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Background National testing strategy, including monitoring and evaluation, is critical in responding to HIV, sexually transmitted infections, and viral hepatitis. Community-based voluntary counselling and testing contributes to early HIV diagnoses among key populations. Countries providing community-based testing, should integrate some core data on testing and linkage to care in these services into national surveillance and monitoring and evaluation systems. This study aimed to support the integration of community-based voluntary counselling and testing data into respective national surveillance and M&E systems for those infections. Methods Preliminary consensus on indicators for the integration of community-based voluntary counselling and testing data into respective national surveillance and monitoring and evaluation systems was reached. Pilot studies were conducted in Estonia, Poland, Serbia, Slovakia, Slovenia and Spain. After pilot activities were implemented, the final consensus on indicators was reached. An analysis of the facilitators and barriers faced during pilot studies was conducted to inform the final recommendations for implementation. Results The minimum set of six indicators to be integrated into national surveillance and monitoring and evaluation systems were: number of tests, number of clients tested, reactivity rate for tests and clients, positivity (active infection) rates for tests and clients, linkage to care rates for clients with reactive and/or positive test result, proportion of all new diagnoses in a country with first reactive test result at community-based voluntary counselling and testing service. Seven additional indicators were identified. Each indicator should be disaggregated by key population, sex and age group. A list of 10 recommendations for the collection and integration of community-based voluntary counselling and testing data into national surveillance and monitoring and evaluation systems for HIV, sexually transmitted infections and viral hepatitis was identified. Conclusions Integration of some community-based voluntary counselling and testing monitoring and evaluation data into national surveillance and monitoring and evaluation systems in all pilot countries was achieved. The recommendations will support such integration in other European countries. European Centre for Prevention and Control of Diseases included questions from the minimum list of indicators into their Dublin Declaration questionnaire 2020 to contribute to evidence based community testing policies in European countries.

ObjectivesThis paper aims to estimate the percentage of European men who have sex with men (MSM) who may benefit from pre-exposure prophylaxis (PrEP), applying the three most widely used HIV risk indices for MSM (MSM Risk Index, Menza score, San Diego Early Test (SDET) score) and drawing on a large-scale multisite bio-behavioural survey (Sialon II).MethodsThe Sialon II study was a bio-behavioural survey among MSM implemented in 13 European cities using either time-location sampling or respondent-driven sampling. Biological and behavioural data from 4901 MSM were collected. Only behavioural data of HIV-negative individuals were considered. Three widely used risk indices to assess HIV acquisition risk among MSM were used to estimate individual HIV risk scores and PrEP eligibility criteria.Results4219 HIV-negative MSM were considered. Regardless the HIV risk score used and the city, percentages of MSM eligible for PrEP were found to range between 5.19% and 73.84%. Overall, the MSM Risk Index and the Menza score yielded broadly similar percentages, whereas the SDET Index provided estimates constantly lower across all cities. Although all the three scores correlated positively (r>0.6), their concordance was highly variable (0.01ConclusionOur findings showed the impact of different scoring systems on the estimation of the percentage of MSM who may benefit from PrEP in European cities. Although our primary aim was not to compare the performance of different HIV risk scores, data show that a considerable percentage of MSM in each city should be offered PrEP in order to reduce HIV infections. As PrEP is highly effective at preventing HIV among MSM, our findings provide useful, practical guidance for stakeholders in implementing PrEP at city level to tackle HIV infections in Europe.

Comparative European data using Second Generation Surveillance System (SGSS) are scarce among gay, bisexual and other men who have sex with men. This study evaluated the implementation of Sialon II, a bio-behavioural HIV research combined with targeted HIV prevention in 13 European cities conducted in collaboration with community partners. A mixed-methods process evaluation assessed the project's coverage, outputs, quality, challenges and opportunities for improvement. Data collected through structured questionnaire from 71 data collectors from community-based organisations and semi-structured interviews with 17 managers of participating gay venues were analysed. Overall implementation was successful, achieving 4901 valid behavioural questionnaires and obtaining 4716 biological samples. Challenges in conducting bio-behavioural research in gay venues related to strict research protocols and unfavourable characteristics of venues. Formative research, collaboration with community gay venues, and offering HIV prevention emerged as facilitators. Community researchers' training was crucial for fidelity to research protocols, increased trust amongst communities and enabled data collectors to effectively address practical problems in the field. Scientifically sound SGSS with community participation is feasible and allows for including 'hard-to-reach' populations. Prevention benefits include awareness raising, capacity building and sexual health promotion in gay venues. The findings are beneficial for epidemiological research among other HIV key populations.

Background Although men who have sex with men (MSM) are considered at high risk for transmission of sexually transmitted infections, including HIV, there are few studies estimating the population size of MSM in Europe. We used network data from a survey of MSM in four cities to perform successive sampling–population size estimations (SS-PSE) to estimate MSM population sizes. Methods Data were collected in 2013–14 in Bratislava, Bucharest, Verona and Vilnius using respondent-driven sampling (RDS). SS-PSE uses a Bayesian framework to approximate the RDS sampling structure via a successive sampling model and uses the selection order of the sample to provide information about the distribution of network sizes over the population members of MSM. Results We estimate roughly 4600 MSM in Bratislava, 25 300 MSM in Bucharest, 7200 in Verona and 2900 in Vilnius. This represents 2.9% of the estimated adult male population in Bratislava, 2.3% in Bucharest, 2.7% in Verona and 1.5% in Vilnius. The number of MSM living with HIV would roughly be 200 in Bratislava, 4554 in Bucharest, 690 in Verona and 100 in Vilnius. Conclusions Benefits of this method are that no additional information from an RDS survey needs to be collected, that the sizes can be calculated ex post facto a survey and that there is a software programme that can run the SS-PSE models. However, this method relies on having reliable priors. Although many countries are estimating the sizes of their vulnerable populations, European countries have yet to incorporate similar and novel methods.

Background Community-based voluntary counselling and testing contributes to early HIV diagnoses among key populations. Testing data from such decentralized services is however often not standardized nor linked to national surveillance systems. This study aimed to support the integration of community testing data into respective national surveillance and monitoring and evaluation systems for those infections. We present results from three national pilots, focused on improved data collection and transfer. Methods Within the Joint Action INTEGRATE different pilot activities were planned and implemented according to the local context. In Slovakia, standardised data collection tools were implemented in three community testing services. The data generated was used to calculate the proposed indicators. In Poland, positive test results from the community testing database were linked to the national case-based surveillance database using confirmatory test number, to improve the completeness of behavioural data in the national database. In Serbia, voluntary counselling and testing forms were improved enabling identification of community-based testing. A system to generate unique client identifiers was initiated in the National registry of HIV cases to monitor linkage to care. Results All three sites were able to estimate most of the agreed indicators. In Slovakia during the study period 675 people were tested for HIV, 410 for hepatitis C and 457 for syphilis, with reactivity rates of 0.4, 2.5 and 1.8%, respectively. For HIV, 66.7% of reactive cases were confirmed and linked to care. In Poland, 28.9% of the community testing sites’ records were linked to the national surveillance database (and accounted for 14.3% of all new diagnoses registered here during 2017–2018). Reactivity rate ranged between 1.9% and 2.1%. In Serbia, 80 persons were tested at community sites, from which two had a reactive HIV test result. By linking unique client identifiers from voluntary counselling and testing and National Registry of HIV cases databases, linkage to care within a two-month period was observed for one of two people with reactive HIV test result. Conclusions Pilot activities in the three countries demonstrate that integration of community-based testing data into surveillance systems is feasible and can help improve national surveillance data by providing key information.

Data for MSM continue to show a high risk of acquiring HIV-STIs. Within this population, outness seems to have an impact on both risk-taking and on health seeking behaviors. The objective of this study was to assess the relationship between socio-demographic, behavioral characteristics, testing behaviors, and outness level among MSM using data from a multi-center bio-behavioral cross-sectional study carried out in 13 EU cities. A multilevel analysis was conducted to identify factors associated with being open ("out") versus not being open ("in"). A total of 4,901 MSM were enrolled in the study and were classified as "out" in 71% of the cases. MSM "out" were more likely to report HIV testing and being reached by HIV prevention programs compared to MSM who were "in." The results confirm the key role of outness in relation to different healthy and risky behavior, ranging from testing to party-drug use.

Objectives: The objective of this study was to define the natural genotypic variation of the HIV-1 integrase gene across Europe for epidemiological surveillance of integrase strand-transfer inhibitor (InSTI) resistance. Methods: This was a multicentre, cross-sectional study within the European SPREAD HIV resistance surveillance programme. A representative set of 300 samples was selected from 1950 naive HIV-positive subjects newly diagnosed in 2006-07. The prevalence of InSTI resistance was evaluated using quality-controlled baseline population sequencing of integrase. Signature raltegravir, elvitegravir and dolutegravir resistance mutations were defined according to the IAS-USA 2014 list. In addition, all integrase substitutions relative to HXB2 were identified, including those with a Stanford HIVdb score >= 10 to at least one InSTI. To rule out circulation of minority InSTI-resistant HIV, 65 samples were selected for 454 integrase sequencing. Results: For the population sequencing analysis, 278 samples were retrieved and successfully analysed. No signature resistance mutations to any of the InSTIs were detected. Eleven (4%) subjects had mutations at resistance-associated positions with an HIVdb score >= 10. Of the 56 samples successfully analysed with 454 sequencing, no InSTI signature mutations were detected, whereas integrase substitutions with an HIVdb score >= 10 were found in 8 (14.3%) individuals. Conclusions: No signature InSTI-resistant variants were circulating in Europe before the introduction of InSTIs. However, polymorphisms contributing to InSTI resistance were not rare. As InSTI use becomes more widespread, continuous surveillance of primary InSTI resistance is warranted. These data will be key to modelling the kinetics of InSTI resistance transmission in Europe in the coming years.

OBJECTIVES: The long-term side effects of stavudine (d4T) led to recommendations in 2009 to phase out use of this drug. We aimed to describe temporal patterns of d4T use across Europe. METHODS: Patients taking combination antiretroviral therapy (cART) in EuroSIDA with follow-up after 1 January 2006 were included in the study. cART was defined as d4T-containing [d4T plus at least two other antiretrovirals (ARVs) from any class] or non-d4T-containing (at least three ARVs from any class, excluding d4T). Poisson regression was used to describe temporal changes in the prevalence of d4T use and factors associated with initiating d4T. RESULTS: A total of 5850 patients receiving cART on 1 January 2006 were included in the current analysis, rising to 7768 patients on January 1 2013. During this time, the prevalence of d4T use fell from 11.2% to 0.7%, with an overall decline of 19% per 6 months [95% confidence interval (CI) 19-20%]. d4T use declined fastest in Northern Europe [26% (95% CI 23-29%) per 6 months], and slowest in Eastern Europe [17% (95% CI 16-19%) per 6 months]. In multivariable Poisson regression models, new d4T initiations decreased by 14% per 6 months [adjusted incidence rate ratio (aIRR) 0.86; 95% CI 0.80-0.91]. Factors associated with initiating d4T were residence in Eastern Europe (aIRR 4.31; 95% CI 2.17-9.98) versus other European regions and HIV RNA > 400 copies/mL (aIRR 3.11; 95% CI 1.60-6.02) versus HIV RNA < 400 copies/mL. CONCLUSIONS: d4T use has declined sharply since 2006 to low levels in most regions; however, a low but persistent level of d4T use remains in Eastern Europe, where new d4T initiations post 2006 are also more common. The reasons for the regional differences may be multifactorial, but it is important to ensure that all clinicians treating HIV-positive patients are aware of the potential harmful effects associated with d4T.

Introduction The HIV epidemic represents an important public health issue in Europe particularly among men who have sex with men (MSM). Global AIDS Monitoring indicators (GAM) have been widely and jointly promoted as a set of crucial standardised items to be adopted for monitoring and responding to the epidemic. Methods The Sialon II study, implemented in 13 European cities (2013-14), was a complex multi-centre integrated bio-behavioural cross-sectional survey targeted at MSM, with a concomitant collection of behavioural and biological (oral fluid or blood specimens) data. Rigorous sampling approaches for hard-to-reach populations were used (time-location sampling and respondent-driven sampling) and GAM indicators were calculated; sampling frames were adapted to allow weighted estimates of GAM indicators. Results 4,901 MSM were enrolled. HIV prevalence estimates ranged from 2.4% in Stockholm to 18.0% in Bucharest. When exploring city-level correlations between GAM indicators, prevention campaigns significantly correlated with levels of condom use and level of HIV testing among MSM. Conclusion The Sialon II project has made an important contribution to the monitoring and evaluation of the HIV epidemic across Europe, integrating the use of GAM indicators within a second generation HIV surveillance systems approach and in participatory collaboration with MSM communities. It influenced the harmonisation of European data collection procedures and indicators via GAM country reporting and contributed essential knowledge informing the development and implementation of strategic, evidence-based HIV prevention campaigns for MSM.

Background : HIV testing is generally accepted as being the lynchpin of a prevention strategy to tackle the HIV epidemic among MSM. However, few studies have analysed in detail the factors that influence HIV test seeking behaviour. Methods : The objective of this article is to analyse the relationship between HIV test seeking behaviour and individual, social and demographic factors in a sample of MSM recruited though a multi-centre bio-behavioural cross-sectional study. A multi-level analysis was conducted to identify factors associated with HIV test seeking behaviour. Results : A total of 2400 men were included in the sample. Age, self-reported sexual orientation, residence, household composition, educational status and perceived homonegativity all seem to impact on test seeking behaviour. Conclusions : The results suggest the need for more targeted testing promotion strategies among MSM that take structural and environmental factors into consideration, as part of a comprehensive public health strategy to address the HIV epidemic.

BACKGROUND: Globally, the HIV epidemic continues to represent a pressing public health issue in Europe and elsewhere. There is an emerging and progressively urgent need to harmonise HIV and STI behavioural surveillance among MSM across European countries through the adoption of common indicators, as well as the development of trend analysis in order to monitor the HIV-STI epidemic over time. The Sialon II project protocols have been elaborated for the purpose of implementing a large-scale bio-behavioural survey among MSM in Europe in line with a Second Generation Surveillance System (SGSS) approach. METHODS/DESIGN: Sialon II is a multi-centre biological and behavioural cross-sectional survey carried out across 13 European countries (Belgium, Bulgaria, Germany, Italy, Lithuania, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden, and the UK) in community settings. A total of 4,966 MSM were enrolled in the study (3,661 participants in the TLS survey, 1,305 participants in the RDS survey). Three distinct components are foreseen in the study protocols: first, a preliminary formative research in each participating country. Second, collection of primary data using two sampling methods designed specifically for 'hard-to-reach' populations, namely Time Location Sampling (TLS) and Respondent Driven Sampling (RDS). Third, implementation of a targeted HIV/STI prevention campaign in the broader context of the data collection. DISCUSSION: Through the implementation of combined and targeted prevention complemented by meaningful surveillance among MSM, Sialon II represents a unique opportunity to pilot a bio-behavioural survey in community settings in line with the SGSS approach in a large number of EU countries. Data generated through this survey will not only provide a valuable snapshot of the HIV epidemic in MSM but will also offer an important trend analysis of the epidemiology of HIV and other STIs over time across Europe. Therefore, the Sialon II protocol and findings are likely to contribute significantly to increasing the comparability of data in EU countries through the use of common indicators and in contributing to the development of effective public health strategies and policies in areas of high need. publishersversion published

Slovakia belongs to the group of European countries with a low prevalence of HIV infection. The major proportion of HIV-positive cases in Slovakia is still represented by MSM, followed by heterosexuals infected through unprotected sexual intercourse. This study was conducted to update the description of HIV subtypes circulating in Slovakia. HIV-1 partial pol gene sequences from 143 individuals were prospectively collected from 2004 to 2008 and analyzed. Phylogenetic analysis based on HIV-1 partial pol gene sequences revealed the highest prevalence of HIV-1 B subtype (93.0 %), predominantly associated with the MSM group. Ten (7.0%) individuals were infected with HIV-1 non-B subtypes. The pure subtypes were more frequent (7; 4.9%) than CRFs (3; 2.1%) and their occurrence was as follows: subtype C (3; 2, 1%), subtype A (2; 1.4%), subtype F (2; 1.4%), CRF_01AE (1; 0.7%), CRF_02AG (1; 0.7%), and CRF08_BC (1; 0.7%). Data show slightly increasing HIV-1 subtype diversity, with HIV-1 subtype B still having the highest prevalence in the Slovak-infected population.

Aim of the study was to investigate serological markers of selected sexually and blood transmitted infections (HBV, HCV, CMV, and Treponema pallidum) in the group of pregnant women and in newborns of HIV-positive mothers in Slovakia. IgG antibodies to CMV were found in 78 of 97 women, from them in 6 of 7 HIV-positive and in 72 of 90 HIV-negative persons. Occurrence of HbsAg and HCV was significantly higher in the group of HIV-positive women (1/7 and 2/7) comparing to the HIV-negative one (4/90 and 0/92, respectively). Antibodies to T. pallidum were found only in one HIV-negative woman from 92 women tested. Five of seven children born to HIV-1 infected mothers were found HIV-1 negative, two children are still under control. Four of 7 newborns were found anti-CMV IgG positive. Although one woman, IDU, was confirmed HbsAg and anti-HCV positive, vertical transmission of HBV and HCV to her newborn was not observed by molecular-biological methods. Similarly, HCV antibodies were found in one more women and neither in her child HCV infection was confirmed. In no one of mother - child pair's antibodies to T. pallidum were observed. Due to these findings strong attention should be paid to health education and prophylaxis of mother to child HIV and other STIs transmission in Slovakia.

The HIV infection remains a major public health issue in the world and especially in those countries where there exists unprotected sexual intercourse between people of the same sex. It is namely the category of men having sex with men (MSM) that still represents a group at high risk of being infected with HIV or transmitting the virus. The aim of our study was to present HIV 2nd generation surveillance data on MSM in Slovakia in the period between the years 2008 and 2009. Time-location sampling (TLS) was used to recruit participants and oral fluid samples together with completed anonymous questionnaires were collected simultaneously. The oral fluids were tested with use of the Genscreen HIV 1/2 version 2, (Bio-Rad) and Western Blot (Genlabs) diagnostic kits. The data analysis was performed using Stata version 8. Saliva testing revealed HIV prevalence of 6.1% (21/349) among MSM in Slovakia. 75% of HIV-positive cases were undiagnosed. The high-risk behaviour of MSM in respect to the number of their sexual partners as well as drug and condom usage did not correspond with their relatively high knowledge about HIV/AIDS. People's attitude towards MSM was found to be the worst in the religious context. Though our results reflect a relative good knowledge of MSM about HIV/AIDS infection, new HIV-positive cases and high-risk behaviour still appear, suggesting the need for more effective HIV prevention among members of this high-risk group in Slovakia.

Aim of the study was to investigate serological markers of selected sexually and blood transmitted infections (HBV, HCV, CMV, and Treponema pallidum) in the group of pregnant women and in newborns of HIV-positive mothers in Slovakia. IgG antibodies to CMV were found in 78 of 97 women, from them in 6 of 7 HIV-positive and in 72 of 90 HIV-negative persons. Occurrence of HbsAg and HCV was significantly higher in the group of HIV-positive women (1/7 and 2/7) comparing to the HIV-negative one (4/90 and 0/92, respectively). Antibodies to T. pallidum were found only in one HIV-negative woman from 92 women tested. Five of seven children born to HIV-1 infected mothers were found HIV-1 negative, two children are still under control. Four of 7 newborns were found anti-CMV IgG positive. Although one woman, IDU, was confirmed HbsAg and anti-HCV positive, vertical transmission of HBV and HCV to her newborn was not observed by molecular-biological methods. Similarly, HCV antibodies were found in one more women and neither in her child HCV infection was confirmed. In no one of mother - child pair's antibodies to T. pallidum were observed. Due to these findings strong attention should be paid to health education and prophylaxis of mother to child HIV and other STIs transmission in Slovakia.

Background Within the BORDERNETwork-project a biobehavioural sentinel surveillance was established in Austria, Bulgaria, Romania and Slovakia in 2010–12. The objectives were to record lab-confirmed STI (chlamydia, gonorrhoea, syphilis, HIV) in clinical settings and merge them with demographic and behavioural data to assess migration aspects, vulnerable groups and risk factors and recognise necessity for targeted interventions. Methods On a monthly base, physicians reported aggregated STI testing data. Individual data was provided for each positive patient including demographics, re- and co-infections and assumed risk behaviour. Via patient questionnaires, information on socio-demographics, way of transmission and sexual behaviour was collected. All questionnaires were sent via regional to coordinating partners for merging and analysis. Results Overall, 467797 tests were performed in 45 sentinel sites (Austria 13, Slovakia 14, Romania 13, Bulgaria 5). The countries varied in the number of STI tests (range: 6071 – 298645), positivity rate (range: 2–13%), patient characteristics and sexual behaviour. 75% of all women with an STI in Austria were sexworkers, compared to 5% and 8% in Bulgaria and Romania. 34% of all men with an STI in Slovakia had sex with men, compared to 4% in Romania. STI patients, especially women had a migration background in 79% in Austria, but less than 7% in the other three countries. Casual partners were the presumed cause of infection in the majority of MSM in all countries, whereas condom use in the last 6 months with these partners varied significantly between the 4 countries. Conclusions Although not representative, sentinel surveillance gathers useful information on groups most at risk and can be compared between countries when using the same instruments. Legal and social issues can hinder disclosure of sexual preferences and practises and hamper targeted prevention. Enhancement of condom use with casual partners in MSM seems to be crucial, particularly in the East.