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BACKGROUND: Opioid substitution treatment seems to improve adherence to highly active antiretroviral therapy (HAART) in drug users (DU). DU in Amsterdam receive methadone within a harm reduction programme. We hypothesized that not only receiving methadone, but joining this complete comprehensive programme would improve HAART adherence. METHODS: Included were 102 HIV-positive DU attending the Amsterdam Cohort Study (ACS), reporting HAART use at multiple visits between 1999 and 2009. Non-adherence was defined as taking less than 95% of medication in the past 6 months (self-reported). Harm reduction intensity (HR) was measured by combining injecting drug use, methadone dosage and needle exchange, in different levels of participation, ranging from no/incomplete HR, complete HR to low or no dependence on HR. We studied the association between non-adherence and harm reduction intensities with logistic regression models adjusted for repeated measurements. RESULTS: Non-adherence was reported in 11.9% of ACS visits. Non-injecting DU with low dependence on HR were less adherent than DU with complete HR (aOR 1.78; CI 95% 1.00-3.16), although there was no overall effect of HR. No difference was demonstrated in adherence between DU with complete HR and incomplete HR. Unsupervised housing (no access to structural support at home) (aOR 2.58; CI 95% 1.40-4.73) and having a steady partner (aOR 0.48; CI 95% 0.24-0.96) were significantly associated with respectively more and less non-adherence. CONCLUSIONS: In Amsterdam, still-injecting DU who are exposed to systematic and integrated care, although not practising complete harm reduction, can be just as adherent to HAART as DU who make use of complete harm reduction and non-injecting DU with no dependence on harm reduction. These findings suggest the importance of a systematic and comprehensive support system including supervised housing and social and medical support to increase HAART adherence rates amongst all HIV-infected DU. When such programmes are introduced in settings where injecting drug use is highly prevalent, access to HAART for drug users in these settings can and should be increased. [ABSTRACT FROM AUTHOR]

This cross-sectional study among heterosexual migrant groups in south-eastern Amsterdam, the city area where the largest migrant groups live, provides an insight into HIV testing behaviour in this particular group. Participants were recruited at street locations (May 19973/July 1998) and interviewed using structured questionnaires. They also donated saliva for HIV testing. In total, 705 males and 769 females were included in this study (Afro-Surinamese (45%), Dutch-Antilleans (15%) and West Africans (40%)). Prior HIV testing was reported by 38% of all migrants (556/1479), of which only a minority (28%) had actively requested HIV testing. Multivariate logistic regression showed that not actively requesting HIV testing was more likely among younger (< 23 years) migrants, especially women (OR[SUBwomen]: 4.79, p<0.01, OR[SUBmen]: 1.81, p<0.05). Furthermore, women without previous STI treatment (OR 2.19, p<0.05) with Afro-Surinamese ethnicity (OR 2.12, p<0.05), men without health insurance (OR 2.17, p<0.05) and with low education (p<0.01) were also more likely to not actively request HIV testing. Active requests for HIV testing in case of HIV risk should be facilitated by promoting HIV testing and by improving accurate self-assessment of risk for HIV infection, especially among the groups that do not actively request HIV testing. This would increase HIVawareness and provide the opportunity of better medical care earlier in HIV infection. [ABSTRACT FROM AUTHOR]

Background: Dengue is increasing rapidly in endemic regions. Data on incidence among travelers to these areas are limited. Five prospective studies have been performed thus far, mainly among short-term travelers., Objective: To obtain the attack and incidence rate (AR, IR) of dengue virus (DENV) infection among long-term travelers and identify associated risk factors., Methods: A prospective study was performed among long-term travelers (12-52 weeks) attending the Public Health Service in Amsterdam. Clients planning to travel to (sub)tropical countries were invited to participate. Participants kept a travel diary, recording itinerary, symptoms, and physician visits. Pre- and post-travel blood samples were serologically tested for the presence of Anti-DENV IgG antibodies. Seroconversion was considered suggestive of a primary DENV infection. Anti-DENV IgG present in both corresponding samples in combination with a post-/pre-travel ratio of ≥4:1 was suggestive of a secondary infection. Risk factors for a DENV infection were studied using poisson regression., Results: In total, 600 participants were included; median age was 25 years (IQR: 23-29), 35.5% were male, and median travel duration was 20 weeks (IQR: 15-25). In 39 of 600 participants (AR: 6.5%; 95% CI 4.5-8.5%) anti-DENV IgG test results were suggestive of a recent infection, yielding an IR of 13.9 per 1,000 person-months traveling (95%CI: 9.9-19.1). No secondary infections were found. IR for Asia, Africa, and America were comparable and 13.5, 15.8, and 13.6 per 1,000 person-months respectively. Of participants with a recent DENV infection, 51% did not report dengue-like illness (DLI) or fever, but 10% were hospitalized. In multivariable analysis, travelers who seroconverted were significantly more likely to be vaccinated with ≥2 flavivirus vaccines for the current trip or to have reported DLI in >1 consecutive weeks., Conclusions: Long-term travelers are at substantial risk of DENV infection. Half of those with a DENV infection reported no symptoms, but 10% were hospitalized, demonstrating the importance of advising anti-mosquito measures during travel.

Objectives: There are limited data on the usage of commercially bought self-tests for HIV and other sexually transmitted infections (STIs). Therefore, we studied HIV/STI self-test usage and its determinants among the general population and sexual risk groups between 2007 and 2015 in Amsterdam, the Netherlands., Setting: Data were collected in four different studies among the general population (S1 - 2) and sexual risk groups (S3 - 4)., Participants: S1 - Amsterdam residents participating in representative population-based surveys (2008 and 2012; n=6044) drawn from the municipality register; S2 - Participants of a population-based study stratified by ethnicity drawn from the municipality register of Amsterdam (2011-2015; n=17 603); S3 - Men having sex with men (MSM) participating in an HIV observational cohort study (2008 and 2013; n=597) and S4 - STI clinic clients participating in a cross-sectional survey (2007-2012; n=5655)., Primary and Secondary Outcome Measures: Prevalence of HIV/STI self-test usage and its determinants., Results: The prevalence of HIV/STI self-test usage in the preceding 6-12 months varied between 1% and 2% across studies. Chlamydia self-tests were most commonly used, except among MSM in S3. Chlamydia and syphilis self-test usage increased over time among the representative sample of Amsterdam residents (S1) and chlamydia self-test usage increased over time among STI clinic clients (S4). Self-test usage was associated with African Surinamese or Ghanaian ethnic origin (S2), being woman or MSM (S1 and 4) and having had a higher number of sexual partners (S1-2). Among those in the general population who tested for HIV/STI in the preceding 12 months, 5-9% used a self-test., Conclusions: Despite low HIV/STI self-test usage, we observed increases over time in chlamydia and syphilis self-test usage. Furthermore, self-test usage was higher among high-risk individuals in the general population. It is important to continue monitoring self-test usage and informing the public about the unknown quality of available self-tests in the Netherlands and about the pros and cons of self-testing., Competing Interests: Competing interests: MP, UD and FRZ have received non-financial support (ie, HIV self-test kits) from OraSure Technologies for another (investigator initiated) study concerning HIV self-testing., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: HIV-infected individuals may be at risk for the premature onset of age-associated noncommunicable comorbidities. Being HIV-positive, having comorbidities and being of higher age may adversely impact health-related quality of life (HRQL). We investigated the possible contribution of HIV infection, comorbidities and age on HRQL and depression., Methods: HIV-infected individuals and uninfected controls from the AGEhIV Cohort Study were screened for the presence of comorbidities. They completed the Short Form 36-item Health Survey to assess HRQL and the nine-item Patient Health Questionnaire to assess depression. Linear and logistic regression were used to investigate to which extent comorbidities, aging and HIV infection were independently associated with HRQL and depression., Results: HIV-infected individuals (n = 541) reported significantly worse physical and mental HRQL and had a higher prevalence of depression than HIV-uninfected individuals (n = 526). A higher number of comorbidities and HIV-positive status were each independently associated with worse physical HRQL, whereas HIV-positive status and younger age were independently associated with worse mental HRQL and more depression. The difference in physical HRQL between HIV-positive and HIV-negative individuals did not become greater with a higher number of comorbidities or with higher age., Conclusion: In a cohort of largely well suppressed HIV-positive participants and HIV-negative controls, HIV-positive status was significantly and independently associated with worse physical and mental HRQL and with an increased likelihood of depression. Our finding that a higher number of comorbidities was independently associated with worse physical HRQL reinforces the importance to optimize prevention and management of comorbidities as the HIV-infected population continues to age.

Background: Early treatment of acute HIV-1 infection (AHI) is beneficial for patients and could reduce onward transmission. However, guidelines on whom to test for AHI with HIV-1 RNA testing are lacking., Methods: A risk score for possible AHI based on literature and expert opinion - including symptoms associated with AHI and early HIV-1 - was evaluated using data from the Amsterdam Cohort Studies among men who have sex with men (MSM). Subsequently, we optimized the risk score by constructing two multivariable logistic regression models: one including only symptoms and one combining symptoms with known risk factors for HIV-1 seroconversion, using generalized estimating equations. Several risk scores were generated from these models and the optimal risk score was validated using data from the Multicenter AIDS Cohort Study., Results: Using data from 1562 MSM with 175 HIV-1 seroconversion visits and 17,271 seronegative visits in the Amsterdam Cohort Studies, the optimal risk score included four symptoms (oral thrush, fever, lymphadenopathy, weight loss) and three risk factors (self-reported gonorrhea, receptive condomless anal intercourse, more than five sexual partners, all in the preceding six months) and yielded an AUC of 0.82. Sensitivity was 76.3% and specificity 76.3%. Validation in the Multicenter AIDS Cohort Study resulted in an AUC of 0.78, sensitivity of 56.2% and specificity of 88.8%., Conclusions: The optimal risk score had good overall performance in the Amsterdam Cohort Studies and performed comparable (but showed lower sensitivity) in the validation study. Screening for AHI with four symptoms and three risk factors would increase the efficiency of AHI testing and potentially enhance early diagnosis and immediate treatment.

Current guidelines recommend hepatitis C virus (HCV) testing for HIV-infected men who have sex with men (MSM) with ongoing risk behaviour, without specifying the type of risk behaviour. We developed and validated the HCV-MOSAIC risk score to assist HCV testing in HIV-infected MSM. The risk score consisted of six self-reported risk factors identified using multivariable logistic regression using data from the Dutch MOSAIC study (n = 213, 2009-2013). Area under the ROC curve (AUC), sensitivity, specificity, post-test-probability-of-disease and diagnostic gain were calculated. The risk score was validated in case-control studies from Belgium (n = 142, 2010-2013) and the United Kingdom (n = 190, 2003-2005) and in cross-sectional surveys at a Dutch sexually transmitted infections clinic (n = 284, 2007-2009). The AUC was 0.82; sensitivity 78.0% and specificity 78.6%. In the validation studies sensitivity ranged from 73.1% to 100% and specificity from 56.2% to 65.6%. The post-test-probability-of-disease ranged from 5.9% to 20.0% given acute HCV prevalence of 1.7% to 6.4%, yielding a diagnostic gain of 4.2% to 13.6%. The HCV-MOSAIC risk score can successfully identify HIV-infected MSM at risk for acute HCV infection. It could be a promising tool to improve HCV testing strategies in various settings., (This article is copyright of The Authors, 2017.)

Although PrEP is not yet registered in Europe, including the Netherlands, its approval and implementation are expected in the near future. To inform future pre-exposure prophylaxis (PrEP) implementation, this study aimed to gain insight into motives and preferences for daily or intermittent PrEP use among Dutch HIV-negative men having sex with men (MSM).Between February and December 2013, semistructured interviews were conducted until data saturation was reached (N = 20). Interviews were analyzed using the Grounded Theory approach.Motives for (not) using daily PrEP were based on beliefs about PrEP efficacy and side effects, preferences for other prevention strategies, self-perceived HIV risk, self-perceived efficacy of PrEP adherence, beliefs about possible benefits (e.g., anxiety reduction, sex life improvement), and barriers of PrEP use (e.g., costs, monitoring procedures). The perceived benefits of intermittent versus daily PrEP use were the lower costs and side effects and the lower threshold to decision to start using intermittent PrEP. Barriers of intermittent PrEP versus daily PrEP use were the perceived need to plan their sex life and adhere to multiple prevention strategies. Although some perceived PrEP as a condom substitute, others were likely to combine PrEP and condoms for sexually transmitted infections (STI) prevention and increased HIV protection. Participants preferred PrEP service locations to have specialized knowledge of HIV, antiretroviral therapy, sexual behavior, STIs, patients' medical background, be easily approachable, be able to perform PrEP follow-up monitoring, and provide support.To maximize the public health impact of PrEP, ensuring high uptake among MSM at highest risk is important. Therefore, targeted information about PrEP efficacy and side effects need to be developed, barriers for accessing PrEP services should be minimized, and perceived self-efficacy to use PrEP should be addressed and improved. To prevent increases in STIs, condom use should be monitored and PrEP should be integrated into routine STI screening and counseling.

Background: Patients with HIV, even with suppressed viremia on combination antiretroviral therapy, are at increased risk for cardiovascular disease. The underlying pathophysiology remains to be clarified. Aortic stiffness, known to be associated with cardiovascular disease in the general population, was investigated in a cohort of HIV type 1 (HIV 1)-infected and similar but uninfected individuals., Methods: Aortic stiffness was assessed by measuring pulse wave velocity (PWV) with an Arteriograph. Five hundred seven HIV-uninfected and 566 HIV 1-infected individuals, predominantly with suppressed viremia on combination antiretroviral therapy, aged ≥45 years, participating in the ongoing AGEhIV Cohort Study were included in the analysis. Multivariable linear regression was used to investigate whether HIV was independently associated with aortic stiffness, adjusting for traditional cardiovascular risk factors., Results: Study groups were comparable in demographics; smoking and hypertension were more prevalent in HIV-infected participants. PWV was higher in the HIV-infected group (7.9 vs. 7.7 m/s, P = 0.004). After adjustment for mean arterial pressure, age, gender, and smoking, HIV status was not significantly associated with aortic stiffness. In HIV-infected participants, having a nadir CD4 T-cell count ≤100 cells per cubic millimeter was independently associated with a higher PWV., Conclusions: The increased aortic stiffness in HIV-infected participants was largely explained by a higher prevalence of traditional cardiovascular risk factors, particularly smoking. Although HIV itself was not independently associated with higher aortic stiffness, a prior greater degree of immunodeficiency was. This suggests a detrimental effect of immunodeficiency on the aortic wall, possibly mediated by inflammation.

Purpose: To explore whether the prevalence and determinants of insufficient work ability (WA) of older HIV-positive workers differ from a comparable group of HIV-negative workers., Methods: Cross-sectional data from 359 HIV-negative and 264 HIV-positive middle-aged individuals (45-65 years) participating in paid labor, collected within the AGEhIV Cohort Study between October 2010-September 2012, were selected. Data were collected by self-administered questionnaires and physical examination. Participants self-rated their current WA, ranging from 0 to 10. WA was dichotomized into insufficient (<6) and sufficient (≥6). Using univariable and multivariable logistic regression, we studied the independent effect of HIV status on insufficient WA and determinants of insufficient WA., Results: Overall, 8% of participants reported insufficient WA (HIV-positive 9 vs. HIV-negative 7%, P = 0.20). Twice as many HIV-positive as HIV-negative individuals were declared partly unfit for work (6 vs. 3%, P = 0.02). HIV status itself was not associated with WA in univariable and multivariable analyses. Multivariable analyses revealed that low educational level, working fewer hours, being partly unfit for work, experiencing a high need for recovery after work, staying home from work ≥2 times in the past 6 months, and reporting depressive symptoms were associated with insufficient WA, independent of HIV status., Conclusions: HIV-positive individuals aged 45-65 years participating in paid labor seem to function as well at work as HIV-negative individuals. HIV-positive participants were more often formally declared partly unfit for work, but percentages were low in both groups. Knowledge of determinants of insufficient WA may help employers and professionals to optimize WA.

Objective: The spectrum of risk factors for HIV-associated cognitive impairment is likely very broad and includes not only HIV/antiretroviral therapy-specific factors but also other comorbid conditions. The purpose of this current study was to explore possible determinants for decreased cognitive performance., Design and Methods: Neuropsychological assessment was performed on 103 HIV-1-infected men with suppressed viraemia on combination antiretroviral therapy for at least 12 months and 74 HIV-uninfected highly similar male controls, all aged at least 45 years. Cognitive impairment and cognitive performance were determined by multivariate normative comparison (MNC). Determinants of decreased cognitive performance and cognitive impairment were investigated by linear and logistic regression analysis, respectively., Results: Cognitive impairment as diagnosed by MNC was found in 17% of HIV-1-infected men. Determinants for decreased cognitive performance by MNC as a continuous variable included cannabis use, history of prior cardiovascular disease, impaired renal function, diabetes mellitus type 2, having an above normal waist-to-hip ratio, presence of depressive symptoms, and lower nadir CD4⁺ cell count. Determinants for cognitive impairment, as dichotomized by MNC, included cannabis use, prior cardiovascular disease, impaired renal function, and diabetes mellitus type 2., Conclusion: Decreased cognitive performance probably results from a multifactorial process, including not only HIV-associated factors, such as having experienced more severe immune deficiency, but also cardiovascular/metabolic factors, cannabis use, and depressive symptoms.

Background: Group sex has been suggested as a potential high-risk setting for HIV and other sexually transmitted infections (STIs) among men who have sex with men (MSM). We investigated whether group sex is associated with lower condom use during anal sex and higher proportions of STIs compared with dyadic sex among HIV-negative MSM between 2009 and 2012., Methods: Cross-sectional data from 7 data waves of the Amsterdam Cohort Studies were used. The sample consisted of 465 MSM who either reported both group and dyadic sex (at n = 706 visits) or dyadic sex only (at n = 1339 visits) in the preceding 6 months. Logistic regression with generalized estimating equations was used to investigate the association between sexual setting (group vs. dyadic sex), condomless anal sex, and STI., Results: Group sex was reported at 35% (706/2045) of visits. Condomless sex was more often reported during dyadic than group sex (odds ratio, 3.64 95% confidence interval, 2.57-5.16). Men who had group sex were more likely diagnosed as having gonorrhea compared with men with dyadic sex (odds ratio, 1.71; 95% confidence interval, 1.08-2.97), but this effect was not retained in the multivariate model., Conclusions: Results demonstrate within-person differences in sexual behavior during group and dyadic sex among MSM. Men were more likely to use condoms during group sex than during dyadic sex. Thus, for some, group sex may not necessarily be risky for HIV infection compared with dyadic sex. However, group sex may be a higher-risk setting for acquiring STIs other than HIV, such as gonorrhea. Group sex encounters should be recognized as distinct sexual settings with specific risk characteristics that need to be addressed accordingly.

Objectives: A large portion of anogenital cancers is caused by high-risk human papillomavirus (hrHPV) infections, which are especially common in HIV-infected men. We aimed to compare the incidence and clearance of anal and penile hrHPV infection between HIV-infected and HIV-negative MSM., Design: Analyses of longitudinal data from a prospective cohort study., Methods: MSM aged 18 years or older were recruited in Amsterdam, the Netherlands, and followed-up semi-annually for 24 months. At each visit, participants completed risk-factor questionnaires. Anal and penile self-samples were tested for HPV DNA using the SPF10-PCR DEIA/LiPA25 system. Effects on incidence and clearance rates were quantified via Poisson regression, using generalized estimating equations to correct for multiple hrHPV types., Results: Seven hundred and fifty MSM with a median age of 40 years (interquartile 35-48) were included in the analyses, of whom 302 (40%) were HIV-infected. The incidence rates of hrHPV were significantly higher in HIV-infected compared with HIV-negative MSM [adjusted incidence rate ratio (aIRR) 1.6; 95% confidence interval (CI) 1.3-2.1 for anal and aIRR 1.4; 95%CI 1.0-2.1 for penile infection]. The clearance rate of hrHPV was significantly lower for anal [adjusted clearance rate ratio (aCRR) 0.7; 95%CI 0.6-0.9], but not for penile infection (aCRR 1.3; 95%CI 1.0-1.7). HrHPV incidence or clearance did not differ significantly by nadir CD4 cell count., Conclusion: Increased anal and penile hrHPV incidence rates and decreased anal hrHPV clearance rates were found in HIV-infected compared with HIV-negative MSM, after adjusting for sexual behavior. Our findings suggest an independent effect of HIV infection on anal hrHPV infections.

Background: Frailty is an age-related syndrome of decreased physiological reserve and resistance to stressors, associated with increased morbidity and mortality in the general elderly population. An increased prevalence of frailty has been reported amongst HIV-infected individuals., Methods: Fried frailty phenotype was systematically assessed in predominantly virologically suppressed HIV type 1 (HIV-1)-infected and otherwise comparable HIV-uninfected participants aged at least 45 at enrollment into the AGEhIV Cohort Study. Multivariable ordinal logistic regression was used to investigate associations between HIV- and antiretroviral therapy-related covariates, markers of inflammation and body composition and prefrailty/frailty., Results: Data were available for 521 HIV-infected and 513 HIV-uninfected individuals. Prevalence of frailty (10.6 versus 2.7%) and prefrailty (50.7 versus 36.3%) were significantly higher in HIV-infected individuals (Ptrend < 0.001). HIV infection remained statistically significantly associated with prefrailty/frailty after adjustment for age, sex, race/ethnicity, smoking, hepatitis C infection, comorbidities and depression [adjusted odds ratio (ORadj) 2.16, P < 0.001]. A higher waist-to-hip ratio attenuated the coefficient of HIV-infected status (ORadj 1.93, P < 0.001), but not waist- or hip-circumference individually or markers of inflammation. Within the HIV-infected group, parameters related to body composition were most strongly and independently associated with prefrailty/frailty: current BMI less than 20 kg/m2 (OR 2.83, P = 0.01), nadir BMI less than 20 kg/m2 (OR 2.51, P = 0.001) and waist-to-hip ratio (OR 1.79 per 0.1 higher, P < 0.001)., Conclusion: HIV infection was independently associated with prefrailty/frailty in middle-aged HIV-infected patients compared with HIV-uninfected controls. This partly may be mediated by the higher waist- and lower hip-circumference in the HIV-infected individuals, potentially partially caused by lipodystrophy, and in part be a consequence of historic weight loss associated with advanced HIV-disease.

Objective: To describe changes in sexual risk behavior among Kenyan MSM who received regular risk reduction counseling (RRC)., Design: Data were derived from two cohorts of HIV-1-negative and HIV-1-positive MSM in Kenya. Behavioral data were collected at enrollment and at monthly or quarterly scheduled follow-up visits. At each visit, RRC was provided to all men and HIV-1 testing to seronegative men., Methods: Random effects logistic and Poisson regression models with time since study entry as main variable of interest were used to evaluate changes in number of sex partners and unprotected sex in the past week, and insertive, receptive, and unprotected anal intercourse in the past 3 months. Analyses were adjusted for HIV-1-status, calendar year of follow-up, and several baseline characteristics. Trends over follow-up time were allowed to differ by HIV-1-status. Men were censored when they seroconverted for HIV., Results: Number of regular and casual sex partners and unprotected anal intercourse decreased in both HIV-1-negative and HIV-1-positive men. Unprotected sex with both regular and casual sex partners decreased more strongly early in follow-up in HIV-1-positive men than in HIV-1-negative men. Decreases in insertive anal intercourse were found for HIV-1-positive men only, whereas decreases in receptive anal intercourse were found for HIV-1-negative men only., Conclusion: MSM who were regularly exposed to RRC showed some reductions in sexual risk behavior, but it is uncertain if these reductions are sustained over time. As HIV-1 incidences in Kenyan MSM are very high, RRC should be supported by comprehensive biomedical interventions.

Objective: To investigate site-specific condom-use norms as assumed by visitors of gay venues and websites across The Netherlands and their association with men's own use of condoms., Methods: In 2010, men who have sex with men (MSM) visiting 18 sex venues (e.g., saunas), 30 nonsex venues (e.g., bars), 6 dating websites, and 2 social network websites completed an on-site questionnaire measuring 2 site-specific norms concerning anal sex: descriptive (assumed condom use of others at venue or website) and injunctive (assumed approval of condom use by others at venue or website). We measured the association between assumed descriptive norms and own use of condoms using logistic regression., Results: Among 2,376 participants (median age = 30 years; IQR = 22-43), 62% (n = 1,483) assumed that other visitors would not use condoms. Among men self-reporting on their own use of condoms, 22% (318/1,421) reported condomless anal sex. Men at nonsex venues assumed other visitors would use condoms more often and approved of using them more often compared to men at sex venues. At all sites (venues/websites), men who assumed that others did not use condoms were more likely to have condomless sex themselves., Conclusions: At gay sites across The Netherlands, more than half of MSM believed visitors of these sites would not use condoms during anal sex. The perception that others would not use condoms was associated with less own condom use. HIV prevention should address problematic on-site condom-use norms, as they play a role in influencing sexual behavior between men that meet at these sites., ((c) 2015 APA, all rights reserved).)

Objective: In the Netherlands, men who have sex with men (MSM) are advised via informal guidelines to test for STI at least annually. We estimated the proportion of HIV-negative MSM testing repeatedly at 12-month or smaller intervals at a large STI clinic in the Netherlands. In addition, we explored whether repeated testing is related to risk behaviour., Design and Methods: Longitudinal data of HIV-negative MSM visiting the Amsterdam STI clinic between 2009 and 2012 were analysed. To estimate the timing of repeated testing, Kaplan-Meier methods were used. Determinants for repeated testing (distinguishing testing at 12-month or smaller intervals and less than 12-monthly testing, with single testers as reference group) were identified using multivariate multinomial logistic regression analyses., Results: In total, 19,479 consultations of 9174 HIV-negative MSM were identified. Of these MSM, 35% (95% CI 33% to 36%) were estimated to return to the STI clinic within 1 year following baseline consultation. Among 1767 men with at least two consultations and at least 2 years between baseline and last consultation, 43% tested repeatedly at 12-month or smaller intervals in those first 2 years. Repeated testers reported higher sexual risk behaviour (ie, only casual or both casual and steady sex partners, higher numbers of sex partners) at baseline compared with single testers. This effect tended to be slightly stronger for men testing repeatedly at 12-month or smaller intervals., Conclusions: The proportion of MSM testing for STI annually is low. MSM testing repeatedly had higher baseline levels of risk behaviour. Strategies to motivate MSM to test annually should be explored., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: This study among men who have sex with men (MSM) aimed to (1) assess prevalence of anogenital low-risk human papillomavirus (lrHPV) infections, (2) evaluate associations with HIV infection, and (3) investigate lrHPV concordance., Methods: In 2010 to 2011, MSM 18 years or older were recruited in Amsterdam, the Netherlands, and provided anal and penile self-swabs (HIV & HPV in MSM study). Using the HPV SPF10-PCR/DEIA/LiPA25 system, the presence of lrHPV types 6, 11, 34, 40, 42, 43, 44, 53, 54, 66, 68/73, 70, and 74 could be detected. Logistic regression with generalized estimating equations was used to assess the independent effect of HIV on lrHPV infections. The model was repeated for lrHPV subcategories (nononcogenic and weakly oncogenic infections separately). Concordance was defined as detection of the same lrHPV type in both self-swabs of one individual., Results: A total of 778 MSM were included, of whom 317 (41%) were HIV positive (median CD4 count at enrollment, 530 cells/mm). Prevalence of anal lrHPV was 45% (95% confidence interval [CI], 41%-50%) in HIV-negative MSM and 69% (95% CI, 64%-74%) in HIV-positive MSM. Prevalence of penile lrHPV was 20% (95% CI, 16%-24%) and 37% (95% CI, 31%-42%), respectively. In multivariable analysis, HIV infection was independently associated with anal (adjusted odds ratio [aOR], 1.9; 95% CI, 1.5-2.3) and penile lrHPV (aOR, 2.0; 95% CI, 1.4-2.7). Nononcogenic and weakly oncogenic lrHPV subcategories showed a similar pattern of association. Anal lrHPV infections were strongly associated with the presence of a type-concordant penile infection (aOR, 5.8; 95% CI, 4.4-7.5) and vice versa (aOR, 5.7; 95% CI, 4.4-7.5)., Conclusions: Anal and penile infections with lrHPV are common in MSM. HIV infection was an independent determinant for lrHPV infections.

Objectives: Although preexposure prophylaxis (PrEP) is not registered in Europe, including the Netherlands, its approval and implementation are expected in the near future. We aimed to gain insight into PrEP awareness and the intention to use PrEP among MSM., Design: Cross-sectional study among 448 HIV-negative participants of the Amsterdam Cohort Study who completed a questionnaire concerning behavior and PrEP between 2012 and 2013., Methods: Characteristics, PrEP awareness, and intention to use PrEP were described and multinomial logistic regression was used to identify determinants of a medium and high intention to use PrEP., Results: PrEP awareness was 54%, but only 13% reported a high intention to use PrEP. High-risk MSM were more likely to have a medium [adjusted odds ratio (aOR): 1.78 (95% confidence interval [CI] 1.07-2.97)] or high [aOR: 3.92 (95% CI 1.68-9.15)] intention to use PrEP than low-risk MSM, as were MSM with higher perceptions of self-efficacy to use PrEP [high intention: aOR: 6.15 (95% CI 2.50-15.09)] and higher perceptions of relief due to PrEP [medium intention: aOR: 2.67 (95% CI 1.32-5.40); high intention: aOR: 14.87 (95% CI 5.98-37.01)] than MSM with lower perceptions. MSM with higher perceptions of shame about using PrEP [medium intention: aOR: 0.35 (95% CI 0.19-0.62); high intention: aOR: 0.22 (95% CI 0.07-0.71)] or with more worries about side-effects were less likely to have a high [aOR: 0.18 (95% CI 0.06-0.54)] or medium [aOR: 0.29 (95% CI 0.12-0.72)] intention to use PrEP., Conclusion: The overall intention to use PrEP was relatively low, but higher among high-risk MSM. If PrEP implementation among high-risk MSM in the Netherlands becomes reality, PrEP awareness should be increased and psychosocial determinants that will influence uptake should be addressed.

Objective: The objective of this study is to assess whether multivariate normative comparison (MNC) improves detection of HIV-1-associated neurocognitive disorder (HAND) as compared with Frascati and Gisslén criteria., Methods: One-hundred and three HIV-1-infected men with suppressed viremia on combination antiretroviral therapy (cART) for at least 12 months and 74 HIV-uninfected male controls (comparable regarding age, ethnicity, sexual orientation, premorbid intelligence and educational level), aged at least 45 years, underwent neuropsychological assessment covering six cognitive domains (fluency, attention, information processing speed, executive function, memory, and motor function). Frascati and Gisslén criteria were applied to detect HAND. Next, MNC was performed to compare the cognitive scores of each HIV-positive individual against the cognitive scores of the control group., Results: HIV-infected men showed significantly worse performance on the cognitive domains of attention, information processing speed and executive function compared with HIV-uninfected controls. HAND by Frascati criteria was highly prevalent in HIV-infected [48%; 95% confidence interval (95% CI) 38-58] but nearly equally so in HIV-uninfected men (36%; 95% CI 26-48), confirming the low specificity of this method. Applying Gisslén criteria, HAND-prevalence was reduced to 5% (95% CI 1-9) in HIV-infected men and to 1% (95% CI 1-3) among HIV-uninfected controls, indicating better specificity but reduced sensitivity. MNC identified cognitive impairment in 17% (95% CI 10-24) of HIV-infected men and in 5% (95% CI 0-10) of the control group (P = 0.02, one-tailed), showing an optimal balance between sensitivity and specificity., Conclusion: Prevalence of cognitive impairment in HIV-1-infected men with suppressed viremia on cART estimated by MNC was much higher than that estimated by Gisslén criteria, while the false positive rate was greatly reduced compared with the Frascati criteria., Video Abstract: :

Background: Human immunodeficiency virus (HIV) and combination antiretroviral therapy (cART) may both contribute to the higher prevalence of osteoporosis and osteopenia in HIV-infected individuals., Methods: Using dual-energy X-ray absorptiometry, we compared lumbar spine, total hip, and femoral neck bone mineral density (BMD) in 581 HIV-positive (94.7% receiving cART) and 520 HIV-negative participants of the AGEhIV Cohort Study, aged ≥45 years. We used multivariable linear regression to investigate independent associations between HIV, HIV disease characteristics, ART, and BMD., Results: The study population largely consisted of men who have sex with men (MSM). Osteoporosis was significantly more prevalent in those with HIV infection (13.3% vs 6.7%; P<.001). After adjustment for body weight and smoking, being HIV-positive was no longer independently associated with BMD. Low body weight was more strongly negatively associated with BMD in HIV-positive persons with a history of a Centers for Disease Control and Prevention class B or C event. Interestingly, regardless of HIV status, younger MSM had significantly lower BMD than older MSM, heterosexual men, and women., Conclusions: The observed lower BMD in treated HIV-positive individuals was largely explained by both lower body weight and more smoking. Having experienced symptomatic HIV disease, often associated with weight loss, was another risk factor. The low BMD observed in younger MSM remains unexplained and needs further study., (© The Author 2014. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.)

Background: Human immunodeficiency virus (HIV)-infected individuals may be at increased risk of age-associated noncommunicable comorbidities (AANCCs)., Methods: Cross-sectional analyses of AANCC prevalence (including cardiovascular, metabolic, pulmonary, renal, bone, and malignant disease) and risk factors in a prospective cohort study of HIV type 1-infected individuals and HIV-uninfected controls, who were aged ≥45 years and comparable regarding most lifestyle and demographic factors., Results: HIV-infected participants (n = 540) had a significantly higher mean number of AANCCs than controls (n = 524) (1.3 [SD, 1.14] vs 1.0 [SD, 0.95]; P < .001), with significantly more HIV-infected participants having ≥1 AANCC (69.4% vs 61.8%; P = .009). Hypertension, myocardial infarction, peripheral arterial disease, and impaired renal function were significantly more prevalent among HIV-infected participants. Risk of AANCC by ordinal logistic regression was independently associated with age, smoking, positive family history for cardiovascular/metabolic disease, and higher waist-to-hip ratio, but also with HIV infection (odds ratio, 1.58 [95% confidence interval, 1.23-2.03]; P < .001). In those with HIV, longer exposure to CD4 counts <200 cells/µL, and, to a lesser extent, higher levels of high-sensitivity C-reactive protein and soluble CD14, and longer prior use of high-dose ritonavir (≥400 mg/24 hours) were each also associated with a higher risk of AANCCs., Conclusions: All AANCCs were numerically more prevalent, with peripheral arterial, cardiovascular disease, and impaired renal function significantly so, among HIV-infected participants compared with HIV-uninfected controls. Besides recognized cardiovascular risk factors, HIV infection and longer time spent with severe immunodeficiency increased the risk of a higher composite AANCC burden. There was a less pronounced contribution from residual inflammation, immune activation, and prior high-dose ritonavir use., (© The Author 2014. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.)

Objectives: We aimed to identify temporal trends in all-cause and cause-specific mortality rates among people who use drugs (PWUD) compared with the general Dutch population and to determine whether mortality trends differed by hepatitis C virus (HCV)/HIV (co) infection status., Design: Longitudinal cohort study., Methods: Using data from the Amsterdam Cohort Studies among 1254 PWUD (1985-2012), all-cause and cause-specific standardized mortality ratios (SMRs) were calculated; SMRs were stratified by serological group (HCV/HIV-uninfected, HCV-monoinfected, and HCV/HIV-coinfected) and calendar period. Temporal trends were estimated using Poisson regression., Results: The overall all-cause SMR was 13.9 (95% confidence interval 12.6-15.3). The SMR significantly declined after 1996, especially due to a decline among women (P < 0.001). The highest SMR was observed among HCV/HIV-coinfected individuals during 1990-1996 (SMR 61.9, 95% confidence interval 50.4-76.0), which significantly declined after this period among women (P = 0.001). In contrast, SMR for HCV-monoinfected, and HCV/HIV-uninfected PWUD did not significantly change over time. The SMR for non-natural deaths significantly declined (P = 0.007), whereas the SMR for HIV-related deaths was the highest during all calendar periods., Conclusions: We found evidence for declining all-cause mortality among PWUD compared with the general population rates. Those with HCV/HIV-coinfection showed the highest SMR. The decline in the SMR seems to be attributable to the decline in mortality among women. Mortality rates due to non-natural deaths came closer to those of the general population over time. However, HIV-related deaths remain an important cause of mortality among PWUD when compared with the general Dutch population. This study reinforces the importance of harm-reduction interventions and HCV/HIV treatment to reduce mortality among PWUD.

Hepatitis C virus (HCV) has emerged as a sexually transmitted infection among HIV-positive men who have sex with men (MSM) in high-income countries. Little is reported about HCV awareness among MSM, although this is essential for developing targeted prevention strategies. We, therefore, studied HCV awareness and knowledge among HIV-positive and HIV-negative MSM from the Amsterdam Cohort Studies (ACS). During two visits, 1 year apart and starting in October 2007, MSM from the ACS answered questions regarding HCV awareness, knowledge of HCV transmission (7 items), complications (8 items) and sexual risk behaviour. We examined the percentage of HCV awareness and correctly answered knowledge items, and whether awareness and knowledge improved significantly over time. Using logistic regression, we studied whether HIV status and sexual risk behaviour were associated with awareness. Seventy percent (312/444) of HIV-negative and 80% (74/92) of HIV-positive MSM reported to have ever heard of HCV on the first visit. Overall, awareness increased with 9% between the first and second visit (p < 0.001). In multivariate analysis the association of group sex with HCV awareness was borderline significant (OR 1.49, 95% CI 0.97-2.30). Compared with knowledge of transmission routes, knowledge of complications appeared to be limited. In the ACS, awareness of HCV is high, particularly among those reporting group sex, an important risk factor for HCV transmission. The majority of participants had good knowledge of transmission routes, but limited knowledge of complications of chronic HCV infection. HCV prevention messages could be strengthened, therefore, by further addressing the complications of HCV infection.

Background: We investigated the prevalence and protective value of serosorting [ie, establishing HIV concordance in advance to practice unprotected anal intercourse (UAI)] with casual partners (CP) among HIV-negative men who have sex with men (MSM) using longitudinal data from 2007 to 2011., Methods: Men of the Amsterdam Cohort Studies were tested biannually for HIV-1 antibodies and filled in questionnaires about sexual behavior in the preceding 6 months. HIV incidence was examined among men who practiced UAI, UAI with serosorting, or consistent condom use, using Poisson regression., Results: Of 445 MSM with CPs, 31 seroconverted for HIV during a total follow-up of 1107 person-years. Overall observed HIV incidence rate was 2.8/100 person-years. Consistent condom use was reported in 64%, UAI in 25%, and UAI with serosorting in 11% of the 2137 follow-up visits. MSM who practiced serosorting were less likely to seroconvert [adjusted incidence rate ratio (aIRR) = 0.46; 95% confidence interval (CI): 0.13 to 1.59] than MSM who had UAI, but more likely to seroconvert than MSM who consistently used condoms (aIRR = 1.32; 95% CI: 0.37 to 4.62), although differences in both directions were not statistically significant. MSM who consistently used condoms were less likely to seroconvert than MSM who had UAI (aIRR = 0.37; 95% CI: 0.18 to 0.77)., Discussion: The protective effect for serosorting we found was not statistically significant. Consistent condom use was found to be most protective against HIV infection. Larger studies are needed to demonstrate whether serosorting with CPs offers sufficient protection against HIV infection, and if not, why it fails to do so.

Objective: Anal and penile high-risk human papillomavirus (HPV) infection is associated with anogenital cancer, which is especially common in HIV-infected MSM. We assessed HPV prevalence and determinants in MSM., Design: Analysis of baseline data from a prospective cohort study., Methods: MSM aged 18 years or older were recruited in Amsterdam, the Netherlands. Participants completed risk-factor questionnaires. HPV DNA was analyzed in anal and penile shaft self-swabs and genotyped using a sensitive PCR and reverse line blot assay (SPF10-PCR-DEIA-LiPA25-system). Multivariable logistic regression analyses were performed to assess determinants of high-risk HPV infection., Results: MSM (n = 778) were recruited in 2010-2011, of whom 317 (41%) were HIV-infected. Prevalence of anal high-risk HPV infection was 45% in HIV-negative versus 65% in HIV-infected MSM (P <0.001). HPV-16 was the most frequently detected type and was more common in HIV-infected MSM (13% in HIV-negative and 22% in HIV-infected MSM; P = 0.001). Prevalence of penile high-risk HPV infection was 16% in HIV-negative and 32% in HIV-infected MSM (P <0.001). In multivariable analyses, HIV infection remained associated with anal [adjusted odds ratio (aOR) 2.2; 1.8-2.7] and penile (aOR 2.0; 1.4-2.9) high-risk HPV infection. Higher number of lifetime male sex partners was significantly associated with anal and penile high-risk HPV in HIV-negative, but not HIV-infected MSM. Receptive anal intercourse was associated with anal high-risk HPV in HIV-infected MSM., Conclusion: Anal and penile high-risk HPV infections are very common in MSM. HIV infection is a strong and independent determinant for anal and penile high-risk HPV infection. Determinants for HPV infection appear to differ between HIV-negative and HIV-infected MSM.

Objective: Oral infection with human papillomavirus (HPV) is associated with a subset of head and neck cancers. We compared prevalence of, and risk factors for, oral HPV infection among HIV-negative and HIV-infected MSM., Design: Analysis of baseline data from a prospective cohort study., Methods: MSM aged 18 years or older were recruited from three study sites in Amsterdam, the Netherlands. Participants completed a self-administered risk-factor questionnaire. Oral-rinse and gargle specimens were analyzed for HPV DNA and genotyped using a highly sensitive PCR and reverse line blot assay [short PCR fragment (SPF)10-PCR-DNA Enzyme Immuno Assay (DEIA)/LiPA25 system]., Results: In 2010-2011, 794 MSM were included, of whom 767 participants had sufficient data for analysis. Median age was 40.1 years [interquartile range (IQR) 34.8-47.5] and 314 men were HIV-infected (40.9%). Any of 25 typable HPV types was present in 24.4% of all oral samples. Oncogenic HPV types were detected in 24.8 and 8.8% of oral samples from HIV-infected and HIV-negative MSM, respectively (P < 0.001). Of these high-risk types, HPV-16 was the most common (overall 3.4%). Oral infection with high-risk HPV was associated with HIV infection in multivariable analysis (P < 0.001). Increasing age was significantly associated with oral HPV infection in HIV-negative, but not in HIV-infected MSM., Conclusion: Oral HPV infection is very common among MSM. HIV infection was independently associated with high-risk oral HPV infection, suggesting an important role of HIV in oral HPV infection.

We investigated how often HIV-positive MSM (n = 177) decide to engage in unprotected anal intercourse (UAI) because they have an undetectable viral load (UVL). We found that 20-57% of the UAI acts were related to having UVL, varying by partner type and partner HIV status. Among HIV-concordant partners, consideration of UVL before engaging in UAI was more prevalent with sex buddies (55%) than with casual partners (20%), although marginally significant (p = 0.051). Among HIV-discordant partners, no significant difference was found in the frequency of UVL considerations before engaging in UAI: 40% with sex buddies versus 57% with casual partners. Interestingly, while the decision to engage in UAI based on UVL was frequently discussed with HIV-concordant partners (>91%), it was only discussed with HIV-discordant partners in 13-25% of the UAI cases (according to partner type), suggesting that the decision was mostly unilateral.

A high prevalence of low bone mineral density (BMD) has been reported among men with primary or chronic human immunodeficiency virus (HIV) infection. To gain further insight into the contribution of HIV infection, we compared the BMD of 41 men who have sex with men (MSM) with primary HIV infection, 106 MSM with chronic HIV infection, and a control group of 30 MSM without HIV infection. Low BMD, defined as a z score of ≥ 2.0 SDs below the mean at the lumbar spine or hip, was highly prevalent in all 3 groups. In the multivariate analyses, HIV infection was not associated with BMD, suggesting that low BMD previously reported in HIV-infected MSM may predate HIV acquisition.

Objective: To gain insight in the ongoing HIV transmission, we compared sexual risk behaviour pre-HIV and post-HIV seroconversion in 206 MSM participating in the Amsterdam Cohort Studies (1984-2008) before and after the introduction of combination antiretroviral therapy (cART)., Design and Methods: MSM completed behavioural questionnaires and were tested for HIV antibodies every 6 months. Trends in anal intercourse and number of sex partners from 4 years before HIV seroconversion until 4 years after diagnosis were analysed with latent class random effects logistic regression models., Results: The risk of having unprotected anal intercourse (UAI) 1 year after HIV diagnosis decreased significantly when compared with 1 year before diagnosis in both the pre-cART era [difference, 30%; 95% confidence interval (CI), 22-36%] and cART era (difference, 19%; 95% CI, 9-30%). In contrast to a continuing decrease of UAI in the pre-cART era, the probability of UAI in the cART era increased again to preseroconversion levels (61%; 95% CI, 48-74%)) 4 years after diagnosis., Conclusion: This study provides evidence that recently seroconverted MSM reduce their sexual risk behaviour following HIV diagnosis both in the pre-cART as well as the cART period. However, in the cART period this reduction in sexual risk behaviour is less and returns to pre-cART levels within 4 years. These findings not only confirm the need for early HIV testing but also make it clear that much more effort should go into identifying, counselling, and possibly treating recently seroconverted MSM who have been found to be one of the most important drivers of HIV transmission among MSM.

Background: Human immunodeficiency virus type 1 (HIV-1) superinfection is infection of an HIV-1 seropositive individual with another HIV-1 strain. The rate at which HIV-1 superinfection occurs might be influenced by sexual behavior. Superinfection might be detected more often by analyzing longitudinal samples collected from time periods of unsafe sexual behavior., Methods: Envelope C2-C4 and gag sequences were generated from HIV-1 RNA from longitudinal serum samples that were obtained around self-reported sexual risk periods from 15 homosexual therapy-naïve men who participated in the Amsterdam Cohort Studies on HIV Infection and AIDS. Maximum likelihood phylogenetic analysis was used to determine whether HIV-1 superinfection had occurred., Results: We studied a total of 124 serum samples from 15 patients with a median of 8 samples and of 5.8 person-years of follow-up per patient. Phylogenetic analysis on 907 C2-C4 env and 672 gag sequences revealed no case of HIV-1 superinfection, resulting in a superinfection incidence rate of 0 per 100 person-years [95%CI: 0 - -4.2]., Conclusions: We conclude that HIV-1 superinfection incidence is low in this subgroup of homosexual men who reported unsafe sexual behavior. Additional studies are required to estimate the impact of also other factors, which may determine the risk to acquire HIV-1 superinfection.

Background: To examine the suggested resurgence of the HIV epidemic among men who have sex with men (MSM), we studied trends in HIV-1 incidence rates, sexual risk behaviour, risk factors for HIV-1 seroconversion, and source of HIV-1 infection among MSM in the Amsterdam Cohort Studies from 1984 to 2009., Methods: Trends in HIV-1 incidence and risk factors for HIV-1 infection were studied using Poisson regression. Trends in sexual risk behaviour were evaluated using logistic regression, correcting for intra-individual correlation via generalized estimating equations. Trends in the source of HIV-1 infection were modelled via logistic regression., Results: Of 1642 HIV-1-negative individuals, 217 seroconverted during follow-up. HIV-1 incidence rates strongly decreased from 8.6/100 person-years in 1985 to 1.3/100 person-years in 1992; remained relatively stable around 1.0/100 person-years between 1992 and 1996, and slowly increased to 2.0/100 person-years in 2009 (P = 0.14; linear trend 1996-2009). Reports of unprotected anal intercourse (UAI) increased significantly from 1996 onwards. HIV-1 seroconversion was associated with receptive UAI with casual partners, more than five sexual partners, a history of gonorrhoea (all in the preceding 6 months), and a lower educational level. Currently, MSM are more likely to have contracted HIV-1 from casual partners than from steady partners, but trends of recent years suggest that steady partners became a growing source with increasing age., Conclusions: Following increases in sexual risk behaviour from 1996 onwards, HIV-1 continues to spread among MSM. Targeted prevention messages should continue to focus on sexual behaviour with casual partners, but also on sexual behaviour within steady relationships.

Background: Incidence rates of human immunodeficiency virus type 1 (HIV-1) superinfection differ among cohorts and, as yet, only 2 cohorts of homosexual men have been screened. Here, we investigated the incidence of HIV-1 superinfection during the first year after infection among homosexual participants in the Amsterdam Cohort Studies on HIV infection and AIDS who seroconverted between 1985 and 1997., Methods: We analyzed env C2-C4 diversity in the serum of therapy-naive participants, using a heteroduplex mobility assay; heteroduplexes were considered to be indicators of potential dual infections, in which case env C2-C4 polymerase chain reaction (PCR) products were cloned and sequenced. Sequences were subjected to phylogenetic analysis. Data on the sexual behavior of participants were collected from 1 year before seroconversion until the end of the investigated period., Results: For 89 seroconverters with a detectable viral load (>1000 copies/mL), env PCR products were generated from serum samples obtained at seroconversion and 1 year later. Heteroduplexes were observed in 68 of the 89 patients; among these 68 patients, a median of 9 molecular clones per time point was sequenced. Phylogenetic analysis did not reveal evidence for superinfection; 1 patient was HIV-1 coinfected. Shortly after diagnosis of HIV infection, the number of sex partners decreased, the frequency of anal intercourse declined, and condom use increased., Conclusions: The incidence of HIV-1 superinfection soon after seroconversion in this cohort is low. Risk reduction shortly after HIV-1 diagnosis early during the HIV-1 epidemic in the Netherlands may have contributed to the absence of HIV-1 superinfection observed in this study.

Objectives: In January 2007, opt-out HIV testing replaced provider-initiated testing at the sexually transmitted infections (STI) outpatient clinic in Amsterdam, The Netherlands. The effect of the opt-out strategy on the uptake of HIV testing was studied and factors associated with refusal of HIV testing were identified., Study Design: Data routinely collected at the STI clinic were analysed separately for men who have sex with men (MSM) and heterosexuals. Logistic regression analysis was used to identify factors associated with opting out., Results: In 2007, 12% of MSM and 4% of heterosexuals with (presumed) negative or unknown HIV serostatus declined HIV testing. Refusals gradually decreased to 7% and 2% by the year end. In 2006, before the introduction of opt-out, 38% of MSM and 27% of heterosexuals declined testing. The proportion of HIV-positive results remained stable among MSM, 3.4% in 2007 versus 3.7% in 2006, and among heterosexuals, 0.2% in 2007 versus 0.3% in 2006. In both groups factors associated with opting out were: age >or=30 years, no previous HIV test, the presence of STI-related complaints and no risky anal/vaginal intercourse. Among heterosexuals, men and non-Dutch visitors refused more often; among MSM, those warned of STI exposure by sexual partners and those diagnosed with gonorrhoea or syphilis refused more often., Conclusions: An opt-out strategy increased the uptake of HIV testing. A sharp increase in testing preceeded a more gradual increase, suggesting time must pass to optimise the new strategy. A small group of visitors, especially MSM, still opt out. Counselling will focus on barriers such as fear and low risk perception among high-risk visitors considering opting out.

Background: Since 2000 outbreaks of sexually transmitted hepatitis C Virus (HCV) infections have been reported among HIV-infected men who have sex with men (MSM). We studied the prevalence and determinants of HCV-infection among MSM attending a large sexually transmitted infection (STI) clinic in the Netherlands., Methods: In 2007-2008, 3125 attendees of the STI clinic Amsterdam, including 689 MSM, participated in an anonymous biannual crosssectional survey. Participants were interviewed and screened for HIV and HCV antibodies. Additionally, all anti-HCV positive and HIV-infected individuals were tested for HCV RNA. Using phylogenetic analysis, HCV strains of the STI clinic attendees were compared with those isolated from MSM with acute HCV in 2000-2007. Determinants of HCV-infection were analysed using logistic regression., Results: Two of 532 (0.4%) HIV-negative MSM and 28 of 157 (17.8%) HIV-positive MSM were infected with HCV. Over the study period, HCV prevalence among HIV-infected MSM increased (14.6%-20.9%). Seven of 28 (25.0%) HIV/HCV coinfected MSM had acute HCV infection. Only five of 28 (17.9%) HIV/HCV coinfected MSM ever injected drugs (IDU). HIV-infection, IDU, fisting and gamma hydroxy butyrate (GHB)-use were significantly associated with HCV-infection. Phylogenetic analyses revealed a high degree of MSM-specific clustering., Conclusion: We found a high and increasing HCV prevalence in HIV-infected MSM. Though not statistically significant, this trend, and the relatively large proportion of acute infections suggest ongoing transmission of HCV in HIV-positive MSM. Regardless of IDU, rough sexual techniques and use of recreational drugs were associated with HCV-infection; phylogenetic analysis supported sexual transmission. Targeted prevention, like raising awareness and routine testing, is needed to stop the further spread among HIV-infected MSM, and to prevent possible spillover to HIV-negative MSM.

In general, little is known about the incidence of hepatitis B virus (HBV) among drug users, especially among non-injecting drug users. Therefore, changes in incidence, risk factors, and circulating genotypes over time were determined among drug users in Amsterdam over an 18-year period (1985-2002). Sera of 1,268 drug users, both injecting and non-injecting, were screened for anti-HBc. HBV genotypes of the anti-HBc seroconverters were determined. Poisson regression was used to test for temporal trends in incidence and to identify risk factors for seroconversion. Of the 598 participants who were anti-HBc negative at entry, 83 seroconverted for anti-HBc. The incidence of HBV declined from 5.9/100 Person Years up to 1993 to 0/100 Person Years in 2002. Of the drug users infected acutely, both injecting and non-injecting, 88% were infected with the same genotype D, serotype ayw3 strain. Multivariate analyses revealed current injecting, age, and calendar year of visit as independent risk factors. The decline in the incidence of HBV among drug users in Amsterdam is probably caused by a decline in injecting behavior. Injecting and non-injecting drug users were infected with the same strain, indicating that drug users infect one another, regardless of their risk behavior. After 2000, no injecting drug users with an acute HBV infection were reported to the Public Health Service Amsterdam and the specific genotype D strain had disappeared. These findings suggest that drug users may no longer be a high-risk group for HBV infection in Amsterdam. However, trends in drug use need to be monitored., (Copyright 2009 Wiley-Liss, Inc.)

Objective: To investigate HIV-testing behaviour and HIV prevalence among homosexual visitors of a sexually transmitted infection (STI) outpatient clinic, and to investigate determinants of unknown HIV status, and of HIV testing separately for men with unknown and negative HIV status., Design: Cross-sectional survey conducted from March 2002 to December 2003 among homosexual men with negative or unknown HIV status visiting the Amsterdam STI clinic., Methods: A convenience sample of 1201 men with negative or unknown HIV status answered a written questionnaire about history of HIV testing, sexual risk behaviour and behavioural determinants (non-response, 35%). Information was matched to the STI registration system. Associations were determined using logistic regression., Results: 817 men reported a negative HIV status, and 384 reported an unknown HIV status. The overall HIV prevalence among the 523 men who tested at new STI consultation was 2.8%. The proportion of men with unknown HIV status was relatively high among those diagnosed with infectious syphilis and those reporting unprotected anal intercourse with a casual partner. Their testing rates at new STI clinic visit were lower. Among men with an unknown HIV status, those aged <30 years and reporting risky sexual behaviour tested the least (OR 0.13, 95% CI 0.03 to 0.61)., Conclusion: Although HIV testing rates have increased, they are still lower than in other industrialised countries. Moreover, some men still undertake high-risk sex without knowing their own HIV status, which might pose a risk for ongoing HIV transmission. Therefore, more active testing promotion is needed.

Objectives: The incidence of HIV and STIs increased among men who have sex with men (MSM) visiting our STI clinic in Amsterdam. Interestingly, HIV increased mainly among older (> or =35 years) MSM, whereas infection rates of rectal gonorrhoea increased mainly in younger men. To explore this discrepancy we compared trends in STIs and HIV in a cohort of young HIV negative homosexual men from 1984 until 2002., Methods: The study population included 863 men enrolled at < or =30 years of age from 1984 onward in the Amsterdam Cohort Studies (ACS). They had attended at least one of the 6 monthly follow up ACS visits at which they completed a questionnaire (including self reported gonorrhoea and syphilis episodes) and were tested for syphilis and HIV. Yearly trends in HIV and STI incidence and risk factors were analysed using Poisson regression., Results: Mean age at enrollment was 25 years. The median follow up time was 4 years. Until 1995 trends in HIV and STI incidence were concurrent, however since 1995 there was a significant (p<0.05) increase in syphilis (0 to 1.4/100 person years (PY)) and gonorrhoea incidence (1.1 to 6.0/100 PY), but no change in HIV incidence (1.1 and 1.3/100 PY)., Conclusions: The incidence of syphilis and gonorrhoea has increased among young homosexual men since 1995, while HIV incidence has remained stable. Increasing STI incidence underscores the potential for HIV spread among young homosexual men. However, several years of increasing STIs without HIV, makes the relation between STI incidence and HIV transmission a subject for debate.

Background: Increases in sexual risk behaviour and sexually transmitted infections among HIV-infected homosexual men after the introduction of highly active antiretroviral therapy (HAART) confirm the need for innovative prevention activities. The present study focused on time trends in sexual risk behaviour and predictors for unprotected anal intercourse in the HAART era among HIV-infected homosexual men., Methods: In 2000-2003, 57 HIV-infected homosexual men (mean age 45 years) were interviewed in three serial data waves. Logistic regression, correcting for repeated measurements, was used to assess time trends in risky sex, and the association between HAART-related beliefs, and both the perceived and actual viral load level and CD4 cell counts and subsequent risky sex., Results: Risky sex with casual partners increased from 10.5% in 2000 to 27.8% in 2003 (P < 0.01), and with steady partners of negative or unknown HIV status from 5.3% to 10.7% (P = 0.6). Homosexual men with a favourable perception of their viral load were more likely to engage in subsequent risky sex with steady partners of negative or unknown HIV status than men with a less favourable perception of their viral load; this association was independent of the actual HIV-1-RNA load and CD4 cell counts., Conclusion: Risky sex increased in this group of HIV-infected homosexual men. The perceived viral load, but not the actual load, is associated with subsequent risky sex with steady partners of negative or unknown HIV status. Care givers should discuss with patients not only their actual viral load and CD4 cell count but also their perceived viral load.

Objective: To investigate longitudinally the association between highly active antiretroviral therapy (HAART)-related beliefs and the change from protected to unprotected anal intercourse with casual partners on an individual level., Methods: The study population included 217 HIV-negative homosexual men participating in the Amsterdam Cohort Study from September 1999 to May 2002, including five data waves with a 6-month interval. The selection criteria were: being under 31 years of age, having had anal sex with casual partners in the preceding 6 months, and participating in at least two data waves. Information was collected on the individual change from protected to unprotected receptive anal intercourse (URAI) and unprotected insertive anal intercourse (UIAI) and the level of agreement with different HAART-related beliefs., Results: The majority of men disagreed with the three treatment-belief factors that resulted from the principal component analysis: perceiving less HIV/AIDS threat since HAART, perceiving less need for safe sex since HAART, and perceiving high effectiveness of HAART in curing HIV/AIDS. Multivariate analyses revealed that the more men inclined to agree with the belief 'perceiving less HIV/AIDS threat', the more likely they were to change to URAI (adjusted OR 1.60; 95% CI 1.16-2.22)., Conclusion: Homosexual men are quite realistic about the effectiveness of HAART, the continued need for condom use, and the HIV/AIDS threat since HAART. However, a tendency towards agreement with 'perceiving less HIV/AIDS threat' was found to predict an individuals' change to URAI. This finding supports the hypothesis of a causal relationship between decreased HIV/AIDS threat since HAART and a change to URAI.

Increases in sexually transmitted diseases and sexual risk behaviour among men who have sex with men in the Western world have raised concern with regard to the HIV/AIDS epidemic in this group. The aim of this review is to give an overview of possible explanations for these alarming increases and to indicate what impact they might have on this epidemic.