Excess Mortality During 2020 in Spain: The Most Affected Population, Age, and Educational Group by the COVID-19 Pandemic.

OBJECTIVE: The objective of this work was to study mortality increase in Spain during the first and second academic semesters of 2020, coinciding with the first 2 waves of the Covid-19 pandemic; by sex, age, and education. METHODS: An observational study was carried out, using linked populations and deaths' data from 2017 to 2020. The mortality rates from all causes and leading causes other than Covid-19 during each semester of 2020, compared to the 2017-2019 averages for the same semester, was also estimated. Mortality rate ratios (MRR) and differences were used for comparison. RESULTS: All-cause mortality rates increased in 2020 compared to pre-covid, except among working-age, (25-64 years) highly-educated women. Such increases were larger in lower-educated people between the working age range, in both 2020 semesters, but not at other ages. In the elderly, the MMR in the first semester in women and men were respectively, 1.14, and 1.25 among lower-educated people, and 1.28 and 1.23 among highly-educated people. In the second semester, the MMR were 1.12 in both sexes among lower-educated people and 1.13 in women and 1.16 in men among highly-educated people. CONCLUSION: Lower-educated people within working age and highly-educated people at older ages showed the greatest increase in all-cause mortality in 2020, compared to the pre-pandemic period.

Heavy Drinking by Occupation in Spain: Differences Between Weekdays and the Weekend.

Estimating occupational disparity in heavy drinking jointly for weekdays and the weekend may be misleading for prevention purposes, because reasons for disparity in both periods may differ. The main objective was to assess occupational disparity in heavy average drinking (HAD) by week period and sex. 42,108 employees aged 16-64 were recruited from national surveys in Spain between 2011 and 2020. The outcome was HAD, defined as daily alcohol intake over 20 g (men) or 10 g (women). Occupation was classified in 15 categories. HAD adjusted prevalence ratios (HAD-aPRs) taking all occupations as reference, and relative adjusted excess prevalences (HAD-aEPs) comparing the weekend to weekdays in each occupation, were estimated using Poisson regression models with robust variance adjusted for sociodemographic and health covariates. The HAD-aPRs comparing each occupation with all occupations ranged 0.63-1.92 on weekdays and 0.65-1.45 on the weekend, with the highest aPRs on weekdays in construction, hospitality and primary-sector workers (1.92-1.62). The weekend-weekdays HAD-aEPs by occupation ranged 2.60-8.33, with the highest values in technicians/administrators, other professionals, teachers and health professionals (8.33-6.44). The global aEP was higher in women (6.04) than in men (3.92), especially in occupations just mentioned (8.70-11.73 in women vs. 3.64-6.32 in men). There was a considerable relative disparity in HAD risk between occupations on weekdays, with the highest risks in certain low-skilled occupations. Such disparity decreased on the weekend. The relative weekend increase in HAD risk was greater in women and in certain high-skilled occupations. This should be considered when designing prevention interventions on harmful drinking.

Gaps in HIV and Hepatitis C Testing Among 3486 HIV-Negative Men Who have Sex with Men in Spain in the Era of Highly Effective Antiviral Therapies.

High uptake of HIV and hepatitis C (HCV) testing in Gay, bisexual, and other men who have sex with men (GBMSM) is needed to interrupt transmission. The objective was to identify subgroups with increased probability of lack of testing among HIV-negative GBMSM in Spain. Cross-sectional study including 3486 HIV-negative GBMSM attending prevention facilities in Madrid and Barcelona, 2018-2020. Data came from self-administered online sociodemographic, health, and risk behaviors questionnaires. Outcomes were lack of HCV (lifetime) and HIV (lifetime, last year) testing. Crude and adjusted prevalences and prevalence ratios were assessed for each outcome using negative binomial regression models. Lifetime lack of HIV and HCV testing prevalence was 6.3% and 35.8%, respectively, while lack of HIV testing in the last year was 22.4%. Prevalences were also substantial in GBMSM with high-risk behaviors. After sociodemographic adjustment, the highest probability of lack of HCV testing (lifetime) and HIV (last year) was among GBMSM with insufficient viral hepatitis knowledge, no history of STI, or HCV (or HIV) testing, aged < 25, non-outness about sex life with men, and less high-risk behaviors. Lack of HCV (lifetime) and HIV testing (last year) among HIV-negative GBMSM in Spain is still high, despite high-risk behaviors.

Hepatitis C antibody prevalence and active hepatitis C infection in HIV-negative gay, bisexual, and other men who have sex with men in Barcelona and Madrid, Spain (March 2018-March 2021).

Objectives: Hepatitis C virus (HCV) has been recognized as a sexually transmitted infection (STI) in HIV-positive men who have sex with men (MSM), with an increased notification in HIV-negative MSM. The aim of this study was to determine the prevalence of HCV antibody and active HCV infection in HIV-negative gay, bisexual, and other MSM (GBMSM), and their characteristics, in Barcelona and Madrid, from March 2018 to March 2021. Methods: Cross-sectional study conducted on 3548 HIV-undiagnosed GBMSM, across four HIV/STI testing centers. Respondents submitted an online, self-administered questionnaire after consultation, which collected information on sociodemographics, sexual health history, HCV knowledge, and substance consumption. Prevalence of HCV antibodies was determined by a reactive result in a rapid anti-HCV test or enzyme-linked immunosorbent assay (ELISA), while active HCV infection was determined by participants who were also positive on an HCV-RNA test. Crude and adjusted Poisson analyses with robust variance are presented for both prevalence and active infection. Results: In total, 97.6% of participants (n = 3463) were HIV-negative. Of those, 18 were found to have HCV antibodies (0.52%), of which nine (0.26%) were also HCV-RNA positive. Those with HCV antibodies were associated to have lived with an HCV (+) person (adjusted prevalence ratio [APR]: 7.84, [95% confidence interval: 2.50-24.53]), using injectable drugs for sex (APR: 6.92, [1.20-39.79]) and testing positive for an STI in the previous year (APR: 4.06, [1.09-15.12]). Presenting an active infection was strongly associated with a previous HCV diagnosis (APR: 100.82 [22.16-458.76]), sexualized injectable drug use (APR: 17.53 [2.70-113.76]), and sharing douching material (APR: 7.45, [2.12-25.95]). Conclusion: Sexual practices with a higher risk of bleeding and sexualized drug use, particularly sexualized injectable drug use, were associated with higher rates of HCV diagnosis in GBMSM. Identifying these practices during consultation, contact tracing new cases and regularly testing those with a previous history of HCV, will facilitate HCV eradication.

New Patients in Treatment for Opioid Addiction in Spain.

Introduction: Patients seeking first time treatment for opioid consumption reflect the characteristics of the consumer population. This group has not been studied in Spain in decades. The objective of this study was to characterize the opioid user population seeking first time treatment (incidents) and compare them group with those with prior treatment (prevalents). Methods: Cross-sectional study (N = 3325) with patients with opioid addiction seeking care at public addiction centers in the Community of Madrid from 2017 through 2019. Differentiation and comparisons were carried out using bivariate analysis, adjusted by sociodemographic characteristics related and those related to substance use consumption in incident and prevalent patients. Results: About 12.2% were incidents. Compared to prevalents, there were more foreigners (34.1% vs 19.1% P < .001), but with a better social network. Regarding opioid use, incidents were less likely to use injection (10.7% compared to 16.8% P = .008), but had greater daily frequency (75.8% vs 52.2%, P < .001). The age of initial consumption was greater (27 years vs 21.3 years, (P < .001)). About 15.5% of incidents sought care for non-heroin opioids, compared to 4.8% of prevalents (P < .001). Women sought care at twice the rate of men (29.3% vs 12.3%; P > .001). Discussion: New patients presented a profile with many stable characteristics, but which highlighted an increase in the use of other opioids, as occurs in the international context. Surveillance of the new patient characteristics can serve as an early indicator of consumption changes in. Thus, periodic monitoring is important.

Free Access to Direct-Acting Antivirals in Spain: More Favorable Impact on Hepatitis C Mortality Among Highly Educated People.

BACKGROUND: In 2015, hepatitis C treatment with direct-acting antivirals (DAAs) became free and widespread in Spain, significantly reducing hepatitis C-related mortality. However, health interventions can sometimes widen health inequalities. The objective of this study is to assess the impact of DAA treatment on hepatitis C-related mortality by educational level. METHODS: We analyzed deaths from hepatitis C, unspecified liver cirrhosis, hepatocellular carcinoma, alcohol-related liver diseases, other liver diseases, and human immunodeficiency virus (HIV) disease among individuals living in Spain during 2012-2019 and aged ≥25 years. We calculated age-standardized mortality rates per million person-years by period, sex, and education. Using quasi-Poisson segmented regression models, we estimated the annual percent change in rates in pre- and postintervention periods by education level and the relative inequality index (RII). RESULTS: Hepatitis C mortality rates among low, middle, and highly educated people decreased from 25.2, 23.2, and 20.3/million person-years in the preintervention period to 15.8, 13.7, and 10.4 in the postintervention period. Mortality rates from other analyzed causes also decreased. Following the intervention, downward trends in hepatitis C mortality accelerated at all education levels, although more in highly educated people, and the RII increased from 2.1 to 2.7. For other analyzed causes of death, no favorable changes were observed in mortality trends, except for liver cirrhosis, hepatocellular carcinoma, HIV disease, and alcohol-related liver disease among higher educated people. CONCLUSIONS: Results suggest that DAA treatments had a very favorable impact on hepatitis C mortality at all education levels. However, even in a universal and free healthcare system, highly educated people seem to benefit more from DAA treatment than less educated people.

Evolution of mortality attributable to alcohol in Spain according to age, sex, cause of death and type of drinker (2001-2017). / Evolución de la mortalidad atribuible al alcohol en España según edad, sexo, causa de muerte y tipo de bebedor (2001-2017).

There are no recent estimates of alcohol-attributable mortality in Spain with Spanish alcohol consumption data. The objective is to estimate it and know its evolution between 2001 and 2017 in people ≥15 years, according to sex, age, period, cause of death and type of drinker. The cause-specific approach and Levin's equation were used. Survey consumption was corrected for underestimation with respect to sales statistics, and past consumption and binge drinking were considered. The average annual number of deaths attributable to alcohol in 2010-2017 was 14,927, 58.6% of which were premature (<75 years). The age-standardized alcohol-attributable mortality rate was 39.4/100,000 inhabitants, representing 3.9% of overall mortality. Using standardized percentages, 68.7% corresponded to heavy drinkers. The most frequent causes of alcohol-attributable mortality were cancer (44.7%) and digestive diseases (33.2%).  The rate of alcohol-attributable mortality was 3.5 times higher in men than in women (with higher ratios for young people and external causes). Between 2001-2009 and 2010-2017, the average annual rate decreased 16.8% (60.7% in 15-34 years; 19.4% in men and 9.8% in women). The contribution of heavy drinkers, digestive diseases and external causes to the risk of alcohol-attributable mortality decreased slightly between the two periods, while the contribution of cancer and circulatory diseases increased. These estimates are conservative. The contribution of alcohol to overall mortality is significant in Spain, requiring collective action to reduce it.

En España no hay estimaciones recientes de la mortalidad atribuible a alcohol con datos de consumo de alcohol españoles. El objetivo es estimarla y conocer la evolución entre 2001 y 2017 en personas ≥15 años, según sexo, edad, periodo, causa de muerte y tipo de bebedor. Se utilizó el enfoque causa específico y la ecuación de Levin. El consumo de las encuestas se corrigió por subestimación con respecto a las estadísticas de ventas y se consideró el consumo pasado y los atracones de alcohol. El número medio anual de muertes atribuibles a alcohol en 2010-2017 fue 14.927, un 58,6% prematuras (<75 años). La tasa de mortalidad atribuible a alcohol estandarizada por edad fue 39,4/ 100.000 habitantes, representando un 3,9% de la mortalidad general. Usando porcentajes estandarizados un 68,7% correspondió a bebedores de alto riesgo. Las causas de mortalidad atribuible a alcohol más frecuentes fueron cáncer (43,8%) y enfermedades digestivas (32,9%).  La tasa de mortalidad atribuible a alcohol fue 3,5 veces mayor en hombres que en mujeres (con cocientes más elevados para jóvenes y causas externas). Entre 2001-2009 y 2010-2017 la tasa media anual disminuyó un 16,8% (60,7% en 15-34 años; 19,4% en hombres y 9,8% en mujeres). La contribución de los bebedores de alto riesgo y de las enfermedades digestivas y causas externas al riesgo de mortalidad atribuible a alcohol disminuyó ligeramente entre los dos períodos, mientras que aumentó la contribución del cáncer y enfermedades circulatorias. Estas estimaciones son conservadoras. La contribución del alcohol a la mortalidad general es importante en España, requiriendo medidas colectivas para reducirla.

Preocupación por el consumo de drogas entre hombres gais, bisexuales y otros hombres que tienen sexo con hombres usuarios de chemsex en España / Concern about Drug Use Among Gay, Bisexual, and Other Men Who Have Sex With Men Engaged in Chemsex Sessions in Spain

El chemsex, una actividad recreativa y ocasional para la mayoría de los hombres gais,bisexuales y otros hombres que tienen sexo con hombres (GBHSH) que lo practican, se ha asociado aconsecuencias negativas en distintas esferas de la salud. Sin embargo, apenas existe evidencia sobre lapreocupación por el consumo de drogas entre usuarios de chemsex. Objetivos: Estimar la proporciónde hombres GBHSH usuarios de chemsex preocupados por su consumo de drogas e identificar susprincipales determinantes, así como las drogas asociadas a mayor preocupación. Materiales y métodos:Se realizó un estudio online entre mayo y julio de 2020, en el que se analizaron 779 hombres GBHSHque habían participado en sesiones de chemsex en los últimos 12 meses. Se estimó la prevalencia depreocupación por consumo de drogas y se realizó un análisis multivariante para identificar los factoresasociados mediante regresión de Poisson con varianza robusta. Resultados: La preocupación porconsumo de drogas en los últimos 12 meses (31,6%) se asoció de forma independiente con: tenermenos de 40 años, haber pagado dinero a cambio de sexo, el consumo de las drogas más asociadascon la práctica del chemsex, así como con el consumo regular y la inyección de drogas en cualquiercircunstancia. Metanfetamina y mefedrona fueron las drogas que más preocuparon a los usuariosde chemsex. Conclusión: Se evidencia la necesidad de implementar medidas dirigidas a identificar yfavorecer el acceso de los usuarios de chemsex preocupados por su consumo de drogas a los recursossociosanitarios. Asimismo, es importante incrementar la conciencia acerca de los riesgos asociados alconsumo de drogas en esta población, especialmente entre los usuarios con patrones potencialmenteproblemáticos como el uso regular o inyectado de drogas. (AU)

Chemsex, a recreational and occasional activity for the majority of gay, bisexual, and othermen who have sex with men (GBMSM) who engage in it, has been associated with negative consequences in various health spheres. However, there is scarce evidence regarding concerns about drug useamong chemsex users. Objectives: To estimate the proportion of GBMSM engaged in chemsex who areconcerned about their drug use and identify its main determinants, as well as the drugs associated withgreater concern. Materials and Methods: An online study was conducted between May and July 2020,analyzing 779 GBMSM engaged in chemsex sessions in the last 12 months. The prevalence of concernabout drug use was estimated, and a multivariate analysis was performed to identify associated factorsusing Poisson regression with robust variance. Results: Concern about drug use in the last 12 months(31.6%) was independently associated with being under 40 years old, having paid for sex, the use ofdrugs most associated with chemsex practice, as well as regular drug use and drug injection in any circumstance. Methamphetamine and mephedrone were the drugs that most concerned chemsex users.Conclusion: These results show the need to implement measures aimed at identifying and promotingthe access of chemsex users concerned about their drug use to social and health resources. Likewise, itis important to increase awareness about the risks associated with drug use in this population, especiallyamong users with potentially problematic patterns such as regular or injecting drug use. (AU)

Evolución de la mortalidad atribuible al alcohol en España según edad, sexo, causa de muerte y tipo de bebedor (2001-2017) / Evolution of mortality attributable to alcohol in Spain according to age, sex, cause of death and type of drinker (2001-2017)

En España no hay estimaciones recientes de la mortalidad atribuible a alcohol con datos de consumo de alcohol españoles. El objetivo es estimarla y conocer la evolución entre 2001 y 2017 en personas ≥15 años, según sexo,edad, periodo, causa de muerte y tipo de bebedor. Se utilizó el enfoque causa específico y la ecuación de Levin. El consumo de las encuestas se corrigió por subestimación con respecto a las estadísticas de ventas y se consideró el consumo pasado y los atracones de alcohol. El número medio anual de muertes atribuibles a alcohol en 2010-2017 fue 14.927, un 58,6% prematuras(<75 años). La tasa de mortalidad atribuible a alcohol estandarizada por edad fue 39,4/ 100.000 habitantes, representando un 3,9% de la mortalidad general. Usando porcentajes estandarizados un 68,7% correspondió a bebedores de alto riesgo. Las causas de mortalidad atribuible a alcohol más frecuentes fueron cáncer (43,8%) y enfermedades digestivas (32,9%). La tasa de mortalidad atribuible a alcohol fue 3,5 veces mayor en hombres que en mujeres (con cocientes más elevados para jóvenes y causas externas). Entre2001-2009 y 2010-2017 la tasa media anual disminuyó un 16,8% (60,7%en 15-34 años; 19,4% en hombres y 9,8% en mujeres). La contribución de los bebedores de alto riesgo y de las enfermedades digestivas y causas externas al riesgo de mortalidad atribuible a alcohol disminuyó ligeramente entre los dos períodos, mientras que aumentó la contribución del cáncer y enfermedades circulatorias. Estas estimaciones son conservadoras. La contribución del alcohol a la mortalidad general es importante en España, requiriendo medidas colectivas para reducirla. (AU)

There are no recent estimates of alcohol-attributable mortality in Spain with Spanish alcohol consumption data. The objective is to estimate it and knowits evolution between 2001 and 2017 in people ≥15 years, according to sex, age, period, cause of death and type of drinker. The cause-specific approach and Levin’s equation were used. Survey consumption was corrected forunder estimation with respect to sales statistics, and past consumption and binge drinking were considered. The average annual number of deaths attributable to alcohol in 2010-2017 was 14,927, 58.6% of which were premature (<75 years). The age-standardized alcohol-attributable mortality rate was 39.4/100,000 inhabitants, representing 3.9% of overall mortality.Using standardized percentages, 68.7% corresponded to heavy drinkers. The most frequent causes of alcohol-attributable mortality were cancer(44.7%) and digestive diseases (33.2%). The rate of alcohol-attributable mortality was 3.5 times higher in men than in women (with higher ratiosfor young people and external causes). Between 2001-2009 and 2010-2017,the average annual rate decreased 16.8% (60.7% in 15-34 years; 19.4% inmen and 9.8% in women). The contribution of heavy drinkers, digestive diseases and external causes to the risk of alcohol-attributable mortality decreased slightly between the two periods, while the contribution of cancer and circulatory diseases increased. These estimates are conservative. The contribution of alcohol to overall mortality is significant in Spain, requiring collective action to reduce it. (AU)

Sexualized drug use among men who have sex with men in Madrid and Barcelona: The gateway to new drug use?

This original study compares the prevalences of drug use for any purpose and for sexualized drug use (SDU) among MSM. It also describes relevant characteristics of first SDU, analyzes to what extent SDU has been the first experience (the gateway) with different drugs by age and explores the correlates of SDU. Study participants included 2,919 HIV-negative MSM attending four HIV/STI diagnosis services in Madrid and Barcelona. They answered an online, self-administered questionnaire. Poisson regression models with robust variance were used. About 81.4% had ever used any drug, and 71.9% had done so in the last-12-months, while 56% had ever engaged in SDU, and 50% had done so in the last-12-months. Participants under 25 years old had the lowest prevalences of SDU, and the 25-39 age group the highest, except for Viagra, which was higher among those over age 40. The most frequently used drugs for first SDU were poppers (53.6%), cannabis (19.6%) and Viagra (12.2%). These drugs were also the most ever consumed for SDU. Among sexualized users, methamphetamine (78.3%) and Mephedrone (75.4%) were used always/most of the times for sex in the last-12-months. Around 72.2% of Mephedrone sexualized users and 69.6% of Methamphetamine vs 23.1% of ecstasy users' first consumption of these drugs involved use for sex. These drugs were provided to them free where they have sex for 66.8, 79.1, and 31.9%, respectively. On that occasion, 8.1% of Mephedrone, 6.8% of Methamphetamine and 18.4% of ecstasy users had sex only with steady partner; with 50.2, 56.2, and 26.2% respectively using a condom with any partner. SDU in the first use was associated with similar variables for recreational and chemsex drugs. The highest prevalence ratios were for having ever been penetrated by >20 men and having ever injected drugs. It can be concluded that the prevalence of SDU was more than half of the prevalence for any purpose. Thus SDU was the gateway to use for many drugs in an important proportion of users, who frequently consumed drugs that were free and had condomless anal sex with occasional and multiple partners. These circumstances were much more common for chemsex than for recreational drugs.

Excessive Drinking Among Men Who Have Sex With Men Recruited From Web-Based Resources: Cross-sectional Questionnaire Study.

BACKGROUND: US and Northern European studies have found a higher prevalence of alcohol-related problems among men who have sex with men (MSM) than among the general population of men (GPM). However, most of them relied on traditional sampling methods, not profiting from MSM dating apps and websites for recruitment. Besides, analogous comparisons in Southern Europe are lacking. OBJECTIVE: This study aimed to compare several indicators of excessive drinking between MSM and GPM in Spain. METHODS: Overall, 5862 MSM were recruited through dating apps or websites for the Méthysos Project, and 10,349 GPM were recruited using probability sampling via the Household Survey on Alcohol and Drugs in Spain from 2018 to 2020. The outcomes were the prevalence of hazardous or harmful drinking (Alcohol Use Disorders Identification Test [AUDIT] ≥8), hazardous drinking (AUDIT-Consumption ≥4), harmful drinking (AUDIT-Problem ≥4), regular hazardous drinking (>14 standard drinks per week), and monthly binge drinking. The prevalence of excessive drinking indicators was calculated for MSM and GPM and compared using the adjusted prevalence ratio (aPR). Two different aPRs and their 95% CIs were estimated using Poisson regression models with robust variance. The first was adjusted for sociodemographic characteristics, and the second was adjusted for the aforementioned covariates plus other drug use. RESULTS: The prevalence of hazardous or harmful drinking was 15.6% (913/5862) among MSM versus 7.7% (902/10,349) among GPM. After adjusting for sociodemographic covariates, the risk was higher in MSM than in GPM for harmful or hazardous drinking (aPR 1.8, 95% CI 1.6-2.0), harmful drinking (aPR 2.3, 95% CI 2.0-2.7), and binge drinking (aPR 1.7, 95% CI 1.5-1.9); the same in both populations for hazardous drinking (aPR 0.9, 95% CI 0.9-1.0); and higher in GPM than in MSM for regular hazardous drinking (aPR 0.7, 95% CI 0.6-0.9). The relative excess risk of harmful drinking and binge drinking among MSM tended to increase with increasing education level and size of the place of residence, and the opposite was true for the deficit risk in regular hazardous drinking. Additional adjustment for other drug use greatly buffered the relative excess risk in harmful drinking and binge drinking in MSM, while it deepened its deficit risk in regular hazardous drinking. CONCLUSIONS: The use of web-based resources allowed recruiting a large sample of MSM. The risk of hazardous or harmful drinking was 80% greater in MSM than in GPM, which was mainly because of the higher risk of harmful drinking and binge drinking among MSM. Nearly 1 in 6 MSM would benefit from early brief alcohol intervention procedures. The subgroup with harmful or binge drinking combined with other drug use is an important contributor to excess MSM risk in hazardous or harmful drinking and must be a priority target for harm reduction interventions.

Awareness and Use of HIV Self-Testing Among Men Who Have Sex With Men Remains Low in Spain 2 Years After Its Authorization.

Objectives: HIV self-testing has been available in Spain since 2017 as a diagnostic tool to promote earlier diagnosis. We aimed to assess awareness and previous use of HIV self-testing in a sample of men who have sex with men (MSM) recruited online more than 2 years after its legal authorization in Spain. Methods: We analyzed 5,492 MSM recruited between May and July 2020 in gay dating apps/websites and other social networks. We estimated the proportion of participants who were aware of the existence of HIV self-testing and the proportion who reported previous use. To identify factors associated with both outcomes we built two Poisson regression models. Among those who reported previous use we described several aspects related to their last self-test. Results: Awareness of HIV self-test was reported by 29.7% and its previous use by 5% of participants. Awareness was independently associated with recruitment in gay dating apps/websites, being ≥40 years old, born in Spain-other European countries, having higher educational level, living in medium-small municipalities and living sex life openly. Independent associations were also found with having received a sexually transmitted infection diagnosis (STI) or an HIV negative test in the last 12 months, and being HIV positive. Use was significantly higher among participants who were paid for sex or diagnosed with an STI in the last 12 months and who received their last HIV test in the preceding year. Self-testing occurred recently, with kits acquired at pharmacies and carried out alone. Conclusion: Awareness and use probably have not increased sufficiently in order to make a relevant impact to the promotion of early HIV diagnosis. Additional efforts, mainly focused on less favored MSM, should be made to take better advantage of the possibilities offered by this testing option.

Estimating the Prevalence of Recreational Opioid Use in Spain Using a Multiplier Method.

Acknowledgement of the prevalence of recreational opioid use (PROU) is key to the planning and evaluation of care services. However, in Spain, the prevalence of PROU in recent years is unknown. The objective of this study was to estimate the PROU between 2005 and 2019 in the general populations of six Spanish cities. A benchmark-multiplier methodology was used to estimate the PROU population size. The benchmark used was overdose deaths from recreational opioid use in Spain's six most populated cities. The multiplier was the overdose death rate in a cohort of heroin users. Linear regression was used to estimate the trend of the PROU estimate over the set period of years. In 2005, the PROU was 4.78 (95%CI 3.16-7.91) per 1000 people. The estimated trend decreased, with the two lowest values being 2.35 per 1000 in 2015 and 2.29 in 2018. In 2019 the PROU was 2.60 per 1000 (95%CI 1.72-4.31), 45% lower than in 2005. While the decline in the PROU continues, its deceleration over the last four years calls for increased vigilance, especially in light of the opioid crisis in North America that has occurred over the last few years.

Educational Gradients in Drinking Amount and Heavy Episodic Drinking among Working-Age Men and Women in Spain.

Alcohol-related harm decreases as socioeconomic position increases, although sometimes the opposite happens with alcohol intake. The objective was to know the educational gradient in monthly measures of drinking amount and heavy episodic drinking (HED) among people aged 25−64 years in Spain from 1997−2017. Such gradient was characterized with the relative percent change (PC) in drinking measures per year of education from generalized linear regression models after adjusting for age, year, region, marital status and immigration status. Among men, the PCs were significantly positive (p < 0.05) for prevalence of <21 g alcohol/day (2.9%) and 1−3 HED days (1.4%), and they were negative for prevalences of 21−40 g/day (−1.1%), >40 g/day (−6.0%) and ≥4 HED days (−3.2%), while among women they ranged from 3.6% to 5.7%. The gradient in prevalences of >40 g/day (men) and >20 g/day (women) was greatly attenuated after additionally adjusting for HED, while that of ≥4 HED days was only slightly attenuated after additionally adjusting for drinking amount. Among women, the gradients, especially in HED measures, seem steeper in 2009−2017 than in 1997−2007. Educational inequality remained after additional adjustment for income and occupation, although it decreased among women. These results can guide preventive interventions and help explain socioeconomic inequalities in alcohol-related harm.

Knowledge and Prior Use of HIV Self-Testing in Madrid and Barcelona among Men Who Have Sex with Men More than One Year after Its Legal Authorization in Spain.

This study assessed the knowledge and prior use of HIV self-testing in a sample of men who have sex with men (MSM) recruited in a sexual health clinic and two community-based testing sites in Madrid and Barcelona, >12 months after its legal authorization. Between March 2019 and December 2020, we recruited 2044 MSM. Participants completed a self-administered questionnaire while waiting to be tested for HIV and other STIs. We built two Poisson regression models to assess factors associated with prior knowledge and with use. Among those who had used self-testing in the past we assessed frequency of use and several aspects related to the last testing episode. The proportion of participants that knew about the existence of self-testing and had already used it was of 26.3% and 5.1% respectively. Both, knowledge and use were independently associated with being born in Spain or other western European countries, university education and more recent HIV testing. Additionally, knowledge was associated with older age, having a more favorable economic situation, and not living sexuality in total secrecy. Use was also associated with having received money in exchange for sex. Most (69.5%) reported having self-tested once, 64.8% had self-tested <12 months ago, 63.8% self-tested alone and 71.4% acquired the kit at a pharmacy over the counter. In spite of its authorization and becoming legally available, knowledge and use of HIV self-testing remain low among MSM attending sites specialized in the diagnosis of HIV and other STIs. When designing scale-up strategies, lower levels of knowledge and use in less favored subgroups of MSM need to be factored in.

Consumo sexualizado de drogas entre hombres que tienen sexo con hombres residentes en España / Substance use in sexual context among Spanish resident men who have sex with men

Analizar los patrones de consumo sexualizado de drogas (CSD) e identificar cual es el de mayor riesgo para la adquisición/transmisión del VIH y de otras infecciones de transmisión sexual (ITS) en una muestra de hombres que tienen sexo con hombres (HSH) residentes en España. Adicionalmente, también se identifican las subpoblaciones más afectadas por el patrón de CSD de mayor riesgo. En 2016, se realizó una encuesta online en app de contacto gay. Se identificaron los patrones de CSD y se estimaron las prevalencias de varios indicadores de riesgo para el VIH/ITS para cada uno. Se construyeron dos modelos multivariantes de Poisson identificando factores asociados al patrón de mayor riesgo. Todos los análisis se realizaron en función del estado serológico frente al VIH. De 2883 HSH, el 21,9% refirió CSD en los últimos 12 meses. Todos los patrones de CSD fueron más frecuentes en los VIH+. De los cuatro patrones identificados (chemsex, drogas recreacionales, drogas para mejorar el rendimiento sexual y cannabinoides) el más prevalente y de mayor riesgo, fue el chemsex (21,9% en VIH+ vs. 6,6% en VIH-). En los VIH- el chemsex se asoció con: ciudad de residencia > 1 000 000 habitantes, vivir la sexualidad abiertamente, haber cobrado por tener sexo, haber mantenido relaciones anales desprotegidas (RAD) en el último año y haber sido diagnosticado de una ITS. En los VIH+ se asoció con: tener 30-49 años, haber pagado por tener relaciones sexuales, haber tenido RAD y haber sido diagnosticado de ITS en el último año. Dada su elevada prevalencia especialmente en VIH+ y a que se observa fundamentalmente en poblaciones con perfiles de alto riesgo, el chemsex podría estar jugando un papel relevante en la adquisición y/o transmisión del VIH y otras ITS.(AU)

We analysed patterns of sexualized drug use (SDU) and pinpointed the one with the highest risk for the acquisition/transmission of HIV/ Sexually Transmitted Infections (STIs) in a sample of men who have sex with men (MSM) residing in Spain. Additionally, we also identified the most affected subpopulations by highest risk SDU pattern. In 2016, we promoted an online survey in gay dating apps. We estimated the prevalence of several HIV/STI risk indicators for each identified SDU pattern. We built two different Poisson regression models identifying factors associated to the pattern associated with the highest risk.All analyses were carried out by HIV status. Of 2,883 MSM, 21.9% self-reported SDU in the last 12 months. All patterns of SDU were more frequent in HIV+ MSM. Of the four SDU patterns identified (chemsex, recreational drugs, sexual performance enhancing drugs, and cannabinoids), the most frequent was chemsex (21.9% in HIV+ vs 6.6% in HIV-). It also comprised the highest risk profile for HIV/ STI. Among HIV-, chemsex was associated with living in a city of > 1,000,000 inhabitants, living sexuality in an open way and having been paid for sex, having had unprotected anal intercourse (UAI) in the last 12 months and having ever received an STI diagnosis. Among HIV+, it was associated with being 30-49 years old, having paid for sex, having had UAI and having been diagnosed with an STI in the last 12 months. Given its high prevalence, especially among HIV positive individuals, and its association with subpopulations with high-risk behaviour, chemsex could be playing a relevant role in the acquisition/ transmission of HIV and other STIs.(AU)

Alcohol and educational inequalities: Hazardous drinking prevalence and all-cause mortality by hazardous drinking group in people aged 50 and older in Europe.

BACKGROUND: We examined educational inequalities in hazardous drinking prevalence among individuals aged 50 or more in 14 European countries, and explored educational inequalities in mortality in hazardous drinkers in European regions.Methods: We analyzed data from waves 4, 5 and 6 of the Survey of Health Ageing and Retirement in Europe (SHARE). We estimated age-standardized hazardous drinking prevalence, and prevalence ratios (PR) of hazardous drinking by country and educational level using Poisson regression models with robust variance. We estimated the relative index of inequality (RII) for all-cause mortality among hazardous drinkers and non-hazardous drinkers using Cox proportional hazards regression models and for each region (North, South, East and West).Results: In men, educational inequalities in hazardous drinking were not observed (PRmedium = 1.09 [95%CI: 0.98-1.21] and PRhigh = 0.99 [95%CI: 0.88-1.10], ref. low), while in they were observed in women, having the highest hazardous drinking prevalence in the highest educational levels (PRmedium = 1.28 [95%CI: 1.15-1.42] and PRhigh = 1.53 [95%CI: 1.36-1.72]). Overall, the Relative Index of Inequality (RII) in all-cause mortality among hazardous drinkers was 1.12 [95%CI: 1.03-1.22] among men and 1.10 [95%CI: 0.97-1.25] among women. Educational inequalities among hazardous drinkers were observed in Eastern Europe for both men (RIIhazardous = 1.21 [95%CI: 1.01-1.45]) and women (RIIhazardous = 1.46 [95%CI: 1.13-1.87]). Educational inequalities in mortality among non-hazardous drinkers were observed in Southern, Western and Eastern Europe among men, and in Eastern Europe among women.Conclusions: Higher educational attainment is positively associated with hazardous drinking prevalence among women, but not among men in most of the analyzed European countries. Clear educational inequalities in mortality among hazardous drinkers were only observed in Eastern Europe. Further research on the associations between alcohol use and inequalities in all-cause mortality in different regions is needed.

Avoidable mortality for causes amenable to medical care and suicide in physicians in Spain.

OBJECTIVE: To compare avoidable mortality for causes amenable to medical care and suicide in physicians versus other professionals with similar university studies and socioeconomic position in Spain. METHODS: All people aged 25-64 years who were employed on 1 November 2001 (8,697,387 men and 5,282,611 women) were included. Their vital status was followed for 10 years and the cause of death of deceased was recorded. Using a Poisson regression to estimate the mortality rate ratio (MRR), we compared mortality due to causes of death amenable to medical care, all other causes, and suicide in physicians versus other professionals. Mortality in physicians was used as a reference. RESULTS: The lowest MRR for causes amenable to medical care was observed in engineers/architects (men: 0.84, 95% confidence interval [CI] 0.72, 0.97; women: 0.93, 95% CI 0.64, 1.35) and healthcare professions other than physicians/pharmacists/nurses (men: 0.86, 95% CI 0.56, 1.34; women: 0.69, 95% CI 0.32, 1.46). Regarding mortality for all other causes of death, professionals from these and other occupations presented lower mortality than physicians. Other healthcare professions, entrepreneurs, and managers/executives completed suicide at a higher rate than physicians. CONCLUSION: Although the accessibility to the healthcare system and to the pharmacological drugs could suggest that physicians would present low rates for causes amenable to medical care and high rates of suicide, our results show that this is not the case in Spain.

Substance use in sexual context among Spanish resident men who have sex with men. / Consumo sexualizado de drogas entre hombres que tienen sexo con hombres residentes en España.

We analysed patterns of sexualized drug use (SDU) and pinpointed the one with the highest risk for the acquisition/transmission of HIV/Sexually Transmitted Infections (STIs) in a sample of men who have sex with men (MSM) residing in Spain. Additionally, we also identified the most affected subpopulations by highest risk SDU pattern. In 2016, we promoted an online survey in gay dating apps. We estimated the prevalence of several HIV/STI risk indicators for each identified SDU pattern. We built two different Poisson regression models identifying factors associated to the pattern associated with the highest risk. All analyses were carried out by HIV status. Of 2,883 MSM, 21.9% self-reported SDU in the last 12 months. All patterns of SDU were more frequent in HIV+ MSM. Of the four SDU patterns identified (chemsex, recreational drugs, sexual performance enhancing drugs, and cannabinoids), the most frequent was chemsex (21.9% in HIV+ vs 6.6% in HIV-). It also comprised the highest risk profile for HIV/STI. Among HIV-, chemsex was associated with living in a city of > 1,000,000 inhabitants, living sexuality in an open way and having been paid for sex, having had unprotected anal intercourse (UAI) in the last 12 months and having ever received an STI diagnosis. Among HIV+, it was associated with being 30-49 years old, having paid for sex, having had UAI and having been diagnosed with an STI in the last 12 months. Given its high prevalence, especially among HIV positive individuals, and its association with subpopulations with high-risk behaviour, chemsex could be playing a relevant role in the acquisition/transmission of HIV and other STIs.

Analizar los patrones de consumo sexualizado de drogas (CSD) e identificar cual es el de mayor riesgo para la adquisición/transmisión del VIH y de otras infecciones de transmisión sexual (ITS) en una muestra de hombres que tienen sexo con hombres (HSH) residentes en España. Adicionalmente, también se identifican las subpoblaciones más afectadas por el patrón de CSD de mayor riesgo. En 2016, se realizó una encuesta online en app de contacto gay. Se identificaron los patrones de CSD y se estimaron las prevalencias de varios indicadores de riesgo para el VIH/ITS para cada uno.  Se construyeron dos modelos multivariantes de Poisson identificando factores asociados al patrón de mayor riesgo. Todos los análisis se realizaron en función del estado serológico frente al VIH. De 2883 HSH, el 21,9% refirió CSD en los últimos 12 meses. Todos los patrones de CSD fueron más frecuentes en los VIH+. De los cuatro patrones identificados (chemsex, drogas recreacionales, drogas para mejorar el rendimiento sexual y cannabinoides) el más prevalente y de mayor riesgo, fue el chemsex (21,9% en VIH+ vs. 6,6% en VIH-). En los VIH- el chemsex se asoció con: ciudad de residencia > 1 000 000 habitantes, vivir la sexualidad abiertamente, haber cobrado por tener sexo, haber mantenido relaciones anales desprotegidas (RAD) en el último año y haber sido diagnosticado de una ITS. En los VIH+ se asoció con: tener 30-49 años, haber pagado por tener relaciones sexuales, haber tenido RAD y haber sido diagnosticado de ITS en el último año. Dada su elevada prevalencia especialmente en VIH+ y a que se observa fundamentalmente en poblaciones con perfiles de alto riesgo, el chemsex podría estar jugando un papel relevante en la adquisición y/o transmisión del VIH y otras ITS.

Comparison of Polydrug Use Prevalences and Typologies between Men Who Have Sex with Men and General Population Men, in Madrid and Barcelona.

This study compares the prevalence of drug use and the typologies of polydrug use (PDU) in men who have sex with men (MSM) and general population men (GPM). Participants were men aged 16-64, living in the provinces of Madrid and Barcelona: 1720 were recruited in a GPM survey, and 2658 were HIV-negative MSM from HIV/STIs diagnosis services. Lifetime and last-year prevalence of drug use and prevalence ratios (PRs) of MSM to GPM for the different drugs were calculated using Poisson regression. Latent class analysis (LCA) was performed to identify typologies of PDU. Lifetime use of the drugs considered was higher in MSM, and even higher for drug use in the last-year: PRs for cannabis, hallucinogens and cocaine ranged from 2-5; for amphetamine, ecstasy and methamphetamine 12-16; and above 60 for ketamine, GHB/GBL, inhalants and mephedrone. In the LCA for lifetime PDU four classes arose from the GPM (No-PDU (79.6%); Conventional PDU (13.8%); Intensive conventional PDU (4.9%); Heavy PDU (1.8%)) and four among MSM (No-PDU (57.7%); Conventional PDU plus poppers (18.8%); PDU preferring chemsex drugs (6.4%); Heavy PDU (17.2%)). For PDU during the last-year, three classes arose in the GPM: No-PDU (94.7%); Conventional PDU (4.3%); Heavy PDU (0.9%). For MSM, we identified four classes: No-PDU (64.7%); Conventional PDU plus poppers (15.6%); PDU preferring chemsex drugs (6.2%); Heavy PDU (13.5%). MSM should be considered a priority group for the prevention of the use of all drugs but the heterogeneity of PDU typologies regarding users' preference towards conventional and/or sexualised drugs needs to be taken into account.