Implementation of a protocol and staff educational sessions improves the care of survivors of sexual assault.

OBJECTIVE: We previously conducted an audit of the care provided for survivors of sexual violence seen at our emergency department and observed that 90% of them did not receive optimal care. This study analysed whether the implementation of a new protocol and educational sessions for staff increased the proportion of such patients who received optimal medical care. METHODS: A computerized chart detailing a new care protocol was developed specifically for rape survivors. Educational sessions focusing on the use of the new protocol were organized for healthcare providers. We then conducted another audit that reviewed retrospectively the charts of all survivors of sexual violence who were cared for at a public university hospital. MAIN OUTCOME MEASURE: Optimal medical care was defined as including systematic investigations for sexually transmitted diseases, and the provision of prophylactic antibiotics, a pregnancy test, emergency contraception, and psychological and medical follow-up. RESULTS: We analysed the charts of 362 survivors of sexual violence and observed that all of the required procedures were completed for 337 patients (93%) and the required preventive measures were provided to 325 patients (90%). CONCLUSION: After the implementation of the new protocol and educational sessions, the proportion of survivors who received optimal medical care increased from 10% to 90%. Nevertheless, optimal management also implies social, psychological and legal support. We hope that the establishment of specialist sexual assault centres will further improve management.

HIV testing history and access to treatment among migrants living with HIV in Europe.

INTRODUCTION: Migrants are overrepresented in the European HIV epidemic. We aimed to understand the barriers and facilitators to HIV testing and current treatment and healthcare needs of migrants living with HIV in Europe. METHODS: A cross-sectional study was conducted in 57 HIV clinics in nine countries (Belgium, Germany, Greece, Italy, The Netherlands, Portugal, Spain, Switzerland and United Kingdom), July 2013 to July 2015. HIV-positive patients were eligible for inclusion if they were as follows: 18 years or older; foreign-born residents and diagnosed within five years of recruitment. Questionnaires were completed electronically in one of 15 languages and linked to clinical records. Primary outcomes were access to primary care and previous negative HIV test. Data were analysed using random effects logistic regression. Outcomes of interest are presented for women, heterosexual men and gay/bisexual men. RESULTS: A total of 2093 respondents (658 women, 446 heterosexual men and 989 gay/bisexual men) were included. The prevalence of a previous negative HIV test was 46.7%, 43.4% and 82.0% for women, heterosexual and gay/bisexual men respectively. In multivariable analysis previous testing was positively associated with: receipt of post-migration antenatal care among women, permanent residency among heterosexual men and identifying as gay rather than bisexual among gay/bisexual men. Access to primary care was found to be high (>83%) in all groups and was strongly associated with country of residence. Late diagnosis was common for women and heterosexual men (60.8% and 67.1%, respectively) despite utilization of health services prior to diagnosis. Across all groups almost three-quarters of people on antiretrovirals had an HIV viral load <50 copies/mL. CONCLUSIONS: Migrants access healthcare in Europe and while many migrants had previously tested for HIV, that they went on to test positive at a later date suggests that opportunities for HIV prevention are being missed. Expansion of testing beyond sexual health and antenatal settings is still required and testing opportunities should be linked with combination prevention measures such as access to PrEP and treatment as prevention.

Adherence to HIV post-exposure prophylaxis: A multivariate regression analysis of a 5 years prospective cohort.

BACKGROUND: Non-occupational post-exposure prophylaxis (nPEP) is a recommended public health intervention after a sexual or percutaneous exposure to human immunodeficiency virus (HIV). METHODS: We conducted a prospective observational study recording consultations for nPEP at a reference HIV center in Brussels, Belgium from January 2011 to December 2015. We recorded attendance to follow-up, reported completion of nPEP and pharmacy records to measure adherence. Multivariate logistic regressions were performed to identify independent risk factors for adherence to nPEP and attendance to first follow-up visit at the STI clinic. FINDINGS: Among 1881 patients receiving nPEP, 66.4% had a documented completion of a 28-day course of nPEP and 87.3% attended their first follow-up clinic visit. MSM (OR, 1.40; 95%CI, 1.04-1.90), being a native Belgian (OR, 1.50; 95%CI, 1.18-1.90), older age (OR, 1.02; 95%CI, 1.01-1.04), being a sexual assault survivor (OR, 0.59; 95%CI, 0.38-0.91), having had a previous nPEP treatment (OR, 1.44; 95%CI, 1.02-2.02), consultation during daytime (OR, 1.35; 95%CI, 1.07-1.70) and benefitting from a health insurance (OR, 2.11; 95%CI, 1.58-2.89) were significant independent predictors for adherence to nPEP. Patients whose initial treatment was AZT/3TC/IDV/r had similar adherence than patients on d4T/3TC/LPV/r (OR, 0.898; 95%CI, 0.68-1.20). INTERPRETATION: Multiple independent risk factors for nPEP retention into care and adherence are present at treatment initiation and might be targeted by tailored interventions. Sexual assault victims are overexposed to deleterious consequences of the lack of health insurance on compliance.

Factors Associated With Access to HIV Testing and Primary Care Among Migrants Living in Europe: Cross-Sectional Survey.

BACKGROUND: There is a heavy and disproportionate burden of human immunodeficiency virus (HIV) infection among migrant communities living in Europe. Despite this, the published evidence related to HIV testing, prevention, and treatment needs for migrants is sparse. OBJECTIVE: The aim of this study was to identify the factors associated with access to primary care and HIV testing among migrant groups living in Europe. METHODS: A Web-based survey (available in 14 languages) was open to all people aged 18 years and older, living outside their country of birth in the World Health Organization (WHO) European area. Community organizations in 9 countries promoted the survey to migrant groups, focusing on those at a higher risk of HIV (sub-Saharan Africans, Latin Americans, gay or bisexual men, and people who inject drugs). Multivariable analysis examined factors associated with access to primary care and previous history of an HIV test. RESULTS: In total, 559 women, 395 heterosexual men, and 674 gay or bisexual men were included in the analysis, and 68.1% (359/527) of women, 59.5% (220/371) of heterosexual men, and 89.6% (596/664) of gay or bisexual men had tested for HIV. Low perceived risk was the reason given for not testing by 62.3% (43/69) of gay or bisexual men and 83.3% (140/168) of women and heterosexual men who reported never having tested for HIV. Access to primary care was >60% in all groups. Access to primary care was strongly positively associated with living in Northern Europe compared with Southern Europe (women: adjusted odds ratio, aOR 34.56 [95% CI 11.58-101]; heterosexual men: aOR 6.93 [95% CI 2.49-19.35], and gay or bisexual men: aOR 2.53 [95% CI 1.23-5.19]), whereas those with temporary residency permits were less likely to have access to primary care (women: aOR 0.41 [95% CI 0.21-0.80] and heterosexual men: aOR 0.24 [95% CI 0.10-0.54] only). Women who had experience of forced sex (aOR 3.53 [95% CI 1.39-9.00]) or postmigration antenatal care (aOR 3.07 [95% CI 1.55-6.07]) were more likely to have tested for HIV as were heterosexual men who had access to primary care (aOR 3.13 [95% CI 1.58-6.13]) or reported "Good" health status (aOR 2.94 [95% CI 1.41-5.88]). CONCLUSIONS: Access to primary care is limited by structural determinants such as immigration and health care policy, which varies across Europe. For those migrants who can access primary care and other health services, missed opportunities for HIV testing remain a barrier to earlier testing and diagnosis for migrants in Europe. Clinicians should be aware of these potential structural barriers to HIV testing as well as low perception of HIV risk in migrant groups.

High levels of postmigration HIV acquisition within nine European countries.

OBJECTIVE: We aimed to estimate the proportion of postmigration HIV acquisition among HIV-positive migrants in Europe. DESIGN: To reach HIV-positive migrants, we designed a cross-sectional study performed in HIV clinics. METHODS: The study was conducted from July 2013 to July 2015 in 57 clinics (nine European countries), targeting individuals over 18 years diagnosed in the preceding 5 years and born abroad. Electronic questionnaires supplemented with clinical data were completed in any of 15 languages. Postmigration HIV acquisition was estimated through Bayesian approaches combining extensive information on migration and patients' characteristics. CD4 cell counts and HIV-RNA trajectories from seroconversion were estimated by bivariate linear mixed models fitted to natural history data. Postmigration acquisition risk factors were investigated with weighted logistic regression. RESULTS: Of 2009 participants, 46% were MSM and a third originated from sub-Saharan Africa and Latin America & Caribbean, respectively. Median time in host countries was 8 years. Postmigration HIV acquisition was 63% (95% confidence interval: 57-67%); 72% among MSM, 58 and 51% in heterosexual men and women, respectively. Postmigration HIV acquisition was 71% for Latin America and Caribbean migrants and 45% for people from sub-Saharan Africa. Factors associated with postmigration HIV acquisition among heterosexual women and MSM were age at migration, length of stay in host country and HIV diagnosis year and among heterosexual men, length of stay in host country and HIV diagnosis year. CONCLUSION: A substantial proportion of HIV-positive migrants living in Europe acquired HIV postmigration. This has important implications for European public health policies.

Advancing Migrant Access to Health Services in Europe (AMASE): Protocol for a Cross-sectional Study.

BACKGROUND: Migrants form a substantial proportion of the population affected by the human immunodeficiency virus (HIV) epidemic in Europe, yet HIV prevention for this population is hindered by poor understanding of access to care and of postmigration transmission dynamics. OBJECTIVE: We present the design and methods of the advancing Migrant Access to health Services in Europe (aMASE) study, the first European cross-cultural study focused on multiple migrant populations. It aims to identify the structural, cultural, and financial barriers to HIV prevention, diagnosis, and treatment and to determine the likely country of HIV acquisition in HIV-positive migrant populations. METHODS: We delivered 2 cross-sectional electronic surveys across 10 countries (Belgium, France, Germany, Greece, Italy, the Netherlands, Portugal, Spain, Switzerland, and United Kingdom). A clinic survey aimed to recruit up to 2000 HIV-positive patients from 57 HIV clinics in 9 countries. A unique study number linked anonymized questionnaire data to clinical records data (viral loads, CD4 cell counts, viral clades, etc). This questionnaire was developed by expert panel consensus and cognitively tested, and a pilot study was carried out in 2 countries. A Web-based community survey (n=1000) reached those living with HIV but not currently accessing HIV clinics, as well as HIV-negative migrants. It was developed in close collaboration with a community advisory group (CAG) made up of representatives from community organizations in 9 of the participating countries. The CAG played a key role in data collection by promoting the survey to higher-risk migrant groups (sub-Saharan Africans, Latin Americans, men who have sex with men, and people who inject drugs). The questionnaires have considerable content overlap, allowing for comparison. Questions cover ethnicity, migration, immigration status, HIV testing and treatment, health-seeking behavior, sexual risk, and drug use. The electronic questionnaires, which were available in 15 languages, allowed for complex routing, preventing respondents from answering irrelevant questions. RESULTS: In total, we recruited 2249 participants from 57 HIV clinics as part of the clinic survey and retrieved 1637 complete responses as part of the community survey. CONCLUSIONS: The findings will provide much-needed information for improving HIV prevention interventions and access to services for migrant communities.

Prescription of Non-Occupational Post-Exposure HIV Prophylaxis by Emergency Physicians: An Analysis on Accuracy of Prescription and Compliance.

We conducted a retrospective analysis of data from a prospective nPEP (non-Occupational Post Exposure Prophylaxis) registry based on patients consulting at one academic Emergency department located in Brussels, Belgium. We review here 1,357 cases consulting from January 2011 to December 2013.The objective of the study is to determine whether emergency physicians prescribe nPEP according to national guideline with support from IDS (infectious disease specialists). As this intervention has a high cost we wanted to verify correct allocation of treatment to high risk patients. Moreover we wanted to determine whether compliance to nPEP when prescribed by an Emergency Physician was different from literature reports. Finally we wanted to describe the population consulting for nPEP at our center. Emergency physicians prescribed nPEP more frequently in high risk exposures (98.6%) compared to intermediate risk exposures (53.2%); adequately allocating resources from a public health perspective. Appropriateness of prescription when evaluated according to nPEP Belgian guidelines was 98.8%.Compliance with nPEP prescribed by Emergency physicians was 60% in our study. Compliance was the highest in MSM (Men who have Sex with Men) while sexual assault victims showed the lowest compliance. Altogether this study suggests that Emergency physicians can safely and adequately prescribe nPEP when supported by a comprehensive guideline. Recognizing intrinsic differences within heterogeneous populations consulting for nPEP may improve compliance to this high-cost public health intervention.

Atypical hyperplasia of the marginal zone of B follicles in a polymorphic Epstein-Barr virus-associated lymphoproliferative disorder occurring in an adolescent with human immunodeficiency virus infection.

Epstein-Barr virus (EBV)-associated lymphoid proliferations that are similar to post-transplantation lymphoproliferative disorders may occasionally occur in the setting of human immunodeficiency virus (HIV) infection. Herein, we describe such a lesion involving the adenoids in a HIV-seropositive adolescent who acquired immunity against EBV during childhood. On microscopic examination, the marginal zone of B follicles and the interfollicular area were enlarged due to the accumulation of small or intermediate-sized lymphocytes, immunoblasts, epithelioid histiocytes, and plasma cells. A few atypical immunoblasts resembling Reed-Sternberg cells were also present. Most of the cells seen in these expanded regions belonged to the B-cell lineage and displayed a phenotype consistent with that of postgerminal center B cells. No clonal rearrangement of the genes coding for the heavy chain of the immunoglobulin could be demonstrated by polymerase chain reaction analysis. In-situ hybridization studies revealed the presence of EBV early RNA in a significant number of these cells, which suggests the participation of this virus in the pathogenesis of such a B-cell proliferation. The clinical course was benign; no progression or recurrence could be seen more than 24 months after the diagnosis. This atypical lymphoproliferative disorder is probably related to polyclonal reactivation of a latent EBV infection due to a local or systemic immune imbalance induced by HIV replication. Recognition of this reactive condition is important to prevent overtreatment.