Dengue virus infection among long-term travelers from the Netherlands: A prospective study, 2008-2011.

BACKGROUND: Dengue is increasing rapidly in endemic regions. Data on incidence among travelers to these areas are limited. Five prospective studies have been performed thus far, mainly among short-term travelers. OBJECTIVE: To obtain the attack and incidence rate (AR, IR) of dengue virus (DENV) infection among long-term travelers and identify associated risk factors. METHODS: A prospective study was performed among long-term travelers (12-52 weeks) attending the Public Health Service in Amsterdam. Clients planning to travel to (sub)tropical countries were invited to participate. Participants kept a travel diary, recording itinerary, symptoms, and physician visits. Pre- and post-travel blood samples were serologically tested for the presence of Anti-DENV IgG antibodies. Seroconversion was considered suggestive of a primary DENV infection. Anti-DENV IgG present in both corresponding samples in combination with a post-/pre-travel ratio of ≥4:1 was suggestive of a secondary infection. Risk factors for a DENV infection were studied using poisson regression. RESULTS: In total, 600 participants were included; median age was 25 years (IQR: 23-29), 35.5% were male, and median travel duration was 20 weeks (IQR: 15-25). In 39 of 600 participants (AR: 6.5%; 95% CI 4.5-8.5%) anti-DENV IgG test results were suggestive of a recent infection, yielding an IR of 13.9 per 1,000 person-months traveling (95%CI: 9.9-19.1). No secondary infections were found. IR for Asia, Africa, and America were comparable and 13.5, 15.8, and 13.6 per 1,000 person-months respectively. Of participants with a recent DENV infection, 51% did not report dengue-like illness (DLI) or fever, but 10% were hospitalized. In multivariable analysis, travelers who seroconverted were significantly more likely to be vaccinated with ≥2 flavivirus vaccines for the current trip or to have reported DLI in >1 consecutive weeks. CONCLUSIONS: Long-term travelers are at substantial risk of DENV infection. Half of those with a DENV infection reported no symptoms, but 10% were hospitalized, demonstrating the importance of advising anti-mosquito measures during travel.

Usage of purchased self-tests for HIV and sexually transmitted infections in Amsterdam, the Netherlands: results of population-based and serial cross-sectional studies among the general population and sexual risk groups.

OBJECTIVES: There are limited data on the usage of commercially bought self-tests for HIV and other sexually transmitted infections (STIs). Therefore, we studied HIV/STI self-test usage and its determinants among the general population and sexual risk groups between 2007 and 2015 in Amsterdam, the Netherlands. SETTING: Data were collected in four different studies among the general population (S1-2) and sexual risk groups (S3-4). PARTICIPANTS: S1-Amsterdam residents participating in representative population-based surveys (2008 and 2012; n=6044) drawn from the municipality register; S2-Participants of a population-based study stratified by ethnicity drawn from the municipality register of Amsterdam (2011-2015; n=17 603); S3-Men having sex with men (MSM) participating in an HIV observational cohort study (2008 and 2013; n=597) and S4-STI clinic clients participating in a cross-sectional survey (2007-2012; n=5655). PRIMARY AND SECONDARY OUTCOME MEASURES: Prevalence of HIV/STI self-test usage and its determinants. RESULTS: The prevalence of HIV/STI self-test usage in the preceding 6-12 months varied between 1% and 2% across studies. Chlamydia self-tests were most commonly used, except among MSM in S3. Chlamydia and syphilis self-test usage increased over time among the representative sample of Amsterdam residents (S1) and chlamydia self-test usage increased over time among STI clinic clients (S4). Self-test usage was associated with African Surinamese or Ghanaian ethnic origin (S2), being woman or MSM (S1 and 4) and having had a higher number of sexual partners (S1-2). Among those in the general population who tested for HIV/STI in the preceding 12 months, 5-9% used a self-test. CONCLUSIONS: Despite low HIV/STI self-test usage, we observed increases over time in chlamydia and syphilis self-test usage. Furthermore, self-test usage was higher among high-risk individuals in the general population. It is important to continue monitoring self-test usage and informing the public about the unknown quality of available self-tests in the Netherlands and about the pros and cons of self-testing.

Development and validation of a risk score to assist screening for acute HIV-1 infection among men who have sex with men.

BACKGROUND: Early treatment of acute HIV-1 infection (AHI) is beneficial for patients and could reduce onward transmission. However, guidelines on whom to test for AHI with HIV-1 RNA testing are lacking. METHODS: A risk score for possible AHI based on literature and expert opinion - including symptoms associated with AHI and early HIV-1 - was evaluated using data from the Amsterdam Cohort Studies among men who have sex with men (MSM). Subsequently, we optimized the risk score by constructing two multivariable logistic regression models: one including only symptoms and one combining symptoms with known risk factors for HIV-1 seroconversion, using generalized estimating equations. Several risk scores were generated from these models and the optimal risk score was validated using data from the Multicenter AIDS Cohort Study. RESULTS: Using data from 1562 MSM with 175 HIV-1 seroconversion visits and 17,271 seronegative visits in the Amsterdam Cohort Studies, the optimal risk score included four symptoms (oral thrush, fever, lymphadenopathy, weight loss) and three risk factors (self-reported gonorrhea, receptive condomless anal intercourse, more than five sexual partners, all in the preceding six months) and yielded an AUC of 0.82. Sensitivity was 76.3% and specificity 76.3%. Validation in the Multicenter AIDS Cohort Study resulted in an AUC of 0.78, sensitivity of 56.2% and specificity of 88.8%. CONCLUSIONS: The optimal risk score had good overall performance in the Amsterdam Cohort Studies and performed comparable (but showed lower sensitivity) in the validation study. Screening for AHI with four symptoms and three risk factors would increase the efficiency of AHI testing and potentially enhance early diagnosis and immediate treatment.

Impact of comorbidity and ageing on health-related quality of life in HIV-positive and HIV-negative individuals.

BACKGROUND: HIV-infected individuals may be at risk for the premature onset of age-associated noncommunicable comorbidities. Being HIV-positive, having comorbidities and being of higher age may adversely impact health-related quality of life (HRQL). We investigated the possible contribution of HIV infection, comorbidities and age on HRQL and depression. METHODS: HIV-infected individuals and uninfected controls from the AGEhIV Cohort Study were screened for the presence of comorbidities. They completed the Short Form 36-item Health Survey to assess HRQL and the nine-item Patient Health Questionnaire to assess depression. Linear and logistic regression were used to investigate to which extent comorbidities, aging and HIV infection were independently associated with HRQL and depression. RESULTS: HIV-infected individuals (n = 541) reported significantly worse physical and mental HRQL and had a higher prevalence of depression than HIV-uninfected individuals (n = 526). A higher number of comorbidities and HIV-positive status were each independently associated with worse physical HRQL, whereas HIV-positive status and younger age were independently associated with worse mental HRQL and more depression. The difference in physical HRQL between HIV-positive and HIV-negative individuals did not become greater with a higher number of comorbidities or with higher age. CONCLUSION: In a cohort of largely well suppressed HIV-positive participants and HIV-negative controls, HIV-positive status was significantly and independently associated with worse physical and mental HRQL and with an increased likelihood of depression. Our finding that a higher number of comorbidities was independently associated with worse physical HRQL reinforces the importance to optimize prevention and management of comorbidities as the HIV-infected population continues to age.

Development and validation of the HCV-MOSAIC risk score to assist testing for acute hepatitis C virus (HCV) infection in HIV-infected men who have sex with men (MSM).

Current guidelines recommend hepatitis C virus (HCV) testing for HIV-infected men who have sex with men (MSM) with ongoing risk behaviour, without specifying the type of risk behaviour. We developed and validated the HCV-MOSAIC risk score to assist HCV testing in HIV-infected MSM. The risk score consisted of six self-reported risk factors identified using multivariable logistic regression using data from the Dutch MOSAIC study (n = 213, 2009-2013). Area under the ROC curve (AUC), sensitivity, specificity, post-test-probability-of-disease and diagnostic gain were calculated. The risk score was validated in case-control studies from Belgium (n = 142, 2010-2013) and the United Kingdom (n = 190, 2003-2005) and in cross-sectional surveys at a Dutch sexually transmitted infections clinic (n = 284, 2007-2009). The AUC was 0.82; sensitivity 78.0% and specificity 78.6%. In the validation studies sensitivity ranged from 73.1% to 100% and specificity from 56.2% to 65.6%. The post-test-probability-of-disease ranged from 5.9% to 20.0% given acute HCV prevalence of 1.7% to 6.4%, yielding a diagnostic gain of 4.2% to 13.6%. The HCV-MOSAIC risk score can successfully identify HIV-infected MSM at risk for acute HCV infection. It could be a promising tool to improve HCV testing strategies in various settings.

Motives of Dutch men who have sex with men for daily and intermittent HIV pre-exposure prophylaxis usage and preferences for implementation: A qualitative study.

Although PrEP is not yet registered in Europe, including the Netherlands, its approval and implementation are expected in the near future. To inform future pre-exposure prophylaxis (PrEP) implementation, this study aimed to gain insight into motives and preferences for daily or intermittent PrEP use among Dutch HIV-negative men having sex with men (MSM).Between February and December 2013, semistructured interviews were conducted until data saturation was reached (N = 20). Interviews were analyzed using the Grounded Theory approach.Motives for (not) using daily PrEP were based on beliefs about PrEP efficacy and side effects, preferences for other prevention strategies, self-perceived HIV risk, self-perceived efficacy of PrEP adherence, beliefs about possible benefits (e.g., anxiety reduction, sex life improvement), and barriers of PrEP use (e.g., costs, monitoring procedures). The perceived benefits of intermittent versus daily PrEP use were the lower costs and side effects and the lower threshold to decision to start using intermittent PrEP. Barriers of intermittent PrEP versus daily PrEP use were the perceived need to plan their sex life and adhere to multiple prevention strategies. Although some perceived PrEP as a condom substitute, others were likely to combine PrEP and condoms for sexually transmitted infections (STI) prevention and increased HIV protection. Participants preferred PrEP service locations to have specialized knowledge of HIV, antiretroviral therapy, sexual behavior, STIs, patients' medical background, be easily approachable, be able to perform PrEP follow-up monitoring, and provide support.To maximize the public health impact of PrEP, ensuring high uptake among MSM at highest risk is important. Therefore, targeted information about PrEP efficacy and side effects need to be developed, barriers for accessing PrEP services should be minimized, and perceived self-efficacy to use PrEP should be addressed and improved. To prevent increases in STIs, condom use should be monitored and PrEP should be integrated into routine STI screening and counseling.

Difference in Aortic Stiffness Between Treated Middle-Aged HIV Type 1-Infected and Uninfected Individuals Largely Explained by Traditional Cardiovascular Risk Factors, With an Additional Contribution of Prior Advanced Immunodeficiency.

BACKGROUND: Patients with HIV, even with suppressed viremia on combination antiretroviral therapy, are at increased risk for cardiovascular disease. The underlying pathophysiology remains to be clarified. Aortic stiffness, known to be associated with cardiovascular disease in the general population, was investigated in a cohort of HIV type 1 (HIV 1)-infected and similar but uninfected individuals. METHODS: Aortic stiffness was assessed by measuring pulse wave velocity (PWV) with an Arteriograph. Five hundred seven HIV-uninfected and 566 HIV 1-infected individuals, predominantly with suppressed viremia on combination antiretroviral therapy, aged ≥45 years, participating in the ongoing AGEhIV Cohort Study were included in the analysis. Multivariable linear regression was used to investigate whether HIV was independently associated with aortic stiffness, adjusting for traditional cardiovascular risk factors. RESULTS: Study groups were comparable in demographics; smoking and hypertension were more prevalent in HIV-infected participants. PWV was higher in the HIV-infected group (7.9 vs. 7.7 m/s, P = 0.004). After adjustment for mean arterial pressure, age, gender, and smoking, HIV status was not significantly associated with aortic stiffness. In HIV-infected participants, having a nadir CD4 T-cell count ≤100 cells per cubic millimeter was independently associated with a higher PWV. CONCLUSIONS: The increased aortic stiffness in HIV-infected participants was largely explained by a higher prevalence of traditional cardiovascular risk factors, particularly smoking. Although HIV itself was not independently associated with higher aortic stiffness, a prior greater degree of immunodeficiency was. This suggests a detrimental effect of immunodeficiency on the aortic wall, possibly mediated by inflammation.

Determinants of reduced cognitive performance in HIV-1-infected middle-aged men on combination antiretroviral therapy.

OBJECTIVE: The spectrum of risk factors for HIV-associated cognitive impairment is likely very broad and includes not only HIV/antiretroviral therapy-specific factors but also other comorbid conditions. The purpose of this current study was to explore possible determinants for decreased cognitive performance. DESIGN AND METHODS: Neuropsychological assessment was performed on 103 HIV-1-infected men with suppressed viraemia on combination antiretroviral therapy for at least 12 months and 74 HIV-uninfected highly similar male controls, all aged at least 45 years. Cognitive impairment and cognitive performance were determined by multivariate normative comparison (MNC). Determinants of decreased cognitive performance and cognitive impairment were investigated by linear and logistic regression analysis, respectively. RESULTS: Cognitive impairment as diagnosed by MNC was found in 17% of HIV-1-infected men. Determinants for decreased cognitive performance by MNC as a continuous variable included cannabis use, history of prior cardiovascular disease, impaired renal function, diabetes mellitus type 2, having an above normal waist-to-hip ratio, presence of depressive symptoms, and lower nadir CD4⁺ cell count. Determinants for cognitive impairment, as dichotomized by MNC, included cannabis use, prior cardiovascular disease, impaired renal function, and diabetes mellitus type 2. CONCLUSION: Decreased cognitive performance probably results from a multifactorial process, including not only HIV-associated factors, such as having experienced more severe immune deficiency, but also cardiovascular/metabolic factors, cannabis use, and depressive symptoms.

Is Group Sex a Higher-Risk Setting for HIV and Other Sexually Transmitted Infections Compared With Dyadic Sex Among Men Who Have Sex With Men?

BACKGROUND: Group sex has been suggested as a potential high-risk setting for HIV and other sexually transmitted infections (STIs) among men who have sex with men (MSM). We investigated whether group sex is associated with lower condom use during anal sex and higher proportions of STIs compared with dyadic sex among HIV-negative MSM between 2009 and 2012. METHODS: Cross-sectional data from 7 data waves of the Amsterdam Cohort Studies were used. The sample consisted of 465 MSM who either reported both group and dyadic sex (at n = 706 visits) or dyadic sex only (at n = 1339 visits) in the preceding 6 months. Logistic regression with generalized estimating equations was used to investigate the association between sexual setting (group vs. dyadic sex), condomless anal sex, and STI. RESULTS: Group sex was reported at 35% (706/2045) of visits. Condomless sex was more often reported during dyadic than group sex (odds ratio, 3.64 95% confidence interval, 2.57-5.16). Men who had group sex were more likely diagnosed as having gonorrhea compared with men with dyadic sex (odds ratio, 1.71; 95% confidence interval, 1.08-2.97), but this effect was not retained in the multivariate model. CONCLUSIONS: Results demonstrate within-person differences in sexual behavior during group and dyadic sex among MSM. Men were more likely to use condoms during group sex than during dyadic sex. Thus, for some, group sex may not necessarily be risky for HIV infection compared with dyadic sex. However, group sex may be a higher-risk setting for acquiring STIs other than HIV, such as gonorrhea. Group sex encounters should be recognized as distinct sexual settings with specific risk characteristics that need to be addressed accordingly.

Prevalence and determinants of insufficient work ability in older HIV-positive and HIV-negative workers.

PURPOSE: To explore whether the prevalence and determinants of insufficient work ability (WA) of older HIV-positive workers differ from a comparable group of HIV-negative workers. METHODS: Cross-sectional data from 359 HIV-negative and 264 HIV-positive middle-aged individuals (45-65 years) participating in paid labor, collected within the AGEhIV Cohort Study between October 2010-September 2012, were selected. Data were collected by self-administered questionnaires and physical examination. Participants self-rated their current WA, ranging from 0 to 10. WA was dichotomized into insufficient (<6) and sufficient (≥6). Using univariable and multivariable logistic regression, we studied the independent effect of HIV status on insufficient WA and determinants of insufficient WA. RESULTS: Overall, 8% of participants reported insufficient WA (HIV-positive 9 vs. HIV-negative 7%, P = 0.20). Twice as many HIV-positive as HIV-negative individuals were declared partly unfit for work (6 vs. 3%, P = 0.02). HIV status itself was not associated with WA in univariable and multivariable analyses. Multivariable analyses revealed that low educational level, working fewer hours, being partly unfit for work, experiencing a high need for recovery after work, staying home from work ≥2 times in the past 6 months, and reporting depressive symptoms were associated with insufficient WA, independent of HIV status. CONCLUSIONS: HIV-positive individuals aged 45-65 years participating in paid labor seem to function as well at work as HIV-negative individuals. HIV-positive participants were more often formally declared partly unfit for work, but percentages were low in both groups. Knowledge of determinants of insufficient WA may help employers and professionals to optimize WA.

HIV infection is independently associated with frailty in middle-aged HIV type 1-infected individuals compared with similar but uninfected controls.

BACKGROUND: Frailty is an age-related syndrome of decreased physiological reserve and resistance to stressors, associated with increased morbidity and mortality in the general elderly population. An increased prevalence of frailty has been reported amongst HIV-infected individuals. METHODS: Fried frailty phenotype was systematically assessed in predominantly virologically suppressed HIV type 1 (HIV-1)-infected and otherwise comparable HIV-uninfected participants aged at least 45 at enrollment into the AGEhIV Cohort Study. Multivariable ordinal logistic regression was used to investigate associations between HIV- and antiretroviral therapy-related covariates, markers of inflammation and body composition and prefrailty/frailty. RESULTS: Data were available for 521 HIV-infected and 513 HIV-uninfected individuals. Prevalence of frailty (10.6 versus 2.7%) and prefrailty (50.7 versus 36.3%) were significantly higher in HIV-infected individuals (Ptrend < 0.001). HIV infection remained statistically significantly associated with prefrailty/frailty after adjustment for age, sex, race/ethnicity, smoking, hepatitis C infection, comorbidities and depression [adjusted odds ratio (ORadj) 2.16, P < 0.001]. A higher waist-to-hip ratio attenuated the coefficient of HIV-infected status (ORadj 1.93, P < 0.001), but not waist- or hip-circumference individually or markers of inflammation. Within the HIV-infected group, parameters related to body composition were most strongly and independently associated with prefrailty/frailty: current BMI less than 20 kg/m2 (OR 2.83, P = 0.01), nadir BMI less than 20 kg/m2 (OR 2.51, P = 0.001) and waist-to-hip ratio (OR 1.79 per 0.1 higher, P < 0.001). CONCLUSION: HIV infection was independently associated with prefrailty/frailty in middle-aged HIV-infected patients compared with HIV-uninfected controls. This partly may be mediated by the higher waist- and lower hip-circumference in the HIV-infected individuals, potentially partially caused by lipodystrophy, and in part be a consequence of historic weight loss associated with advanced HIV-disease.

The effect of HIV infection on anal and penile human papillomavirus incidence and clearance: a cohort study among MSM.

OBJECTIVES: A large portion of anogenital cancers is caused by high-risk human papillomavirus (hrHPV) infections, which are especially common in HIV-infected men. We aimed to compare the incidence and clearance of anal and penile hrHPV infection between HIV-infected and HIV-negative MSM. DESIGN: Analyses of longitudinal data from a prospective cohort study. METHODS: MSM aged 18 years or older were recruited in Amsterdam, the Netherlands, and followed-up semi-annually for 24 months. At each visit, participants completed risk-factor questionnaires. Anal and penile self-samples were tested for HPV DNA using the SPF10-PCR DEIA/LiPA25 system. Effects on incidence and clearance rates were quantified via Poisson regression, using generalized estimating equations to correct for multiple hrHPV types. RESULTS: Seven hundred and fifty MSM with a median age of 40 years (interquartile 35-48) were included in the analyses, of whom 302 (40%) were HIV-infected. The incidence rates of hrHPV were significantly higher in HIV-infected compared with HIV-negative MSM [adjusted incidence rate ratio (aIRR) 1.6; 95% confidence interval (CI) 1.3-2.1 for anal and aIRR 1.4; 95%CI 1.0-2.1 for penile infection]. The clearance rate of hrHPV was significantly lower for anal [adjusted clearance rate ratio (aCRR) 0.7; 95%CI 0.6-0.9], but not for penile infection (aCRR 1.3; 95%CI 1.0-1.7). HrHPV incidence or clearance did not differ significantly by nadir CD4 cell count. CONCLUSION: Increased anal and penile hrHPV incidence rates and decreased anal hrHPV clearance rates were found in HIV-infected compared with HIV-negative MSM, after adjusting for sexual behavior. Our findings suggest an independent effect of HIV infection on anal hrHPV infections.

Changes in sexual risk behavior among MSM participating in a research cohort in coastal Kenya.

OBJECTIVE: To describe changes in sexual risk behavior among Kenyan MSM who received regular risk reduction counseling (RRC). DESIGN: Data were derived from two cohorts of HIV-1-negative and HIV-1-positive MSM in Kenya. Behavioral data were collected at enrollment and at monthly or quarterly scheduled follow-up visits. At each visit, RRC was provided to all men and HIV-1 testing to seronegative men. METHODS: Random effects logistic and Poisson regression models with time since study entry as main variable of interest were used to evaluate changes in number of sex partners and unprotected sex in the past week, and insertive, receptive, and unprotected anal intercourse in the past 3 months. Analyses were adjusted for HIV-1-status, calendar year of follow-up, and several baseline characteristics. Trends over follow-up time were allowed to differ by HIV-1-status. Men were censored when they seroconverted for HIV. RESULTS: Number of regular and casual sex partners and unprotected anal intercourse decreased in both HIV-1-negative and HIV-1-positive men. Unprotected sex with both regular and casual sex partners decreased more strongly early in follow-up in HIV-1-positive men than in HIV-1-negative men. Decreases in insertive anal intercourse were found for HIV-1-positive men only, whereas decreases in receptive anal intercourse were found for HIV-1-negative men only. CONCLUSION: MSM who were regularly exposed to RRC showed some reductions in sexual risk behavior, but it is uncertain if these reductions are sustained over time. As HIV-1 incidences in Kenyan MSM are very high, RRC should be supported by comprehensive biomedical interventions.

Association of HIV Infection With Anal and Penile Low-Risk Human Papillomavirus Infections Among Men Who Have Sex With Men in Amsterdam: The HIV & HPV in MSM Study.

BACKGROUND: This study among men who have sex with men (MSM) aimed to (1) assess prevalence of anogenital low-risk human papillomavirus (lrHPV) infections, (2) evaluate associations with HIV infection, and (3) investigate lrHPV concordance. METHODS: In 2010 to 2011, MSM 18 years or older were recruited in Amsterdam, the Netherlands, and provided anal and penile self-swabs (HIV & HPV in MSM study). Using the HPV SPF10-PCR/DEIA/LiPA25 system, the presence of lrHPV types 6, 11, 34, 40, 42, 43, 44, 53, 54, 66, 68/73, 70, and 74 could be detected. Logistic regression with generalized estimating equations was used to assess the independent effect of HIV on lrHPV infections. The model was repeated for lrHPV subcategories (nononcogenic and weakly oncogenic infections separately). Concordance was defined as detection of the same lrHPV type in both self-swabs of one individual. RESULTS: A total of 778 MSM were included, of whom 317 (41%) were HIV positive (median CD4 count at enrollment, 530 cells/mm). Prevalence of anal lrHPV was 45% (95% confidence interval [CI], 41%-50%) in HIV-negative MSM and 69% (95% CI, 64%-74%) in HIV-positive MSM. Prevalence of penile lrHPV was 20% (95% CI, 16%-24%) and 37% (95% CI, 31%-42%), respectively. In multivariable analysis, HIV infection was independently associated with anal (adjusted odds ratio [aOR], 1.9; 95% CI, 1.5-2.3) and penile lrHPV (aOR, 2.0; 95% CI, 1.4-2.7). Nononcogenic and weakly oncogenic lrHPV subcategories showed a similar pattern of association. Anal lrHPV infections were strongly associated with the presence of a type-concordant penile infection (aOR, 5.8; 95% CI, 4.4-7.5) and vice versa (aOR, 5.7; 95% CI, 4.4-7.5). CONCLUSIONS: Anal and penile infections with lrHPV are common in MSM. HIV infection was an independent determinant for lrHPV infections.

Is anyone around me using condoms? Site-specific condom-use norms and their potential impact on condomless sex across various gay venues and websites in The Netherlands.

OBJECTIVE: To investigate site-specific condom-use norms as assumed by visitors of gay venues and websites across The Netherlands and their association with men's own use of condoms. METHODS: In 2010, men who have sex with men (MSM) visiting 18 sex venues (e.g., saunas), 30 nonsex venues (e.g., bars), 6 dating websites, and 2 social network websites completed an on-site questionnaire measuring 2 site-specific norms concerning anal sex: descriptive (assumed condom use of others at venue or website) and injunctive (assumed approval of condom use by others at venue or website). We measured the association between assumed descriptive norms and own use of condoms using logistic regression. RESULTS: Among 2,376 participants (median age = 30 years; IQR = 22-43), 62% (n = 1,483) assumed that other visitors would not use condoms. Among men self-reporting on their own use of condoms, 22% (318/1,421) reported condomless anal sex. Men at nonsex venues assumed other visitors would use condoms more often and approved of using them more often compared to men at sex venues. At all sites (venues/websites), men who assumed that others did not use condoms were more likely to have condomless sex themselves. CONCLUSIONS: At gay sites across The Netherlands, more than half of MSM believed visitors of these sites would not use condoms during anal sex. The perception that others would not use condoms was associated with less own condom use. HIV prevention should address problematic on-site condom-use norms, as they play a role in influencing sexual behavior between men that meet at these sites.

What do Dutch MSM think of preexposure prophylaxis to prevent HIV-infection? A cross-sectional study.

OBJECTIVES: Although preexposure prophylaxis (PrEP) is not registered in Europe, including the Netherlands, its approval and implementation are expected in the near future. We aimed to gain insight into PrEP awareness and the intention to use PrEP among MSM. DESIGN: Cross-sectional study among 448 HIV-negative participants of the Amsterdam Cohort Study who completed a questionnaire concerning behavior and PrEP between 2012 and 2013. METHODS: Characteristics, PrEP awareness, and intention to use PrEP were described and multinomial logistic regression was used to identify determinants of a medium and high intention to use PrEP. RESULTS: PrEP awareness was 54%, but only 13% reported a high intention to use PrEP. High-risk MSM were more likely to have a medium [adjusted odds ratio (aOR): 1.78 (95% confidence interval [CI] 1.07-2.97)] or high [aOR: 3.92 (95% CI 1.68-9.15)] intention to use PrEP than low-risk MSM, as were MSM with higher perceptions of self-efficacy to use PrEP [high intention: aOR: 6.15 (95% CI 2.50-15.09)] and higher perceptions of relief due to PrEP [medium intention: aOR: 2.67 (95% CI 1.32-5.40); high intention: aOR: 14.87 (95% CI 5.98-37.01)] than MSM with lower perceptions. MSM with higher perceptions of shame about using PrEP [medium intention: aOR: 0.35 (95% CI 0.19-0.62); high intention: aOR: 0.22 (95% CI 0.07-0.71)] or with more worries about side-effects were less likely to have a high [aOR: 0.18 (95% CI 0.06-0.54)] or medium [aOR: 0.29 (95% CI 0.12-0.72)] intention to use PrEP. CONCLUSION: The overall intention to use PrEP was relatively low, but higher among high-risk MSM. If PrEP implementation among high-risk MSM in the Netherlands becomes reality, PrEP awareness should be increased and psychosocial determinants that will influence uptake should be addressed.

Multivariate normative comparison, a novel method for more reliably detecting cognitive impairment in HIV infection.

OBJECTIVE: The objective of this study is to assess whether multivariate normative comparison (MNC) improves detection of HIV-1-associated neurocognitive disorder (HAND) as compared with Frascati and Gisslén criteria. METHODS: One-hundred and three HIV-1-infected men with suppressed viremia on combination antiretroviral therapy (cART) for at least 12 months and 74 HIV-uninfected male controls (comparable regarding age, ethnicity, sexual orientation, premorbid intelligence and educational level), aged at least 45 years, underwent neuropsychological assessment covering six cognitive domains (fluency, attention, information processing speed, executive function, memory, and motor function). Frascati and Gisslén criteria were applied to detect HAND. Next, MNC was performed to compare the cognitive scores of each HIV-positive individual against the cognitive scores of the control group. RESULTS: HIV-infected men showed significantly worse performance on the cognitive domains of attention, information processing speed and executive function compared with HIV-uninfected controls. HAND by Frascati criteria was highly prevalent in HIV-infected [48%; 95% confidence interval (95% CI) 38-58] but nearly equally so in HIV-uninfected men (36%; 95% CI 26-48), confirming the low specificity of this method. Applying Gisslén criteria, HAND-prevalence was reduced to 5% (95% CI 1-9) in HIV-infected men and to 1% (95% CI 1-3) among HIV-uninfected controls, indicating better specificity but reduced sensitivity. MNC identified cognitive impairment in 17% (95% CI 10-24) of HIV-infected men and in 5% (95% CI 0-10) of the control group (P = 0.02, one-tailed), showing an optimal balance between sensitivity and specificity. CONCLUSION: Prevalence of cognitive impairment in HIV-1-infected men with suppressed viremia on cART estimated by MNC was much higher than that estimated by Gisslén criteria, while the false positive rate was greatly reduced compared with the Frascati criteria. VIDEO ABSTRACT: :

Low bone mineral density in patients with well-suppressed HIV infection: association with body weight, smoking, and prior advanced HIV disease.

BACKGROUND: Human immunodeficiency virus (HIV) and combination antiretroviral therapy (cART) may both contribute to the higher prevalence of osteoporosis and osteopenia in HIV-infected individuals. METHODS: Using dual-energy X-ray absorptiometry, we compared lumbar spine, total hip, and femoral neck bone mineral density (BMD) in 581 HIV-positive (94.7% receiving cART) and 520 HIV-negative participants of the AGEhIV Cohort Study, aged ≥45 years. We used multivariable linear regression to investigate independent associations between HIV, HIV disease characteristics, ART, and BMD. RESULTS: The study population largely consisted of men who have sex with men (MSM). Osteoporosis was significantly more prevalent in those with HIV infection (13.3% vs 6.7%; P<.001). After adjustment for body weight and smoking, being HIV-positive was no longer independently associated with BMD. Low body weight was more strongly negatively associated with BMD in HIV-positive persons with a history of a Centers for Disease Control and Prevention class B or C event. Interestingly, regardless of HIV status, younger MSM had significantly lower BMD than older MSM, heterosexual men, and women. CONCLUSIONS: The observed lower BMD in treated HIV-positive individuals was largely explained by both lower body weight and more smoking. Having experienced symptomatic HIV disease, often associated with weight loss, was another risk factor. The low BMD observed in younger MSM remains unexplained and needs further study.

Repeated STI and HIV testing among HIV-negative men who have sex with men attending a large STI clinic in Amsterdam: a longitudinal study.

OBJECTIVE: In the Netherlands, men who have sex with men (MSM) are advised via informal guidelines to test for STI at least annually. We estimated the proportion of HIV-negative MSM testing repeatedly at 12-month or smaller intervals at a large STI clinic in the Netherlands. In addition, we explored whether repeated testing is related to risk behaviour. DESIGN AND METHODS: Longitudinal data of HIV-negative MSM visiting the Amsterdam STI clinic between 2009 and 2012 were analysed. To estimate the timing of repeated testing, Kaplan-Meier methods were used. Determinants for repeated testing (distinguishing testing at 12-month or smaller intervals and less than 12-monthly testing, with single testers as reference group) were identified using multivariate multinomial logistic regression analyses. RESULTS: In total, 19,479 consultations of 9174 HIV-negative MSM were identified. Of these MSM, 35% (95% CI 33% to 36%) were estimated to return to the STI clinic within 1 year following baseline consultation. Among 1767 men with at least two consultations and at least 2 years between baseline and last consultation, 43% tested repeatedly at 12-month or smaller intervals in those first 2 years. Repeated testers reported higher sexual risk behaviour (ie, only casual or both casual and steady sex partners, higher numbers of sex partners) at baseline compared with single testers. This effect tended to be slightly stronger for men testing repeatedly at 12-month or smaller intervals. CONCLUSIONS: The proportion of MSM testing for STI annually is low. MSM testing repeatedly had higher baseline levels of risk behaviour. Strategies to motivate MSM to test annually should be explored.