosed mental and behavioral disorders we explored in this study were: mood/affective; neurotic, stress-related and somatoform; psychological development; behavioral and emotional; and overall mental and behavioral disorders. We assessed 300 m network buffer residential proximity to overall outdoor play spaces (i.e., the overall sum of play spaces of any type), outdoor green play spaces, and to a diversity of outdoor play spaces. We used robust Poisson regression models to investigate the association between proximity to outdoor play spaces indicators and each health outcome. We tested interaction terms for indicators of proximity to outdoor play spaces and individual and area SES. For measures with significant interaction terms, we conducted stratified models. We found residential proximity to outdoor play spaces to be protective of disorders of psychological development. Proximity to overall outdoor play spaces, proximity to outdoor green play spaces and proximity to a greater diversity of outdoor play spaces were associated with a 4% (95% CI: 1,7), 4% (95% CI: 1,7) and 5% (95% CI: 2,9) lower prevalence rates of disorders of psychological development respectively. Most of the associations were found to be in the same direction-although more pronounced-in low SES areas, but in the opposite direction for children living in high SES areas. No differences in these associations were found by individual SES. Residential proximity to outdoor play spaces is protective of children's mental and behavioral health living in low SES areas.

Disparities in Coronavirus Disease 2019 Clinical Outcomes and Vaccination Coverage Among Migrants With Human Immunodeficiency Virus in the PISCIS Cohort: A Population-Based Propensity Score-Matched Analysis.

Background: Coronavirus disease 2019 (COVID-19) disproportionately affects migrants and ethnic minorities, including those with human immunodeficiency virus (HIV). Comprehensive studies are needed to understand the impact and risk factors. Methods: Using data from the PISCIS cohort of people with HIV (PWH) in Catalonia, Spain, we investigated COVID-19 outcomes and vaccination coverage. Among 10 640 PWH we compared migrants and non-migrants assessing rates of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing, diagnosis, and associated clinical outcomes through propensity score matching and multivariable Cox regression. Results: The cohort (mean age, 43 years; 83.5% male) included 57.4% (3053) Latin American migrants. Migrants with HIV (MWH) had fewer SARS-CoV-2 tests (67.8% vs 72.1%, P < .0001) but similar COVID-19 diagnoses (29.2% vs 29.4%, P = .847) compared to Spanish natives. Migrants had lower complete vaccination (78.9% vs 85.1%, P < .0001) and booster doses (63.0% vs 65.5%, P = .027). COVID-19 hospitalizations (8.1% vs 5.1%, P < .0001) and intensive care unit (ICU) admissions (2.9% vs 1.2%, P < .0001) were higher among migrants, with similar hospitalization duration (5.5 vs 4.0 days, P = .098) and mortality (3 [0.2%] vs 6 [0.4%], P = .510). Age ≥40 years, CD4 counts <200 cells/µL, ≥2 comorbidities, and incomplete/nonreception of the SARS-CoV-2 vaccine increased the risk of severe COVID-19 among migrants. Conclusions: MWH had lower rates of SARS-CoV-2 testing and vaccination coverage, although the rates of COVID-19 diagnosis were similar between migrants and non-migrants. Rates of COVID-19-associated hospitalizations and ICU admissions were higher among migrants in comparison with non-migrants, with similar hospitalization duration and mortality. These findings can inform policies to address disparities in future pandemic responses for MWH.

The impact of the COVID-19 pandemic on healthcare services utilization among people living with HIV in Catalonia, Spain: A population-based cohort study.

BACKGROUND: The COVID-19 pandemic disrupted healthcare services usage. We estimated the impact of the COVID-19 pandemic on healthcare services utilization among people living with HIV (PLWH) in Catalonia, Spain. METHODS: We accessed public healthcare usage in HIV units, primary care, hospitals, and emergency departments among 17,738 PLWH in the PISCIS cohort from January 1, 2017, to December 31, 2020. We performed an interrupted time series analysis using the autoregressive integrated moving average to estimate the effect of COVID-19 on medical visits and HIV monitoring among PLWH. RESULTS: A non-significant decrease of 17.1% (95% CI: [-29.4, 0.4]) in overall medical visits was observed during the lockdown, followed by a steady resumption until the end of 2020. Three health facilities presented statistically significant declines in visits during the lockdown: HIV units (-44.8% [-56.7, -23.6]), hospitals (-40.4% [-52.8, -18.1]), and emergency departments (-36.9% [-47.0, -21.9]); thereafter, the visits have begun to increase steadily but not to previous levels as of December 2020. In contrast, primary care visits remained unchanged during the lockdown by 1.9% (95% CI: -13.5, 23.9). CD4 cell (54.2% [95% CI: -64.4, -36.0]) and HIV RNA viral load (53.1% [95% CI: -62.9, -36.1]) laboratory monitoring reduced significantly during the lockdown. CONCLUSION: COVID-19 lockdowns significantly disrupted in-person healthcare services usage among PLWH. The reduction in healthcare utilization however did not affect primary care services. Despite services gradually rebounding to pre-pandemic levels, it is imperative to effectively prepare for future pandemics and implement measures to ensure continuous provision of care to PLWH during pandemic lockdowns.

Developing and validating a clinical risk score to predict losses in the PISCIS cohort of people with HIV.

BACKGROUND: People lost to follow-up (LTFU) from HIV care have an increased risk of worse health. The objective of this study is to create and validate a risk score to predict LTFU among PLWH in Catalonia and the Balearic Islands. METHODS: 6661 PLWH were included. LTFU were those without contact with HIV care for 12 months or more. Logistic regression models were used to assess the role of independent factors on LTFU. The validation included a 10-fold iteration to predict the performance of the regression model and the Area under the ROC Curve (AUC). Regression coefficients were rounded and summed to construct the score. RESULTS: Determinants of LTFU included being younger than 34 years (OR: 1.80, CI, 1.44-2.23), not having been born in Spain (OR: 1.32, 1.11-1.58), men who inject drugs (OR: 2.10, 1.38-3.19), having a detectable viral load (OR: 3.14, 2.47-3.99), and ≤2.5 years since HIV diagnosis (OR: 3.84, 3.10-4.75). The validation of determinants resulted in a mean AUC of 0.69 and the risk-score revealed that 28.8% had a medium and 3.4% a high risk of LTFU respectively. CONCLUSIONS: Findings can be used to prevent LTFU in HIV care.

Identifying risk factors for anal cancer in people with HIV in Spain: a multicentre retrospective cohort study nested in the PISCIS cohort.

BACKGROUND: People with HIV have a substantially higher risk of anal cancer than the general population. We aimed to identify risk factors associated with the development of anal cancer among people with HIV to implement more effective and targeted screening strategies. METHODS: We conducted a multicentre retrospective cohort study in 16 hospitals across Catalonia and the Balearic Islands, Spain, between Jan 1, 1998, and Dec 31, 2022. Treatment-naive people with HIV nested in the PISCIS cohort aged 16 years and older with biopsy-proven squamous cell carcinoma of the anus or anal canal were eligible for inclusion. Data were retrieved from every hospital registry and were centrally validated in the PISCIS cohort and the Public Data Analysis for Health Research and Innovation Program. The primary outcome was the incidence rate (IR) of histologically confirmed anal cancer. We used Poisson regression to examine the association between the following risk factors and incidence of anal cancer: age, mode of HIV transmission, nadir CD4 cell count, and time period of HIV diagnosis. FINDINGS: Among 14 238 people with HIV, 107 (0·8%) developed anal cancer, with an overall IR of 72·5 cases per 100 000 person-years (95% CI 59·4-87·6) and median follow-up of 9·5 years (IQR 4·4-15·7). Of these patients with anal cancer, 37 (34·6%) died, of which 24 (64·9%) deaths were related to anal cancer. Incidence was highest among people with HIV with historical nadir CD4 counts of less than 200 cells per µL (IR 105·0 person-years, 95% CI 82·0-132·5) and lowest among those with counts of more than 350 cells per µL (2·9 person-years, 0·1-16·0). Among men who have sex with men (MSM), the IR was 211·5 person-years (95% CI 151·1-211·7) among those with a CD4 count of less than 200 cells per µL, 37·6 person-years (16·2-74·1) among those with a count of 200-350 cells per µL, and 4·8 person-years (0·1-26·9) among those with a count of more than 350 cells per µL. Among people with HIV younger than 30 years, there were no cases of anal cancer among women or men who do not have sex with men, and one case among MSM with a nadir CD4 count of more than 350 cells per µL (IR 4·8 person-years, 95% CI 0·1-26·9). In the multivariable analysis, people with HIV with nadir CD4 counts of more than 350 cells per µL had the lowest risk of developing anal cancer, compared with people with HIV with counts of less than 200 cells per µL (adjusted IR ratio 0·03, 95% CI 0·00-0·25; p=0·0010) or 200-350 cells per µL (0·30, 0·17-0·55; p<0·0001). Compared with people with HIV younger than 30 years, people with HIV aged 60 years and older had an adjusted IR ratio of 27·6 (3·7-206·9; p=0·0010) and people with HIV aged 45-59 years of 21·6 (3·0-156·4; p=0·0020). Compared with individuals diagnosed after 2015, a diagnosis of HIV before 1998 had an adjusted IR ratio of 33·0 (7·9-137·5; p<0·0001). INTERPRETATION: A nadir CD4 count threshold below 350 cells per µL, particularly less than 200 cells per µL, has the potential to identify people with HIV at heightened risk of developing anal cancer. Customised screening strategies that prioritise screening for individuals at high risk with this surrogate marker could maximise available resources. External validation of these data with other cohorts is required before screening recommendations can be updated. FUNDING: Catalan Health Department, Generalitat de Catalunya.