Gender and non-communicable diseases in Mexico: a political mapping and stakeholder analysis.

BACKGROUND: Mexico and other low- and middle-income countries (LMICs) present a growing burden of non-communicable diseases (NCDs), with gender-differentiated risk factors and access to prevention, diagnosis and care. However, the political agenda in LMICs as it relates to health and gender is primarily focused on sexual and reproductive health rights and preventing violence against women. This research article analyses public policies related to gender and NCDs, identifying political challenges in the current response to women's health needs, and opportunities to promote interventions that recognize the role of gender in NCDs and NCD care in Mexico. METHODS: We carried out a political mapping and stakeholder analysis during July-October of 2022, based on structured desk research and interviews with eighteen key stakeholders related to healthcare, gender and NCDs in Mexico. We used the PolicyMaker V5 software to identify obstacles and opportunities to promote interventions that recognize the role of gender in NCDs and NCD care, from the perspective of the political stakeholders interviewed. RESULTS: We found as a political obstacle that policies and stakeholders addressing NCDs do not take a gender perspective, while policies and stakeholders addressing gender equality do not adequately consider NCDs. The gendered social and economic aspects of the NCD burden are not widely understood, and the multi-sectoral approach needed to address these aspects is lacking. Economic obstacles show that budget cuts exacerbated by the pandemic are a significant obstacle to social protection mechanisms to support those caring for people living with NCDs. CONCLUSIONS: Moving towards an effective, equity-promoting health and social protection system requires the government to adopt an intersectoral, gender-based approach to the prevention and control of NCDs and the burden of NCD care. Despite significant resource constraints, policy innovation may be possible given the willingness among some stakeholders to collaborate, particularly in the labour and legal sectors. However, care will be needed to ensure the implementation of new policies has a positive impact on both gender equity and health outcomes. Research on successful approaches in other contexts can help to identify relevant learnings for Mexico.

Dificultades de funcionamiento en la infancia, adolescencia y edad adulta en México, 2022.

OBJETIVO: Conocer las prevalencias nacionales de dificultad del funcionamiento de niñas, niños, adolescentes y adultos. Material y métodos. La Encuesta Nacional de Salud y Nutrición 2022 utilizó los módulos de discapacidad del Fondo de las Naciones Unidas para la Infancia (Unicef) y el Grupo Washington. Se calcularon las prevalencias de dificultad del funcionamiento e intervalos de confianza al 95%. RESULTADOS: El 14.4% de la población de 2-17 años presentó al menos una dificultad del funcionamiento, 3.9% entre 2-4 años y 16.7% para 5-17 años. El 9.7% de los adultos presentaron dificultad del funcionamiento, siendo más frecuente en mujeres (11.3%) y en índice de bienestar bajo (12.2%). Conclusión. Una de cada diez personas adultas en México experimentan dificultades de funcionamiento y es mayor en mujeres adultas y personas con índice de bienestar bajo. El Estado Mexicano debe detectar los problemas de funcionamiento potencialmente tratables y establecer programas de adecuación de los entornos para facilitar el funcionamiento de las personas.

Prevalence and development of a risk score for oral human papillomavirus infection in men who have sex with men in Mexico.

BACKGROUND: Men who have sex with men (MSM) are at high risk for oral human papillomavirus (HPV infection). There are no specific screening guidelines to facilitate the identification of people at risk for oral HPV infection. We aimed to estimate the prevalence of oral high-risk HPV and create a risk score to identify MSM at higher risk for prevalent oral HPV. METHODS: We collected baseline data from a clinical trial from a subsample of 500 MSM attending sexually transmitted disease treatment clinics; they provided an oral gargle sample for high-risk HPV detection. We calculated oral high-risk HPV prevalence and 95% confidence intervals (CIs), used a logistic regression model to identify factors associated with high-risk HPV infection, and created a risk score. RESULTS: The prevalence of any oral high-risk HPV among MSM was 11.1% (95% CI: 8.6-14.2), with a higher prevalence observed among men living with HIV (14.8%). Factors independently associated with oral high-risk HPV were age ≥40 years (OR = 2.71, 95% CI: 1.28-5.73 compared to <40 years), being HIV-positive with CD4 count 200-499 (OR = 2.76, 95% CI: 1.34-5.65 compared to HIV-negative), and recent recreational use of vasodilators (poppers/sildenafil) (OR = 2.02, 95% CI: 1.02-2.97). The risk score had good discriminatory power (AUC = 0.70, 95% CI: 0.63-0.77). CONCLUSIONS: MSM have specific predictors for prevalent oral high-risk HPV, and a risk score could be used by clinicians to target men with vaccine recommendations and counseling, and identify those who could benefit from primary interventions given the available resources, or for referral to dental services for follow-up when available.

Prevalence of cervical human papillomavirus in Mexico, 2010-2017: analysis of 2.7 million women.

PURPOSE: Prevalence of cervical high-risk human papillomavirus (hrHPV) infection varies greatly. Data on distribution of hrHPV infection constitute important evidence for decision-making when implementing HPV testing into cervical cancer screening programs. We estimate the prevalence of cervical hrHPV infection in a large sample of women in a middle-income country and explore variation by age, community marginalization and region in women using public cervical cancer screening services. METHODS: Records covering 2010-2017 from a registry of hrHPV test results (Hybrid Capture 2 and polymerase chain reaction) in 2,737,022 women 35-64 years were analyzed. In this observational study, 32 states were categorized into five geographical regions and classified by degree of marginalization. We stratified by test type and estimated crude and adjusted prevalence and rate ratios and used Poisson models and joinpoint regression analysis. RESULTS: Prevalence was higher in women 35-39 years, at 10.4% (95% CI 10.3-10.5) and women 60-64 years, at 10.1% (95% CI 10.0-10.3). Prevalence was higher in the southeast, at 10.5% (95% CI 10.4-10.6). Women living in less marginalized areas had a significantly higher prevalence, at 10.3% (95% CI 10.2-10.4) compared to those in highly marginalized areas, at 8.7% (95% CI 8.5-8.7). HPV16 infection was detected in 0.92% (2,293/23,854) of women and HPV18 infection was detected in 0.39% (978/23,854) of women. CONCLUSION: Understanding the distribution of HPV prevalence has value as evidence for developing policy in order to improve cervical cancer screening strategies. These results will constitute evidence to allow decision makers to better choose where to focus those resources that they do have.

Comparative performance of the human papillomavirus test and cytology for primary screening for high-grade cervical intraepithelial neoplasia at the population level.

The World Health Organization recommends high-risk human papillomavirus (hrHPV)-based screening for women 39 to 49 years, based on the greater accuracy of hrHPV-based screening for cervical cancer detection. Many cervical cancer screening programs have incorporated hrHPV testing and multiple early cervical cancer detection strategies have been evaluated, mostly under controlled conditions. However, there are few evaluations of combined hrHPV and cytology strategies post-implementation at the population level. Our study sought to estimate the relative yield of hrHPV testing compared to cervical cytology, as a primary screening test for cervical intraepithelial neoplasia grade 2+ (CIN2+), used at the population level. We analyzed screening data from Mexico's public cervical cancer prevention program from 2010 to 2015 in women 35 to 64 years. The study population consisted of two cohorts: one from a total of 2 881 962 cytology-based screening tests and another from a total of 2 004 497 hrHPV-based screening tests, which are concurrent in time. We performed a relative yield analysis using Poisson regression models to compare the effectiveness of hrHPV testing for CIN2+ with cervical cytology. A total of 4 886 459 records were analyzed, including 23 999 biopsies; 0.12% (n = 6166) had a CIN2+ histologic diagnosis. hrHPV testing with cytological triage detects twice as many CIN2+ cases as screening using cytology alone.

Identifying and Minimizing Errors in the Measurement of Early Childhood Development: Lessons Learned from the Cognitive Testing of the ECDI2030.

Challenges in measuring early childhood development (ECD) at scale have been documented, yet little is known about the specific difficulties related to questionnaire design and question interpretation. The purpose of this paper is to discuss the challenges of measuring ECD at scale in the context of household surveys and to show how to overcome them. The paper uses examples from the cognitive interviewing exercises that were conducted as part of the methodological work to develop a measure of ECD outcomes, the ECDI2030. It describes the methodological work carried out to inform the selection and improvement of question items and survey implementation tools as a fundamental step to reduce and mitigate systematic measurement error and improve data quality. The project consisted of a total of five rounds of testing, comprising 191 one-on-one, in-depth cognitive interviews across six countries (Bulgaria, India, Jamaica, Mexico, Uganda, and the USA). Qualitative data analysis methods were used to determine matches and mismatches between intention of items and false positives or false negative answers among subgroups of respondents. Key themes emerged that could potentially lead to systematic measurement error in population-based surveys on ECD: (1) willingness of child to perform task versus ability of child to perform task; (2) performing task versus performing task correctly; (3) identifying letters or numbers versus recognizing letters or numbers; (4) consistently performing task versus correctly performing task; (5) applicability of skills being asked versus observability of skills being asked; and (6) language production versus language comprehension. Through an iterative process of testing and subsequent revision, improvements were made to item wording, response options, and interviewer training instructions. Given the difficulties inherent in population-level data collection in the context of global monitoring, this study's findings confirm the importance of cognitive testing as a crucial step in careful, culturally relevant, and sensitive questionnaire design and as a means to reduce response bias in cross-cultural contexts.

Children and adolescents with neurodevelopmental disorders show cognitive heterogeneity and require a person-centered approach.

We aimed to identify patterns of cognitive differences and characterize subgroups of Mexican children and adolescents with three neurodevelopmental disorders (NDD): intellectual disability (ID), autism spectrum disorders (ASD) and attention deficit/hyperactivity disorder (ADHD). The sample included 74 children and adolescents 6-15 years; 34% had ID, ASD or ADHD, 47% had ID in comorbidity with ASD, ADHD or both, 11% had ASD + ADHD, 8% were children without NDD. We applied WISC-IV, Autism Diagnostic Interview-Revised, Mini-International Neuropsychiatric Structured Interview, Child Behavior Checklist, and UNICEF Child Functioning Module. We evaluated the normality of the WISC-IV sub-scales using the Shapiro-Francia test, then conducted a latent class analysis and assessed inter-class differences in terms of household, parent and child characteristics. The following four-class solution best fit the data: "Lower Cognitive Profile" (LCP), "Lower Working Memory" (LWM), "Higher Working Memory" (HWM), "Higher Cognitive Profile" (HCP). LCP included most of the children with ID, who had a low Working Memory (WM) index score. LWM included mainly children with ASD or ID + ADHD; their Perceptual Reasoning (PR) and Processing Speed (PS) index scores were much higher than those for Verbal Comprehension (VC) and WM. HWM included children with ASD or ADHD; their scores for PR, PS and VC were high with lower WM (although higher than for LWM). HCP included children without NDD and with ASD or ADHD or both and had the highest scores on all indices. Children with NDD show cognitive heterogeneity and thus require individualized treatment plans.

Sex Work and High-Risk Anal Human Papillomavirus Infection Among Transgender Women: The Condesa Study.

Purpose: The prevalence of high-risk human papillomavirus (hrHPV) infection among transgender women has been reported to be very high and sexually transmitted infection (STI) prevention strategies have focused on transgender women who engage in sex work. The purpose of our study was to describe hrHPV infection prevalence among a group of transgender women and to explore the differences according to sex work history (SW). Methods: The Condesa Study, an HPV vaccine, and screening study, recruited 207 transgender women without previous HPV vaccination, ages 18-60, from two clinics in Mexico City that provide HIV and transgender health care (May 2018-December 2019). At enrollment, they completed a questionnaire on sociodemographic and sexual behavior data. The hrHPV DNA genotyping was done on self-collected anal samples. Factors associated with hrHPV, stratified by presence or absence of SW, were assessed with multiple logistic regression. Results: A total of 43.5% of participants reported a history of SW. Anal hrHPV prevalence was 62.0% among participants with a history of SW and 52.0% among those without. Overall, 1 in 4 (26.6%) participants were living with HIV. Independent risk factors associated with hrHPV among transgender women with a history of SW were younger age, younger age at first anal intercourse (15-17 years), and greater number of sexual partners in the last 3 months. Among transgender women who had not done SW, greater number of sexual partners in the last 3 months and self-reported STIs were associated with hrHPV. Conclusions: Prevalence of anal infection with hrHPV was high among transgender women. Our results support that other sexual behaviors different from participating in SW contribute to the high prevalence of HPV and that there is an urgent need to include all transgender women in prevention programs for HPV and associated cancers, regardless of SW.

[Methodological bases of the measurement of earlychildhood development in the Ensanut 100k survey]. / Bases metodológicas de lamedición de desarrollo infantiltemprano en la Ensanut 100k.

OBJECTIVE: The methods that were carried out for the inclusion of the early childhood development module in the Ensanut 100k are presented. MATERIALS AND METHODS: With this module and the questionnaire for children under five years-old, indicators of the state of health, development and well-being of children in the first five years of life are obtained. From November to December 2017, the sample design, instruments and manuals were defined and a test was carried out. Field staff were trained and standardized. The information was collected between January and June 2018. RESULTS: 3 892 children from 0 to 59 months of age were studied in the DIT Module of the Survey. CONCLUSIONS: Training and standardization of field personnel, by trained and standardized personnel, minimizes information biases.

OBJETIVO: Presentar los métodos realizados para la inclu-sión del módulo de Desarrollo Infantil Temprano (DIT) en la Ensanut 100k. MATERIAL Y MÉTODOS: Con dicho módulo y el cuestionario de menores de cinco años, se obtuvieron indicadores del estado de salud, desarrollo y bienestar de niñas/os en los primeros cinco años de vida.De noviembre a diciembre de 2017, se definió el diseño de la muestra, instrumentos y manuales, y se realizó una prueba piloto. Se capacitó y estandarizó al personal de campo. El levantamiento de información se realizó entre enero y junio de 2018. RESULTADOS: Se estudió en el módulo DIT de la encuesta a 3 892 niños/as de 0 a 59 meses de edad. CONCLUSIONES: La capacitación y estandarización del personal de campo, por parte de personal capacitado y estandarizado, minimiza los sesgos de información.

Bases metodológicas de la medición de desarrollo infantil temprano en la Ensanut 100k / Methodological bases of the measurement of early childhood development in the Ensanut 100k survey

Resumen Objetivo: Presentar los métodos realizados para la inclusión del módulo de Desarrollo Infantil Temprano (DIT) en la Ensanut 100k. Material y métodos: Con dicho módulo y el cuestionario de menores de cinco años, se obtuvieron indicadores del estado de salud, desarrollo y bienestar de niñas/os en los primeros cinco años de vida. De noviembre a diciembre de 2017, se definió el diseño de la muestra, instrumentos y manuales, y se realizó una prueba piloto. Se capacitó y estandarizó al personal de campo. El levantamiento de información se realizó entre enero y junio de 2018. Resultados: Se estudió en el módulo DIT de la encuesta a 3 892 niños/as de 0 a 59 meses de edad. Conclusiones: La capacitación y estandarización del personal de campo, por parte de personal capacitado y estandarizado, minimiza los sesgos de información.

Abstract Objective: The methods that were carried out for the inclusion of the early childhood development module in the Ensanut 100k are presented. Materials and methods: With this module and the questionnaire for children under five years-old, indicators of the state of health, development and well-being of children in the first five years of life are obtained. From November to December 2017, the sample design, instruments and manuals were defined and a test was carried out. Field staff were trained and standardized. The information was collected between January and June 2018. Results: 3 892 children from 0 to 59 months of age were studied in the DIT Module of the Survey. Conclusions: Training and standardization of field personnel, by trained and standardized personnel, minimizes information biases.

Barriers and facilitators for colorectal cancer screening in a low-income urban community in Mexico City.

BACKGROUND: Colorectal cancer (CRC) incidence and mortality are increasing in many low- and middle-income countries (LMICs), possibly due to a combination of changing lifestyles and improved healthcare infrastructure to facilitate diagnosis. Unfortunately, a large proportion of CRC cases in these countries remain undiagnosed or are diagnosed at advanced stages, resulting in poor outcomes. Decreasing mortality trends in HICs are likely due to evidence-based screening and treatment approaches that are not widely available in LMICs. Formative research to identify emerging opportunities to implement appropriate screening and treatment programs in LMICs is, therefore, of growing importance. We sought to identify potential barriers and facilitators for future implementation of fecal immunochemical test (FIT)-based CRC screening in a public healthcare system in a middle-income country with increasing CRC incidence and mortality. METHODS: We performed a qualitative study with semi-structured individual and focus group interviews with different CRC screening stakeholders, including 30 lay people at average risk for CRC, 13 health care personnel from a local public clinic, and 7 endoscopy personnel from a cancer referral hospital. All interviews were transcribed verbatim for analysis. Data were analyzed using the constant comparison method, under the theoretical perspectives of the social ecological model (SEM), the PRECEDE-PROCEED model, and the health belief model. RESULTS: We identified barriers and facilitators for implementation of a FIT-based CRC screening program at several levels of the SEM. The main barriers in each of the SEM levels were as follows: (1) at the social context level: poverty, health literacy and lay beliefs related to gender, cancer, allopathic medicine, and religion; (2) at the health services organization level: a lack of CRC knowledge among health care personnel and the community perception of poor quality of health care; and (3) at the individual level: a lack of CRC awareness and therefore lack of risk perception, together with fear of participating in screening activities and finding out about a serious disease. The main facilitators perceived by the participants were CRC screening information and the free provision of screening tests. CONCLUSIONS: This study's findings suggest that multi-level CRC screening programs in middle-income countries such as Mexico should incorporate complementary strategies to address barriers and facilitators, such as (1) provision of free screening tests, (2) education of primary healthcare personnel, and (3) promotion of non-fear-based CRC screening messages to the target population, tailored to address common lay beliefs.

Uptake of the HPV vaccine among people with and without HIV, cisgender and transgender women and men who have sex with men and with women at two sexual health clinics in Mexico City.

Our aim was to better understand Human Papillomavirus (HPV) vaccine acceptance among Mexican adults including people with and without HIV, cisgender men who have sex with men (MSM) or with women (MSW), cisgender and transgender women. A computer-assisted, self-administered questionnaire was completed by healthcare users and participants recruited through community organizations, and the first dose of the quadrivalent HPV vaccine was offered at no cost at a large sexual health clinic in Mexico City, from May to December 2018. Socio-demographic characteristics and factors associated with HPV vaccine acceptance were analyzed using logistic regression.The sample of 1915 participants included 1341 cisgender men (70.9%, 1247 MSM and 94 MSW), 396 (20.7%) cisgender women and 178 (9.3%) transwomen; 615 people (32.1%) were HIV positive. Uptake of the HPV vaccine was higher in men and transwomen (91.5% and 87%, respectively) than among cisgender women (81.8%; p < .001). Cisgender women (OR 0.43, 95%CI 0.30-0.61, p < .05) were less likely to accept HPV vaccination than men. Married/partnered people were less likely to accept HPV vaccination compared to those who were single (OR 0.70, 95%CI 0.51-0.97). People living with HIV were not significantly more likely to accept HPV vaccination (OR 1.7; 95%CI 0.86-1.61).HPV vaccine acceptance was high among adult Mexican study participants; it may be higher than among other Mexican adults given most of these individuals are engaged in care. Modifications will be needed in national and international recommendations on HPV vaccination in adults if healthcare personnel are to recommend the vaccine to the population groups studied.

The importance of the cultural dimension of food in understanding the lack of adherence to diet regimens among Mayan people with diabetes.

OBJECTIVE: To understand non-adherence to medically recommended diets among Mayans with diabetes. DESIGN: Using partially sequential mixed methods, questionnaires, semi-structured brief and in-depth interviews were applied. Questionnaire data were analysed with Pearson's χ2 and Student's t tests and qualitative interviews with grounded theory microanalysis. SETTING: Rural, predominantly Mayan communities in Chiapas, Quintana Roo and Yucatan, Mexico, 2008-2012. PARTICIPANTS: Purposive sample of Mayans with type 2 diabetes; using public health care; 168 women and twenty-seven men; age 21-50+ years. RESULTS: Participants understood diabetes as caused by negative emotions, divine punishment, revenge via spells, chemicals in food and high sugar/fat consumption. Eliminating corn, pork, sugary beverages and inexpensive industrialized foods was perceived as difficult or impossible. More Mayans reporting not understanding physician instructions (30 v. 18 %) reported difficulty reducing red meat consumption (P = 0·051). Non-adherence was influenced by lack of patient-provider shared knowledge and medical recommendations misaligned with local culture. Men whose wives prepared their meals, women who liked vegetables and young adults whose mothers prepared their meals reported greater adherence to dietary recommendations. Partial adherents said it made life tolerable and those making no physician-recommended dietary changes considered them too restrictive (they meant 'starving to death'). Over half (57 %) of participants reported non-adherence; the two principal reasons were dislike of recommended foods (52·5 %) and high cost (26·2 %). CONCLUSIONS: Adherence to dietary regimens in diabetes treatment is largely related to social and cultural issues. Taking cultural diversity, food preferences, local food availability and poverty into consideration is essential when developing health-promotion activities related to diabetes.

Incidence of external genital lesions related to human papillomavirus among Mexican men. A cohort study / Incidencia de lesiones genitales externas relacionadas con el virus del papiloma humano entre hombres mexicanos. Un estudio de cohorte

Abstract: Objective: To determine external genital lesion (EGL) incidence -condyloma and penile intraepithelial neoplasia (PeIN)- and genital HPV-genotype progression to these EGLs. Materials and methods: Participants (healthy males 18-74y from Cuernavaca, Mexico, recruited 2005-2009, n=954) underwent a questionnaire, anogenital examination, and sample collection every six months; including excision biopsy on suspicious EGL with histological confirmation. Linear array assay PCR characterized 37 high/low-risk HPV-DNA types. EGL incidence and cumulative incidence were calculated, the latter with Kaplan-Meier. Results: EGL incidence was 1.84 (95%CI=1.42-2.39) per 100-person-years (py); 2.9% (95%CI=1.9-4.2) 12-month cumulative EGL. Highest EGL incidence was found in men 18-30 years: 1.99 (95%CI=1.22-3.25) per 100py. Seven subjects had PeIN I-III (four with HPV16). HPV11 most commonly progresses to condyloma (6-month cumulative incidence=44.4%, 95%CI=14.3-137.8). Subjects with high-risk sexual behavior had higher EGL incidence. Conclusion: In Mexico, anogenital HPV infection in men is high and can cause condyloma. Estimation of EGL magnitude and associated healthcare costs is necessary to assess the need for male anti-HPV vaccination.

Resumen: Objetivo: Determinar incidencia de lesiones genitales externas (LGE) -condiloma y neoplasia intraepitelial del pene (NIP)- y progresión de genotipos de VPH a LGE. Material y métodos: Se aplicaron cuestionarios, examen anogenital y recolección de muestras cada seis meses a hombres sanos (18-74 años, de Cuernavaca, México, reclutados 2005-2009, n=954) con biopsia y confirmación histológica. Se caracterizaron 37 tipos de ADN-VPH; se calculó incidencia de LGE (cumulativa con Kaplan-Meier). Resultados: Incidencia de LGE=1.84 (IC95%=1.42-2.39) por 100-persona-años (pa); 2.9% (IC95%=1.9-4.2) LGE acumulativa a 12 meses. Mayor incidencia de LGE entre hombres 18-30 años; 1.99 (IC95%=1.22-3.25) por 100pa. Siete sujetos tuvieron NIP I-III. VPH-11 más comúnmente progresa a condiloma (incidencia acumulativa a seis meses=44.4%, IC95%=14.3-137.8). Los sujetos con comportamiento sexual de alto riesgo tuvieron mayor incidencia de LGE. Conclusiones: En México la infección anogenital con VPH es alta y puede causar condiloma. La estimación de magnitud de LGE y los costos sanitarios asociados se necesita para evaluar la necesidad de vacunación contra VPH en hombres.

Prevalence and incidence of anal human papillomavirus infection in Mexican men: Need for universal prevention policies / Prevalencia e incidencia de infección por virus de papiloma humano en canal anal en hombres mexicanos: Necesidad de políticas de prevención universal

Abstract: Objective: Describe the natural history of anal HPV among men. Materials and methods: Prospective study among men 18-70 years (n=665), from Cuernavaca, Mexico who completed questionnaires and provided specimens (HPV genotyped) at enrollment and 1+ follow-up visit. HPV prevalence and incidence were estimated. Prevalence ratios were calculated with Poisson regression using robust variance estimation. Person-time for incident HPV infection was estimated using number of events modeled as Poisson variable for total person-months. Results: Anal infection prevalence: any HPV type=15%, high-risk=8.4%, HPV16=1.4%, tetravalent vaccine types (4vHPV)=4.4%, nonavalent vaccine types (9vHPV)=6.3%. Factors associated with prevalence: 50+ lifetime female sex partners (adjusted prevalence ratio, a PR=3.25, 95% CI:1.12-9.47), 10+ lifetime male sex partners (aPR=3.06, 95%CI:1.4-6.68), and 1+ recent male anal sex partners (aPR=2.28, 95%CI:1.15-4.5). Anal incidence rate: high-risk HPV=7.8/1 000 person-months (95%CI:6.0-10.1), HPV16=1.8/1 000 person-months (95%CI:1.1-2.9),4vHPV=3.4/1 000 person-months (95%CI:2.3-4.9) and 9vHPV=5.5/1000 person-months (95%CI:4.1-7.5). Conclusions: Implementation of universal HPV vaccination programs, including men, is a public health priority.

Resumen: Objetivo: Generar evidencia que apoye la vacunación universal contra VPH. Material y métodos: Estudio prospectivo con hombres 18-70 años (n=665) de Cuernavaca, México con cuestionarios y genotipificación de VPH en muestras (2+mediciones). Se estimó prevalencia e incidencia; se calcularon tasas de prevalencia con regresión Poisson. Se estimó persona-tiempo para infecciones incidentes. Resultados: Prevalencia de infección anal: cualquier tipo de VPH=15%, alto-riesgo=8.4%, VPH16=1.4%, tipos en vacuna tetravalente=4.4% y tipos en vacuna nonavalente=6.3%. Factores asociados con infección prevalente: 50+ parejas sexuales femeninas en la vida (tasa de prevalencia ajustada, TPa=3.25, IC95%:1.12-9.47); 10+ parejas sexuales masculinas en la vida (TPa=3.06, IC95%:1.4-6.68) y 1+ parejas masculinas (sexo anal) recientes (TPa=2.28, IC95%:1.15-4.5). Tasas de incidencia para infección anal: VPH alto-riesgo=7.8/1000 persona-meses (IC95%:6.0-10.1), VPH 16=1.8/1000 persona-meses (95%IC:1.1-2.9), tipos en vacuna tetravalente=3.4/1000 persona-meses y tipos en vacuna nonavalente=5.5/1000 persona-meses. Conclusiones: Implementación de programas de vacunación universal (incluyendo hombres) contra VPH es una prioridad en salud pública.

HPV vaccine acceptance is high among adults in Mexico, particularly in people living with HIV / Aceptación de la vacuna contra VPH es alta entre adultos en México, especialmente en personas con VIH

Abstract: Objective. To measure HPV vaccine acceptance in diverse Mexican adult popula­tions, taking into account HIV status. Materials and methods: A total of 1 329 men and women, with and without HIV, participated in one of three intervention studies, offering HPV vaccination, carried out in the states of Morelos, Tlaxcala and Mexico City; either the bivalent (Morelos n=103, Tlaxcala n=127) or quadrivalent HPV-vaccine (Mexico City n=1 099) was offered. Results: HPV vaccine was accepted by 80.3% of participants; acceptance was higher in people living with HIV than those without (84.4 vs. 78%, p=0.004). Women had greater HPV infection knowledge (p<0.0001) than men and slightly higher (p=0.4) vaccine acceptance. The main reason for vaccine non-acceptance among HIV-positive participants was their doctor recommended they not get vaccinated. Conclusion: Acceptance of HPV-vaccine was high in men and women regardless of HIV status. Even higher rates of acceptability may be achieved by educating healthcare providers to recommend HPV vaccine to their patients.

Resumen: Objetivo. Medir la aceptación de la vacuna de VPH en una muestra diversa de población adulta mexicana, teniendo en cuenta su estado de VIH. Material y métodos: 1 329 hombres y mujeres con y sin VIH participaron en tres estudios de intervención, realizados en los estados de Morelos, Tlaxcala y Ciudad de México. Se ofreció la vacuna bivalente (Morelos n=103, Tlaxcala n=127) o la cuadrivalente (Ciudad de México n=1 099) contra VPH. Resultados: La vacuna fue aceptada por 80.3% de los participantes; la aceptación fue mayor en personas que viven con VIH que en aquéllas que no (84.4 vs. 78%, p=0.004). Las mujeres (p<0.0001) tenían mayor conocimientos sobre VPH que los hombres y una aceptación de la vacuna ligeramente mayor (p=0.4). El motivo principal de la no aceptación de la vacuna entre personas con VIH fue que su médico recomendó que no se vacunaran. Conclusión: La aceptación de la vacuna contra el VPH fue alta en hombres y mujeres, independientemente del estado de VIH. Se pueden lograr mayores tasas de aceptabilidad educando a los proveedores de atención médica para que recomienden la vacuna contra el VPH a sus pacientes.

Prevention and control of neoplasms associated with HPV in high-risk groups in Mexico City: The Condesa Study / Prevención y control de neoplasias asociadas a VPH en grupos de alto riesgo de la Ciudad de México: el Estudio Condesa

Abstract: Objective: To evaluate the effectiveness of a combined strategy of human papillomavirus virus (HPV) vaccination and high-risk HPV screening to reduce the occurrence of anogenital and oropharyngeal neoplasms among men who have sex with men, people with HIV, homeless people, transgender women, female sex workers and rape victims. Materials and methods: This mixed methods study evaluates the effectiveness of a combined vaccination-screening strategy to reduce HPV prevalence/incidence and occurrence of cervical intraepithelial neoplasms grade 2+ and/or anal intraepithelial neoplasms grade 2+, using Kaplan-Meier. The time-to-event method will evaluate time from positive results for specific anogenital HPV to incidence of anogenital lesions containing that HPV type. Results: People vaccinated against HPV and screened for HPV as a primary test will have lower prevalence and incidence of HPV infection and consequently lower frequency of HPV-related anogenital and oropharyngeal lesions. Conclusions: This study will generate scientific evidence on effectiveness of a combined vaccination-screening strategy to reduce the burden of HPV-associated neoplasms.

Resumen: Objetivo: Evaluar la efectividad de una estrategia combinada de vacunación contra el virus de papiloma humano (VPH) y tamizaje de VPH de alto riesgo para reducir neoplasias anogenitales y orofaringeas entre hombres que tienen sexo con hombres, personas con VIH, personas en situación de calle, mujeres transgénero, trabajadoras sexuales y víctimas de violación. Material y métodos: Este estudio evaluará la efectividad de una estrategia combinada de vacunación y tamizaje para reducir la ocurrencia de neoplasias intraepiteliales cervicales grado 2+ o neoplasias intraepiteliales anales grado NIA2+ utilizando Kaplan-Meier. Se evaluará tiempo de resultados positivos para tipos específicos de VPH anogenital a incidencia de lesiones anogenitales con ese tipo de VPH. Resultados: Las personas vacunadas contra VPH y con tamizaje de VPH tendrán menor prevalencia e incidencia de infecciones por VPH y por ende menor frecuencia de lesiones anogenitales y orofaringeas relacionadas con VPH. Conclusiones: Este estudio generará evidencia científica sobre la efectividad de una estrategia combinada de vacunación y tamizaje para reducir la carga de neoplasias asociadas al VPH.

Perceptions of adolescent 'simulated clients' on barriers to seeking contraceptive services in health centers and pharmacies in Mexico.

OBJECTIVE: To examine adolescent simulated clients' perceived barriers to quality care as they sought information on contraceptives in public-sector healthcare facilities and pharmacies in Mexico. STUDY DESIGN: We used a qualitative research design and conducted semi-structured interviews with eight young women who posed as simulated clients at health centers and pharmacies in Mexico City. Grounded Theory was used to analyze the transcripts. RESULTS: Barriers to receiving information about contraceptives included healthcare professionals who gave administrative pretexts to avoid providing services. Simulated clients also felt judged by healthcare professionals and reported a lack of simple, understandable and pertinent information. Healthcare professionals did not ensure clients understood and had no further questions about using contraceptives, which resulted in clients' poor perceived self-efficacy, as well as a lack of confidence in the healthcare system to help them. CONCLUSIONS: When healthcare professionals fail to provide services according to the World Health Organization's five basic criteria of adolescent friendly care, adolescents perceive important barriers in their access to contraceptive methods. Quality of sexual health care in Mexico would benefit from efforts to improve healthcare professionals' knowledge, attitudes and skills related to adolescent friendly service delivery.

Sexual and reproductive health outcomes are positively associated with comprehensive sexual education exposure in Mexican high-school students.

OBJECTIVES: To describe the comprehensive sex education (CSE) coverage and to evaluate a set of indicators related to knowledge, attitudes, and practices associated with the seven components of the CSE framework among Mexican high-school students. METHODS: We conducted a cross-sectional survey of a nationally representative sample of students in public and private high schools in Mexico. Questions about CSE coverage and about knowledge, attitudes, and practices related to sexual health were included. We present descriptive statistics for demographic characteristics, exposure to CSE, and sexual health outcomes. We fitted a series of multivariate logistic regression models to examine the association between each CSE component exposure and sexual health outcomes, adjusting for age and sex. RESULTS: There were significant associations between being exposed to each CSE components and the related sexual health outcomes. The strongest one was for identifying effective contraceptives among those exposed to the Sexual and Reproductive Health component (SRH) (OR 4.10; 95%CI[2.93,5.75]). Also, students exposed to the relationships component had 20% higher odds of affirming they could convince their partner to use condoms (OR 1.20; 95%CI[1.05,1.36]). CONCLUSIONS: This paper provides evidence of the potential beneficial effects of CSE on attitudes, knowledge, and behaviors regarding sexual and reproductive health among adolescents. In addition, it identifies areas that should be strengthened to increase the positive impact of CSE.

Incidence of external genital lesions related to human papillomavirus among Mexican men. A cohort study.

OBJECTIVE: To determine external genital lesion (EGL) incidence -condyloma and penile intraepithelial neoplasia (PeIN)- and genital HPV-genotype progression to these EGLs. MATERIALS AND METHODS: Participants (healthy males 18- 74y from Cuernavaca, Mexico, recruited 2005-2009, n=954) underwent a questionnaire, anogenital examination, and sample collection every six months;including excision biopsy on suspicious EGL with histological confirmation.Linear array assay PCR characterized 37 high/low-risk HPV-DNA types. EGL incidence and cumulative incidence were calculated, the latter with Kaplan-Meier. RESULTS: EGL incidence was 1.84 (95%CI=1.42-2.39) per 100-person-years (py); 2.9% (95%CI=1.9-4.2) 12-month cumulative EGL.Highest EGL inci- dence was found in men 18-30 years:1.99 (95%CI=1.22-3.25) per 100py. Seven subjects had PeIN I-III (four with HPV16). HPV11 most commonly progresses to condyloma (6-month cumulative incidence=44.4%, 95%CI=14.3-137.8). Subject with high-risk sexual behavior had higher EGL incidence. CONCLUSIONS: In Mexico, anogenital HPV infection in men is high and can cause condyloma. Estimation of EGL magnitude and associated healthcare costs is necessary to assess the need for male anti-HPV vaccination.

OBJETIVO: Determinar incidencia de lesiones genitales externas (LGE) ­condiloma y neoplasia intraepitelial del pene (NIP)­ y progresión de genotipos deVPH a LGE. MATERIAL Y MÉTODOS: Se aplicaron cuestionarios,examen anogenital y recolección de muestras cada seis meses a hombres sanos (18-74 años, de Cuernavaca, México, reclutados 2005-2009, n=954) con biopsia y confirmación histológica. Se caracteri- zaron 37 tipos de ADN-VPH; se calculó incidencia de LGE (cumulativa con Kaplan-Meier). RESULTADOS: Incidencia de LGE=1.84 (IC95%=1.42-2.39) por 100-persona-años (pa); 2.9% (IC95%=1.9-4.2) LGE acumulativa a 12 meses. Mayor incidencia de LGE entre hombres 18-30 años; 1.99 (IC95%=1.22-3.25) por 100pa.Siete sujetos tuvieron NIP I-III. VPH-11 más comúnmente progresa a condiloma (incidencia acumulativa a seis meses=44.4%, IC95%=14.3-137.8). Los sujetos con comportamiento sexual de alto riesgo tuvieron mayor incidencia de LGE. CONCLUSIONES: En México la infección anogenital conVPH es alta y puede causar condiloma. La estimación de magnitud de LGE y los costos sanitarios asociados se necesita para evaluar la necesidad de vacunación contra VPH en hombres.