Longer and healthier lives for all? Successes and failures of a universal consumer-driven healthcare system, Switzerland, 1990-2014.

OBJECTIVES: The ability to translate increases in life expectancy into additional years in good health is a crucial challenge for public health policies. We question the success of these policies in Switzerland, a forerunner of longevity, through the evolution of healthy life expectancy (HLE) across socioeconomic groups. METHODS: Education-specific HLE conditioning on surviving to age 30 was computed for 5-year periods from the Swiss National Cohort, a mortality follow-up of the entire resident population, and the Swiss Health Interview Survey, reporting self-rated health. We compare time trends and decompose them into health, mortality and education components. RESULTS: Between 1990 and 2015, comparable gains in LE (males: 5.02 years; females: 3.09 years) and HLE (males: 4.52 years; females: 3.09 years) were observed. People with compulsory education, however, experienced morbidity expansion, while those with middle and high education experienced morbidity compression. CONCLUSIONS: Divergence of morbid years by educational levels may reflect unequal access to preventive care due to high out-of-pockets contributions in the healthcare system. This growing gap and the exhaustion of the educational dividend jeopardize future increases in HLE.

Emergence of Acquired HIV-1 Drug Resistance Almost Stopped in Switzerland: A 15-Year Prospective Cohort Analysis.

BACKGROUND: Drug resistance is a major barrier to successful antiretroviral treatment (ART). Therefore, it is important to monitor time trends at a population level. METHODS: We included 11 084 ART-experienced patients from the Swiss HIV Cohort Study (SHCS) between 1999 and 2013. The SHCS is highly representative and includes 72% of patients receiving ART in Switzerland. Drug resistance was defined as the presence of ≥1 major mutation in a genotypic resistance test. To estimate the prevalence of drug resistance, data for patients with no resistance test was imputed based on the patient's risk of harboring drug-resistant viruses. RESULTS: The emergence of new drug resistance mutations declined dramatically from 401 to 23 patients between 1999 and 2013. The upper estimated prevalence limit of drug resistance among ART-experienced patients decreased from 57.0% in 1999 to 37.1% in 2013. The prevalence of 3-class resistance decreased from 9.0% to 4.4% and was always <0.4% for patients who initiated ART after 2006. Most patients actively participating in the SHCS in 2013 with drug-resistant viruses initiated ART before 1999 (59.8%). Nevertheless, in 2013, 94.5% of patients who initiated ART before 1999 had good remaining treatment options based on Stanford algorithm. CONCLUSIONS: Human immunodeficiency virus type 1 drug resistance among ART-experienced patients in Switzerland is a well-controlled relic from the era before combination ART. Emergence of drug resistance can be virtually stopped with new potent therapies and close monitoring.

HIV-1 Transmission During Recent Infection and During Treatment Interruptions as Major Drivers of New Infections in the Swiss HIV Cohort Study.

BACKGROUND: Reducing the fraction of transmissions during recent human immunodeficiency virus (HIV) infection is essential for the population-level success of "treatment as prevention". METHODS: A phylogenetic tree was constructed with 19 604 Swiss sequences and 90 994 non-Swiss background sequences. Swiss transmission pairs were identified using 104 combinations of genetic distance (1%-2.5%) and bootstrap (50%-100%) thresholds, to examine the effect of those criteria. Monophyletic pairs were classified as recent or chronic transmission based on the time interval between estimated seroconversion dates. Logistic regression with adjustment for clinical and demographic characteristics was used to identify risk factors associated with transmission during recent or chronic infection. FINDINGS: Seroconversion dates were estimated for 4079 patients on the phylogeny, and comprised between 71 (distance, 1%; bootstrap, 100%) to 378 transmission pairs (distance, 2.5%; bootstrap, 50%). We found that 43.7% (range, 41%-56%) of the transmissions occurred during the first year of infection. Stricter phylogenetic definition of transmission pairs was associated with higher recent-phase transmission fraction. Chronic-phase viral load area under the curve (adjusted odds ratio, 3; 95% confidence interval, 1.64-5.48) and time to antiretroviral therapy (ART) start (adjusted odds ratio 1.4/y; 1.11-1.77) were associated with chronic-phase transmission as opposed to recent transmission. Importantly, at least 14% of the chronic-phase transmission events occurred after the transmitter had interrupted ART. CONCLUSIONS: We demonstrate a high fraction of transmission during recent HIV infection but also chronic transmissions after interruption of ART in Switzerland. Both represent key issues for treatment as prevention and underline the importance of early diagnosis and of early and continuous treatment.

Strong Impact of Smoking on Multimorbidity and Cardiovascular Risk Among Human Immunodeficiency Virus-Infected Individuals in Comparison With the General Population.

Background. Although acquired immune deficiency syndrome-associated morbidity has diminished due to excellent viral control, multimorbidity may be increasing among human immunodeficiency virus (HIV)-infected persons compared with the general population. Methods. We assessed the prevalence of comorbidities and multimorbidity in participants of the Swiss HIV Cohort Study (SHCS) compared with the population-based CoLaus study and the primary care-based FIRE (Family Medicine ICPC-Research using Electronic Medical Records) records. The incidence of the respective endpoints were assessed among SHCS and CoLaus participants. Poisson regression models were adjusted for age, sex, body mass index, and smoking. Results. Overall, 74 291 participants contributed data to prevalence analyses (3230 HIV-infected; 71 061 controls). In CoLaus, FIRE, and SHCS, multimorbidity was present among 26%, 13%, and 27% of participants. Compared with nonsmoking individuals from CoLaus, the incidence of cardiovascular disease was elevated among smoking individuals but independent of HIV status (HIV-negative smoking: incidence rate ratio [IRR] = 1.7, 95% confidence interval [CI] = 1.2-2.5; HIV-positive smoking: IRR = 1.7, 95% CI = 1.1-2.6; HIV-positive nonsmoking: IRR = 0.79, 95% CI = 0.44-1.4). Compared with nonsmoking HIV-negative persons, multivariable Poisson regression identified associations of HIV infection with hypertension (nonsmoking: IRR = 1.9, 95% CI = 1.5-2.4; smoking: IRR = 2.0, 95% CI = 1.6-2.4), kidney (nonsmoking: IRR = 2.7, 95% CI = 1.9-3.8; smoking: IRR = 2.6, 95% CI = 1.9-3.6), and liver disease (nonsmoking: IRR = 1.8, 95% CI = 1.4-2.4; smoking: IRR = 1.7, 95% CI = 1.4-2.2). No evidence was found for an association of HIV-infection or smoking with diabetes mellitus. Conclusions. Multimorbidity is more prevalent and incident in HIV-positive compared with HIV-negative individuals. Smoking, but not HIV status, has a strong impact on cardiovascular risk and multimorbidity.

Increases in Condomless Sex in the Swiss HIV Cohort Study.

Condomless sex is a key driver of sexually transmitted diseases. In this study, we assess the long-term changes (2000-2013) of the occurrence of condomless sex among human immunodeficiency virus (HIV)-infected individuals enrolled in the Swiss HIV Cohort study. The frequencies with which HIV-infected individuals reported condomless sex were either stable or only weakly increasing for 2000-2008. For 2008-2013, these rates increased significantly for stable relationships among heterosexuals and men who have sex with men (MSM) and for occasional relationships among MSM. Our results highlight the increasing public health challenge posed by condomless sex and show that condomless sex has been increasing even in the most recent years.

Incident Hepatitis C Virus Infections in the Swiss HIV Cohort Study: Changes in Treatment Uptake and Outcomes Between 1991 and 2013.

Background. The hepatitis C virus (HCV) epidemic is evolving rapidly in patients infected with human immunodeficiency virus (HIV). We aimed to describe changes in treatment uptake and outcomes of incident HCV infections before and after 2006, the time-point at which major changes in HCV epidemic became apparent. Methods. We included all adults with an incident HCV infection before June 2012 in the Swiss HIV Cohort Study, a prospective nationwide representative cohort of individuals infected with HIV. We assessed the following outcomes by time period: the proportion of patients starting an HCV therapy, the proportion of treated patients achieving a sustained virological response (SVR), and the proportion of patients with persistent HCV infection during follow-up. Results. Of 193 patients with an HCV seroconversion, 106 were diagnosed before and 87 after January 2006. The proportion of men who have sex with men increased from 24% before to 85% after 2006 (P < .001). Hepatitis C virus treatment uptake increased from 33% before 2006 to 77% after 2006 (P < .001). Treatment was started during early infection in 22% of patients before and 91% after 2006 (P < .001). An SVR was achieved in 78% and 29% (P = .01) of patients treated during early and chronic HCV infection. The probability of having a detectable viral load 5 years after diagnosis was 0.67 (95% confidence interval [CI], 0.58-0.77) in the group diagnosed before 2006 and 0.24 (95% CI, 0.16-0.35) in the other group (P < .001). Conclusions. In recent years, increased uptake and earlier initiation of HCV therapy among patients with incident infections significantly reduced the proportion of patients with replicating HCV.

Obesity Trends and Body Mass Index Changes After Starting Antiretroviral Treatment: The Swiss HIV Cohort Study.

BACKGROUND: The factors that contribute to increasing obesity rates in human immunodeficiency virus (HIV)-positive persons and to body mass index (BMI) increase that typically occurs after starting antiretroviral therapy (ART) are incompletely characterized. METHODS: We describe BMI trends in the entire Swiss HIV Cohort Study (SHCS) population and investigate the effects of demographics, HIV-related factors, and ART on BMI change in participants with data available before and 4 years after first starting ART. RESULTS: In the SHCS, overweight/obesity prevalence increased from 13% in 1990 (n = 1641) to 38% in 2012 (n = 8150). In the participants starting ART (n = 1601), mean BMI increase was 0.92 kg/m(2) per year (95% confidence interval, .83-1.0) during year 0-1 and 0.31 kg/m(2) per year (0.29-0.34) during years 1-4. In multivariable analyses, annualized BMI change during year 0-1 was associated with older age (0.15 [0.06-0.24] kg/m(2)) and CD4 nadir <199 cells/µL compared to nadir >350 (P < .001). Annualized BMI change during years 1-4 was associated with CD4 nadir <100 cells/µL compared to nadir >350 (P = .001) and black compared to white ethnicity (0.28 [0.16-0.37] kg/m(2)). Individual ART combinations differed little in their contribution to BMI change. CONCLUSIONS: Increasing obesity rates in the SHCS over time occurred at the same time as aging of the SHCS population, demographic changes, earlier ART start, and increasingly widespread ART coverage. Body mass index increase after ART start was typically biphasic, the BMI increase in year 0-1 being as large as the increase in years 1-4 combined. The effect of ART regimen on BMI change was limited.

[Information seeking on the internet: what information are pregnant women seeking?]. / Recherche d'informations sur internet: quels sont les usages des femmes enceintes?

In the literature, uses of the internet by patients are interpreted either as a resource supporting their autonomy, or as a source of perturbation in the doctor-patient relationship. Analysing 50 interviews with pregnant women, this article aims at describing the different uses made during pregnancy. Some women mostly aim at sharing their experience in their use of internet. Others are looking for specialised information, by curiosity, to complement the information received in medical visits or, more rarely, as a result of a lack of information in their exchanges with professionals. Uses of internet by patients will develop in the future and it is important that professionals take into account these different forms of internet use in their practices.

Vaccination against seasonal flu in Switzerland: The indecision of pregnant women encouraged by healthcare professionals.

BACKGROUND: The recommendation for seasonal flu immunization from the second trimester of pregnancy, adopted in summer 2010 in Switzerland, is situated within a social context characterized by reluctance toward some vaccinations, a relatively low vaccination coverage against flu in the general population, and still heated debates fuelled by vaccination campaigns organized around the A(H1N1)pdm09 flu pandemic in winter 2009 to 2010. This study examines Swiss pregnant women's representations of the risks associated with seasonal flu and its vaccination. METHODS: Semi-structured interviews were conducted with 29 women, while in the maternity unit in March 2011, 3 to 5 days after giving birth. The interviews addressed the risks associated with flu, modes of protection, motivations for, and obstacles to vaccination. RESULTS: The interviewees did not show major preoccupations regarding seasonal flu and they tended to distance themselves from the at-risk status. They did not directly challenge seasonal flu immunization; however, they were reluctant to do it. Their attitudes were supported by their personal experience and the experience of their social networks. Healthcare professionals, particularly medical doctors, gave very little direction, or even did not raise the issue with them. CONCLUSIONS: Between the rather moderate positions of those who are against vaccination and those who support it, an intermediate grey zone, characterized by hesitation, was observed. Furthermore, the indecision of pregnant women is reinforced by doubts among the persons they are close to and also among the professionals they met during their pregnancy.

High specificity of line-immunoassay based algorithms for recent HIV-1 infection independent of viral subtype and stage of disease.

BACKGROUND: Serologic testing algorithms for recent HIV seroconversion (STARHS) provide important information for HIV surveillance. We have shown that a patient's antibody reaction in a confirmatory line immunoassay (INNO-LIA HIV I/II Score, Innogenetics) provides information on the duration of infection. Here, we sought to further investigate the diagnostic specificity of various Inno-Lia algorithms and to identify factors affecting it. METHODS: Plasma samples of 714 selected patients of the Swiss HIV Cohort Study infected for longer than 12 months and representing all viral clades and stages of chronic HIV-1 infection were tested blindly by Inno-Lia and classified as either incident (up to 12 m) or older infection by 24 different algorithms. Of the total, 524 patients received HAART, 308 had HIV-1 RNA below 50 copies/mL, and 620 were infected by a HIV-1 non-B clade. Using logistic regression analysis we evaluated factors that might affect the specificity of these algorithms. RESULTS: HIV-1 RNA < 50 copies/mL was associated with significantly lower reactivity to all five HIV-1 antigens of the Inno-Lia and impaired specificity of most algorithms. Among 412 patients either untreated or with HIV-1 RNA ≥ 50 copies/mL despite HAART, the median specificity of the algorithms was 96.5% (range 92.0-100%). The only factor that significantly promoted false-incident results in this group was age, with false-incident results increasing by a few percent per additional year. HIV-1 clade, HIV-1 RNA, CD4 percentage, sex, disease stage, and testing modalities exhibited no significance. Results were similar among 190 untreated patients. CONCLUSIONS: The specificity of most Inno-Lia algorithms was high and not affected by HIV-1 variability, advanced disease and other factors promoting false-recent results in other STARHS. Specificity should be good in any group of untreated HIV-1 patients.

[Complementary medicine use in oncology patients]. / Evaluation du recours aux médecines complémentaires chez les patients en suivi oncologique.

Through an anonymized questionnaire we assessed the prevalence of complementary and alternative medicine (CAM) use in a series of cancer patients treated at the Geneva University Hospitals. 152 among the 300 sollicitated patients responded and 39 (26.5%) recognized to use CAM, particularly young, and moderate to highly educated patients. Patients justify their use of CAM to maximize caring ressources, to achieve physical or psychic relief. Most of them recognize to share these therapeutic options with their doctor. Satisfaction with traditional medicine as well as ignorance of CAM are the main arguments provided by non users. The specificity of our hospital context in which results were collected and the lack of a common and popular definition of CAM remain the main limitations of our enquiry.

[Compliance and resistance to child vaccination: a study among Swiss mothers]. / Adhésion et résistance aux vaccinations infantiles: une étude auprès de mères suisses.

BACKGROUND: This study examines mothers' practices and attitudes in relation to their child's immunization. In this area, like in others, gaps are being observed between the public health model of risk management and the population expectations and behaviors. METHODS: Data were collected using a standardized questionnaire from 1295 women having, in 1999, one child between 7 and 8 years of age of Swiss nationality and attending the public school system in Geneva. RESULTS: Four immunization types were established based on (1) the degree of satisfaction (in relation to past choices), (2) the perception of adequate knowledge about immunization and (3) practices. The mothers were divided into the following categories: compliant (57%), compliant ambivalent (19%), moderately resistant (17%) and resistant (7%). Mothers having reached an intermediate education level are more likely to be resistant. Furthermore, women having negative attitudes towards biomedical institutions, having consulted alternative practitioners and those considering that they have a certain individual control over the health of the family are more often resistant to immunization. CONCLUSION: Our results confirm the existence of a resistance to child immunization among a section of the population. It should not be attributed to mothers' ignorance, but rather could reflect their perplexity towards the choices they are expected to make. In that regards, the importance some parents give to individual control over health can be in contradiction with community objectives of public health. Actions for the promotion of immunization should primarily target families who are uncertain (compliant ambivalent and moderately resistant). At the same time, the difficulties entailed in the - individual and collective - management of risks require that new forms of dialogue be developed between experts and the public.

Breastfeeding among mothers of Pakistani origin living in the UK.

Studies have shown that many ethnic minority women coming to live in the UK adopt artificial feeding, contrary to custom in their country of origin. However a study of women of Pakistani origin living in Cardiff showed that most of the mothers favoured and initiated breastfeeding, but more than half stopped before the baby was three months old. Claudine Burton-Jeangros suggests this represents a missed opportunity for health visitors to advise and support ethnic minority mothers on the advantages of breastfeeding.