Disparities in access to and use of HIV-related health services in the Netherlands by migrant status and sexual orientation: a cross-sectional study among people recently diagnosed with HIV infection.

BACKGROUND: Migrants often face barriers to accessing healthcare. We examined disparities in access to and use of HIV-related health services between migrant and non-migrant people recently diagnosed with HIV living in the Netherlands, taken into account sexual orientation. Also, we examined differences in experiences in living with HIV between these groups. METHODS: We used a questionnaire and clinical data collected between July 2013 and June 2015 among migrant and non-migrant participants of the European cross-sectional aMASE (Advancing Migrant Access to health Services in Europe) study in the Netherlands. Using univariable logistic regression analyses, we compared outcomes on between migrants and non-migrants, stratified by sexual orientation (with non-migrant men having sex with men [MSM] as the reference group). RESULTS: We included 77 migrant MSM, 115 non-migrant MSM, 21 migrant heterosexual men, 14 non-migrant heterosexual men and 20 migrant women. In univariable analyses, all heterosexual groups were less likely to ever have had an HIV-negative test before their diagnosis and were more likely to be diagnosed late than non-migrant MSM. All migrant groups were more likely to have experienced difficulties accessing general healthcare in the Netherlands and were less likely to have heard of post-exposure prophylaxis than non-migrant MSM. Migrants frequently reported uncertainty about their rights to healthcare and language barriers. Most (93%) participants visited a healthcare facility in the 2 years before HIV diagnosis but only in 41% an HIV test was discussed during that visit (no statistical difference between groups). Migrant heterosexuals were more likely to have missed appointments at their HIV clinic due to the travel costs than non-migrant MSM. Migrant MSM and women were more likely to have experienced HIV discrimination in the Netherlands than non-migrant MSM. CONCLUSION: Disparities in access to and use of HIV-related health services and experiences exist by migrant status but also by sexual orientation. Our data suggests heterosexual men and women may particularly benefit from improved access to HIV testing (e.g., through provider-initiated testing), while migrant MSM may benefit from improved access to HIV prevention interventions (e.g., pre-exposure prophylaxis).

Correction: Awareness, knowledge, use, willingness to use and need of Pre-Exposure Prophylaxis (PrEP) during World Gay Pride 2017.

[This corrects the article DOI: 10.1371/journal.pone.0204738.].

Chagas screening and treatment among Bolivians living in Madrid, Spain: The need for an official protocol.

BACKGROUND: It is estimated that around 52,000 people live with Chagas in Spain, but only 10% have been diagnosed. Migrants from Bolivia bear the burden of Chagas infection in Spain. However, little is known about their current management of Chagas diagnosis and treatment patterns. This study aimed to assess the Chagas related disease perception and health behaviour of Bolivians living in Madrid. METHODS AND PRINCIPAL FINDINGS: For a first time, a cross-sectional survey about Chagas' knowledges and practices was carried out in Madrid, Spain. A total of 376 Bolivians were interviewed about their Chagas health-seeking behaviour. Differences between men and women were assessed Most of Bolivians living in Madrid have access to the public health services. 44% of Bolivians included in the survey had a Chagas screening test done. However, while women did their test for Chagas mostly at hospital (59.2%), men also used the community campaigns (17.5%) and blood banks (14.3%). The prevalence reported among Bolivians tested was 27.7%. Unfortunately, more than half of those reporting a positive test for Chagas did not begin or completed treatment. Only 45.7% of positives reported having had their children tested for Chagas. CONCLUSIONS: Despite the increase in the number of Chagas diagnoses done in Madrid, the number of Bolivians who tested positive and then started or completed treatment remains very low. The fact that most Bolivians' access to the health system is through the primary healthcare services should be considered for improving management of cases and follow-up of treatment adherence. Local and national protocol establishing guidelines for the screening and treatment of Chagas disease would help improving case detection and management at all levels of the healthcare system.

Determining the likely place of HIV acquisition for migrants in Europe combining subject-specific information and biomarkers data.

In most HIV-positive individuals, infection time is only known to lie between the time an individual started being at risk for HIV and diagnosis time. However, a more accurate estimate of infection time is very important in certain cases. For example, one of the objectives of the Advancing Migrant Access to Health Services in Europe (aMASE) study was to determine if HIV-positive migrants, diagnosed in Europe, were infected pre- or post-migration. We propose a method to derive subject-specific estimates of unknown infection times using information from HIV biomarkers' measurements, demographic, clinical, and behavioral data. We assume that CD4 cell count (CD4) and HIV-RNA viral load trends after HIV infection follow a bivariate linear mixed model. Using post-diagnosis CD4 and viral load measurements and applying the Bayes' rule, we derived the posterior distribution of the HIV infection time, whereas the prior distribution was informed by AIDS status at diagnosis and behavioral data. Parameters of the CD4-viral load and time-to-AIDS models were estimated using data from a large study of individuals with known HIV infection times (CASCADE). Simulations showed substantial predictive ability (e.g. 84% of the infections were correctly classified as pre- or post-migration). Application to the aMASE study (n = 2009) showed that 47% of African migrants and 67% to 72% of migrants from other regions were most likely infected post-migration. Applying a Bayesian method based on bivariate modeling of CD4 and viral load, and subject-specific information, we found that the majority of HIV-positive migrants in aMASE were most likely infected after their migration to Europe.

Awareness, knowledge, use, willingness to use and need of Pre-Exposure Prophylaxis (PrEP) during World Gay Pride 2017.

OBJECTIVE: To assess the awareness, knowledge, use, and willingness to use and need of PrEP among men who have sex with men (MSM) and transgender women (TW) who attended World Gay Pride (WGP) 2017 in Madrid. DESIGN AND METHODS: Online survey. Participants were recruited through gay-oriented dating apps and HIV Non-Governmental Organizations´ social media. Inclusion criteria included being MSM or TW, age 18 years old or above, and having attended WGP in Madrid. Information regarding the participant's awareness and knowledge, use or willingness to use, and need for PrEP was collected, as well as sociodemographic characteristics. Participants were considered to be in need of PrEP if they met one of the following indication criteria: having practiced unprotected anal intercourse with more than 2 partners, having practiced chemsex, or having engaged in commercial sex-all in the preceding 6 months. Descriptive and multivariable analyses with logistic regression were conducted. RESULTS: 472 participants met the inclusion criteria and completed the questionnaire. The mean age was 38, 97.7% were MSM, 77% had a university education, and 85% were living in Spain, mostly in big cities. Overall, 64% of participants were aware of PrEP, but only 33% knew correctly what PrEP was. 67% of HIV-negative participants were willing to take PrEP, although only 5% were taking it during WGP, mostly due to lack of access. 43% of HIV-negative respondents met at least one PrEP indication criteria. For HIV-negative men living in Spain, university education and living in big cities was associated with PrEP awareness. Lower education level and meeting PrEP criteria was associated with willingness to use PrEP. CONCLUSIONS: Our study shows that among MSM attending WGP 2017 in Madrid, there was limited PrEP awareness, low accuracy of PrEP knowledge, and a high need and willingness to use PrEP. Health authorities should strengthen existing preventive strategies and implement PrEP.

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.

Role of HIV in the desire of procreation and motherhood in women living with HIV in Spain: a qualitative approach.

BACKGROUND: Improved antiretroviral treatments and decrease in vertical transmission of HIV have led to a higher number of women living with HIV to consider childbearing. However, stigma and social rejection result in specific challenges that HIV positive women with procreation intentions have to face with. Our objective was to in depth analyse elements shaping their desire for procreation and specifically investigate the impact of HIV. METHODS: A qualitative study was conducted through open interviews with 20 women living with HIV between 18 and 45 years of age, from the Spanish AIDS Research Network Cohort (CoRIS). Interviews were audio-recorded and transcribed. A content analysis was performed. RESULTS: HIV diagnosis is a turning point in women's sexual and emotional life that is experienced traumatically. HIV diagnosis is usually associated with the fear of an immediate death and the idea of social isolation. At this moment, women temporarily reject future motherhood or having a sexual life. HIV status is only disclosed to the closed social circle and partner support is essential in HIV diagnosis assimilation process. Health professionals provide information on assisted reproductive technology and on how to minimize risk of partner HIV transmission. Most of barriers for procreation acknowledged by women are not related to HIV. However, women fear vertical transmission and experience other barriers derived from HIV infection. In this context, pregnancy makes women feel themselves as "normal women" despite HIV. Motherhood is considered an element of compensation that helps them to cope with HIV diagnosis. All these elements make health professionals key actors: they provide information and support after HIV diagnosis. CONCLUSIONS: Barriers and drivers for procreation are similar among HIV positive women and general population. However, stigma and discrimination linked with HIV weigh in HIV positive women decision of motherhood. In this context, it is necessary to provide these women with the necessary counselling, guidance and resources to take decisions about procreation properly informed.

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.

Implementing and expanding HIV testing in immigrant populations in Europe: Comparing guideline's recommendations and expert's opinions / Implementación y expansión de la prueba de VIH en población inmigrante en Europa: confrontación de las recomendaciones de las guías con las opiniones de los expertos

Immigrant populations, especially those from endemic countries, living in the European Union (EU) suffer a disproportionate burden of HIV, delayed diagnosis and poorer access to antiretroviral treatment. While International Organisations are developing recommendations aimed at increasing the uptake of HIV testing, the feasibility and real outcomes of these measures remain unexplored. The aim of this review was, firstly to identify the recommendations of the main International Organisations (IO) on HIV testing in immigrants. Secondly, to describe the challenges for implementing and expanding HIV testing and counselling interventions targeting immigrants by interviewing key informants. The importance of HIV testing in immigrants is discussed, along with the appropriateness of universal HIV testing approaches vs most at risk targeted approaches. Also addressed is, pre- and post-HIV test counselling characteristics and community initiatives suitable to reach this population and, finally the legal issues regarding access to treatment for illegal immigrants

Las poblaciones inmigrantes que viven en la Unión Europea, especialmente las originarias de países endémicos, sufren una carga desproporcionada de VIH, retraso diagnóstico y barreras de acceso al tratamiento antirretroviral. Mientras las organizaciones internacionales desarrollan recomendaciones para expandir el test de VIH, la factibilidad y los resultados reales de las medidas propuestas están aún por explorar. El objetivo de esta revisión es, en primer lugar, identificar las recomendaciones de los organismos internacionales sobre prueba de VIH a poblaciones inmigrantes. En segundo lugar, nuestro objetivo es describir los retos para implementar y expandir la prueba y el consejo de VIH dirigido a inmigrantes a través de entrevistas con informantes clave. En este artículo describimos la importancia de realizar la prueba en inmigrantes y discutimos la adecuación de las estrategias de cribado de VIH universal, frente a las estrategias de prueba dirigidas a colectivos en situación de especial vulnerabilidad. También se abordan las características del consejo previo y posterior a la prueba y las iniciativas desde la comunidad para alcanzar a esta población. Finalmente, analizamos cuestiones legales sobre el acceso al tratamiento de los inmigrantes en estatus ilegal

Implementing and expanding HIV testing in immigrant populations in Europe: Comparing guideline's recommendations and expert's opinions.

Immigrant populations, especially those from endemic countries, living in the European Union (EU) suffer a disproportionate burden of HIV, delayed diagnosis and poorer access to antiretroviral treatment. While International Organisations are developing recommendations aimed at increasing the uptake of HIV testing, the feasibility and real outcomes of these measures remain unexplored. The aim of this review was, firstly to identify the recommendations of the main International Organisations (IO) on HIV testing in immigrants. Secondly, to describe the challenges for implementing and expanding HIV testing and counselling interventions targeting immigrants by interviewing key informants. The importance of HIV testing in immigrants is discussed, along with the appropriateness of universal HIV testing approaches vs most at risk targeted approaches. Also addressed is, pre- and post-HIV test counselling characteristics and community initiatives suitable to reach this population and, finally the legal issues regarding access to treatment for illegal immigrants.

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.

A systematic review of post-migration acquisition of HIV among migrants from countries with generalised HIV epidemics living in Europe: mplications for effectively managing HIV prevention programmes and policy.

BACKGROUND: Migrant populations from countries with generalised HIV epidemics make up a significant proportion of all HIV/AIDS cases in many European Union and European Economic Area (EU/EEA) countries, with heterosexual transmission the predominant mode of HIV acquisition. While most of these infections are diagnosed for the first time in Europe, acquisition is believed to have predominantly occurred in the home country. A proportion of HIV transmission is believed to be occurring post-migration, and many countries may underestimate the degree to which this is occurring. Our objectives were to review the literature estimating the proportion of migrants believed to have acquired their HIV post-migration and examine which EU member states are able to provide estimates of probable country of HIV acquisition through current surveillance systems. METHODS: A systematic review was undertaken to gather evidence of sexual transmission of HIV within Europe among populations from countries with a generalised epidemic. In addition, national surveillance focal points from 30 EU/EEA Member States were asked to complete a questionnaire about surveillance methods and monitoring of the likely place of HIV acquisition among migrants. RESULTS & DISCUSSION: Twenty-seven papers from seven countries were included in the review and 24 countries responded to the survey. Estimates of HIV acquisition post-migration ranged from as low as 2% among sub Saharan Africans in Switzerland, to 62% among black Caribbean men who have sex with men (MSM) in the UK. Surveillance methods for monitoring post-migration acquisition varied across the region; a range of methods are used to estimate country or region of HIV acquisition, including behavioural and clinical markers. There is little published evidence addressing this issue, although Member States highlight the importance of migrant populations in their epidemics. CONCLUSIONS: There is post-migration HIV acquisition among migrants in European countries but this is difficult to quantify accurately with current data. Migrant MSM appear at particular risk of HIV acquisition post-migration. Countries that identify migrants as an important part of their HIV epidemic should focus on using an objective method for assigning probable country of HIV acquisition. Robust methods to measure HIV incidence should be considered in order to inform national prevention programming and resource allocation.

HIV Infection in Migrant Populations in the European Union and European Economic Area in 2007-2012: An Epidemic on the Move.

BACKGROUND: Migrants are considered a key group at risk for HIV infection. This study describes the epidemiology of HIV and the distribution of late HIV presentation among migrants within the European Union/European Economic Area during 2007-2012. METHODS: HIV cases reported to European Surveillance System (TESSy) were analyzed. Migrants were defined as people whose geographical origin was different than the reporting country. Multiple logistic regression was used to model late HIV presentation. RESULTS: Overall, 156,817 HIV cases were reported, of which 60,446 (38%) were migrants. Of these, 53% were from Sub-Saharan Africa, 12% from Latin America, 9% from Western Europe, 7% from Central Europe, 5% from South and Southeast Asia, 4% from East Europe, 4% from Caribbean, and 3% from North Africa and Middle East. Male and female migrants from Sub-Saharan Africa and Latin America had higher odds of late HIV presentation than native men and women. Migrants accounted for 40% of all HIV notifications in 2007 versus 35% in 2012. HIV cases in women from Sub-Saharan Africa decreased from 3725 in 2007 to 2354 in 2012. The number of HIV cases from Latin America peaked in 2010 to decrease thereafter. HIV diagnoses in migrant men who have sex with men increased from 1927 in 2007 to 2459 in 2012. CONCLUSIONS: Migrants represent two-fifths of the HIV cases reported and had higher late HIV presentation. HIV epidemic in migrant populations in European Union/European Economic Area member states is changing, probably reflecting the global changes in the HIV pandemic, the impact of large-scale ART implementation, and migration fluctuations secondary to the economic crisis in Europe.

HIV testing policies for migrants and ethnic minorities in EU/EFTA Member States.

BACKGROUND: In the context of an European Centre for Disease Prevention and Control (ECDC) research project, our objective was to describe current recommendations regarding HIV testing and counselling targeting migrants and ethnic minorities in the European Union/European Economic Area/European Free Trade Association (EU/EEA/EFTA) Member States. METHODS: An on-line survey was conducted among 31 EU/EEA/EFTA Member States. The survey inquired on the existence of specific HIV testing and counselling recommendations or policies for migrants and/or ethnic minorities and the year of their publication. Additionally, we performed a review of national recommendations, guidelines or any other policy documents retrieved from an Internet search through the different countries' competent bodies. RESULTS: Twenty-nine (94%) country representatives responded the survey, and 28 documents from 27 countries were identified. National guidelines on HIV testing are heterogeneous and tailored, according to the epidemiological situation. Twenty-two countries identify migrants and four countries identify ethnic minorities as particularly vulnerable to HIV. Sixteen countries explicitly recommend offering an HIV test to migrants/ethnic minorities. Guidelines especially target people originating from HIV endemic countries, and benefits of HIV early detection are highlighted. HIV testing is not mandatory in any country, but some countries overtly facilitate this practice. CONCLUSION: Benefits of HIV testing in migrants and ethnic minorities, at both individual and community levels are recognized by many countries. In spite of this, not all countries identify the need to test these groups.

[Process and results of constructing a deprivation index for the districts of Madrid and Barcelona, Spain]. / Construcción de un índice de privación para los barrios de Madrid y Barcelona.

BACKGROUND: There are few economic indicators that take the neighbourhood as the unit of reference in our context. The aim of this article is to describe the process and results of secondary data collection and development of a deprivation index (DI) for the neighbourhoods of the cities of Madrid and Barcelona, discussing their utility for research on health inequalities. METHODS: Initial DI conceptual framework contained different elements that characterize deprivation and for which we collected second-level variables. ID was adapted to the availability of variables and to the results of an exploratory analysis. Finally, a factor analysis was performed to validate the IP. We built a DI based on five dimensions for Madrid (economy, population and territory, housing, cars and demographics) and 4 for Barcelona (all except "demographics"). Neighbourhoods were grouped into quartiles according to their score for the DI (Q4: higher levels of deprivation). Premature mortality rates and premature mortality ratios adjusted by age were calculated for each quartile. RESULTS: The IP explained 55% of the observed variability in the indicators for Madrid and 69% for Barcelona. Premature mortality rate in Madrid for Q1 was 1.65 per 10³ in men and 0.92 per 10³ women and 2.81 per 10³ in men and 1.22 per 10³ in women residing in Q4. In Barcelona, the mortality rate was 2.33 per 10³ men and 1.15 per 10³ women in Q1 and 3.49 per 10³ in men and 1.52 per 103 in women living in Q4. CONCLUSION: Premature mortality rates showed higher premature mortality in the most deprived districts.

Construcción de un índice de privación para los barrios de Madrid y Barcelona / Processand results of constructing a deprivation index for the districts of Madrid and Barcelona, Spain

Fundamentos: los indicadores socioeconómicos que toman el barrio como unidad de referencia en nuestro contexto son escasos. Los objetivos de este artículo son describir el proceso de construcción y la validez de un índice de privación a nivel de barrio y analizar su asociación con la mortalidad. Métodos: el esquema conceptual inicial del IP contuvo elementos que caracterizaban teóricamente la privación y para las que se realizó una recogida de variables de segundo nivel. El IP se adaptó a la disponibilidad de variables y a los resultados de sus análisis exploratorios. Finalmente, se realizó un análisis factorial para la validación del IP que se compuso de 5 dimensiones para Madrid (economía, población y territorio, vivienda, parque móvil y demografía) y 4 para Barcelona (las mismas salvo «demografía»). Los barrios fueron agrupados en cuartiles según la puntuación obtenida para el IP (Q4: mayor nivel de privación). Se calcularon tasas de mortalidad prematura estratificadas por sexo y ajustadas por edad y razones de mortalidad para cada cuartil. Resultados: El IP explicó el 55% de la variabilidad observada en los indicadores para Madrid y el 69% para Barcelona. La tasa de mortalidad prematura para el Q1 en Madrid fue 1,65por 103 en hombres y 0,92 por 103 y de 2,81 por 103 en hombres y 1,22 por 103 en mujeres residentes en Q4. En Barcelona la tasa de mortalidad fue de 2,33 por 103 en hombres y de 1,15 por 103 mujeres en el Q1 y de 3,49 por 103 en hombres y 1,52 por 103 en mujeres del Q4. Conclusión: Las tasas de mortalidad mostraron mayor mortalidad prematura en los barrios con un índice de privación mayor (AU)

Background: There are few economic indicators that take the neighborhood as the unit of reference in our context. The aim of this article is to describe the process and results of secondary data collection and development of a deprivation index (DI) for the neighborhoods of the cities of Madrid and Barcelona, discussing their utility for research on health inequalities. Methods: initial DI conceptual framework contained different elements that characterize deprivation and for which we collected second-level variables. ID was adapted to the availability of variables and to the results of an exploratory analysis. Finally, a factor analysis was performed to validate the IP. We built a DI based on five dimensions for Madrid (economy, population and territory, housing, cars and demographics) and 4 for Barcelona (all except "demographics"). Neighborhoods were grouped into quartiles according to their score for the DI (Q4: higher levels of deprivation). Premature mortality rates and premature mortality ratios adjusted by age were calculated for each quartile. Results: The IP explained 55% of the observed variability in the indicators for Madrid and 69% for Barcelona. Premature mortality rate in Madrid for Q1 was 1.65 per 103 in men and 0.92 per 103 women and 2.81 per 103 in men and 1.22 per 103 in women residing in Q4. In Barcelona,the mortality rate was 2.33 per 103 men and 1.15 per 103 women in Q1 and 3.49 per 103 in men and 1.52 per 103 in women living in Q4. Conclusion: Premature mortality rates showed higher premature mortality in the most deprived districts (AU)

Sports facilities in Madrid explain the relationship between neighbourhood economic context and physical inactivity in older people, but not in younger adults: a case study.

BACKGROUND: Neighbourhood characteristics may contribute to differences in physical inactivity. PURPOSE: To evaluate whether the availability of sports facilities helps explain the differences in physical inactivity according to the economic context of the neighbourhood. METHODS: 6607 participants representative of the population aged 16-74 years, resident in Madrid (Spain) in 2005, were analysed. Using ORs calculated by multilevel logistic regression, the association between per capita income of the neighbourhood of residence and physical inactivity was estimated, after adjusting for age, population density, individual socioeconomic characteristics and the availability of green spaces. The analysis was repeated after further adjustment for the availability of sports facilities to determine if this reduced the magnitude of the association. RESULTS: Residents in the neighbourhoods with the lowest per capita income had the highest OR for the prevalence of physical inactivity. In participants aged 16-49 years, after adjusting for the availability of sports facilities, the magnitude of the OR in the poorest neighbourhoods with respect to the richest neighbourhoods increased in men (from 2.22 to 2.35) and declined by 13% in women (from 2.13 to 1.98). In contrast, in the population aged 50-74 years, this adjustment reduced the magnitude of the OR by 21% in men (from 2.00 to 1.80) and by 53% in women (from 2.03 to 1.48). CONCLUSIONS: The poorest neighbourhoods show the highest prevalence of physical inactivity. The availability of sports facilities explains an important part of this excess prevalence in participants aged 50-74 years, but not in younger individuals.

Violence in adulthood and mental health: gender and immigrant status.

The aim of this study was to describe perceived abuse in adult Spanish and Ecuadorian women and men and to assess its association with mental health. A population-based survey was conducted in Spain in 2006. Data were taken from a probabilistic sample allowing for an equal number of men and women, Spaniards and Ecuadorians. Mental disorder was measured with the General Health Questionnaire-28. The nine questions on exposure to physical, sexual, and psychological abuse during the previous year were self-administered. Multivariate logistic regression was used to assess the association between exposure to abuse and poor mental health, adjusting for potential confounders. The sample was composed of 1,059 individuals aged 18 to 54, 104 of whom reported physical, psychological, or sexual abuse. Some 6% refused to answer the questions on abuse. Overall, reported abuse ranged from 13% in Ecuadorian women to 5% in Spanish men. Psychological abuse was the most frequent. Half the abused women, both Spanish and Ecuadorian, reported intimate partner violence (IPV), as did 22% of abused men. Poor mental health was found in 61% of abused Spanish women (adjusted Odds Ratio [ORa] = 5.1; 95% CI: 1.8-14.4), and 62% abused Ecuadorian women (ORa = 4; 95% CI: 2-7.9), in 36% of abused Spanish men (ORa = 3; 95% CI: 0.9-10.7) and in 30% abused Ecuadorian men (ORa = 2.8; 95% CI: 1-7.7). Interpersonal violence is frequent in relations with the partner, the family, and outside the family, and it seriously affects the mental health. Ecuadorian women stand out as the most vulnerable group.

HIV testing and counselling for migrant populations living in high-income countries: a systematic review.

BACKGROUND: The barriers to HIV testing and counselling that migrants encounter can jeopardize proactive HIV testing that relies on the fact that HIV testing must be linked to care. We analyse available evidence on HIV testing and counselling strategies targeting migrants and ethnic minorities in high-income countries. METHODS: Systematic literature review of the five main databases of articles in English from Europe, North America and Australia between 2005 and 2009. RESULTS: Of 1034 abstracts, 37 articles were selected. Migrants, mainly from HIV-endemic countries, are at risk of HIV infection and its consequences. The HIV prevalence among migrants is higher than the general population's, and migrants have higher frequency of delayed HIV diagnosis. For migrants from countries with low HIV prevalence and for ethnic minorities, socio-economic vulnerability puts them at risk of acquiring HIV. Migrants have specific legal and administrative impediments to accessing HIV testing-in some countries, undocumented migrants are not entitled to health care-as well as cultural and linguistic barriers, racism and xenophobia. Migrants and ethnic minorities fear stigma from their communities, yet community acceptance is key for well-being. CONCLUSIONS: Migrants and ethnic minorities should be offered HIV testing, but the barriers highlighted in this review may deter programs from achieving the final goal, which is linking migrants and ethnic minorities to HIV clinical care under the public health perspective.