HIV epidemic and national response in Portugal under financial constraints and a comparative analysis with three southern european countries

Introdução: A presente agenda global de saúde para o VIH/SIDA visa mobilizar os países de todo o mundo para enfrentar as principais lacunas na resposta ao VIH. A ONUSIDA estabeleceu metas ambiciosas para o tratamento do VIH para serem atingidas até 2020. A OMS recomenda que abordagens baseadas na evidência e estratégias inovadoras, incluindo a profilaxia pré-exposição (PrEP) e o autoteste de VIH, façam parte das respostas nacionais à epidemia de HIV. Este compromisso global sem precedentes foi lançado após uma grave crise financeira global, que forçou muitos países a reduzir a despesa em saúde. Este estudo teve como objetivo analisar os potenciais efeitos desses constrangimentos financeiros na resposta e políticas nacionais para o VIH em Portugal, no contexto de outros países do sul da Europa que também receberam programas de assistência financeira. Métodos: Para os objetivos deste estudo, foram realizadas quatro análises, utilizando diferentes abordagens metodológicas: a) Foi utilizado um modelo hierárquico de regressão de Poisson com efeitos aleatórios para analisar a relação entre o tempo de internamento e variáveis do doente, dos cuidados de saúde e do contexto, utilizando dados nacionais de 20,361 internamentos ocorridos entre 2009 e 2014 em 41 hospitais públicos em Portugal; b) Para o período 2009-2018, foram analisados os resultados dos programas de prevenção do VIH em Portugal: apoio financeiro a organizações privadas sem fins lucrativos, programa de troca de seringas, teste rápido de VIH e distribuição de materiais preventivos; c) Para o período 2005- 2017, foram analisados os dados de vigilância de do VIH/SIDA em Portugal, usando análise descritiva e modelos de regressão linear para testar tendências nos novos diagnósticos de VIH e SIDA e diagnósticos tardios de VIH; d) Foram examinados e comparados um conjunto de indicadores de VIH no Chipre, Grécia, Portugal e Espanha, países que receberam assistência económica da União Europeia durante a crise financeira. Resultados: Este estudo constatou que o tempo de internamento dos doentes com VIH/SIDA entre 2010 e 2014 nos hospitais públicos portugueses foi significativamente menor em comparação com 2009, e que diversas variáveis, incluindo sexo feminino, internamento urgente, mortalidade hospitalar, pneumonia pneumocystis, hepatite C, e o rácio de liquidez do hospital contribuiu para a diminuição do tempo de tempo de internamento dos doentes com VIH/SIDA entre 2009 e 2014. Este estudo também mostrou que, apesar dos cortes transitórios de despesa em 2012-13, o Programa Nacional para a Infecção VIH e SIDA conseguiu melhorar a sua eficiência e manter as suas actividades principais, graças à priorização de gastos na expansão do teste de VIH e a um forte envolvimento com organizações da sociedade civil. A análise das tendências do VIH entre 2005 e 2017 mostrou uma redução significativa das novas infecções em todos os grupos, excepto nos homens que têm sexo com homens (HSH), onde foi observada uma tendência de aumento não significativa. O diagnóstico tardio ainda é comum em todos os grupos de transmissão, excepto nos HSH, enquanto a aquisição de VIH no estrangeiro é relevante entre pessoas nascidas fora de Portugal, excepto entre utilizadores de drogas. A análise comparativa com outros três países do sul da Europa que receberam assistência económica mostra que Portugal é o único país que implementou PrEP e autoteste de VIH. Portugal atingiu as metas 90-90-90 da ONUSIDA para o tratamento do VIH em 2017. Conclusão: Os resultados deste estudo mostram que os constrangimentos financeiros com que Portugal se defrontou não prejudicaram o progresso do país em relação à eliminação da SIDA até 2030, tornando Portugal um estudo de caso interessante no contexto europeu.Background: The current global health agenda for HIV/AIDS aims to mobilise countries worldwide to address major gaps in HIV response. UNAIDS has set ambitious targets to HIV treatment to be met by 2020. WHO recommends that evidence-based approaches and innovative strategies, including pre-exposure prophylaxis (PrEP) and HIV selftesting (HIVST), should be part of countries’ response to the HIV epidemic. This unprecedented call for a global commitment against HIV/AIDS came in the aftermath of a severe global financial crisis that forced many countries to cut health care spending. This study aimed to analyse the potential effects of these financial constraints on the response to HIV/AIDS and associated national policies in Portugal, in the context of other Southern European countries that also received bailout programmes. Methods: For the purposes of this study, four analyses were conducted, using different methodological approaches: a) Hierarchical Poisson regression model with random effects was used to analyse the relation between length of stay and patient, treatment and setting characteristics, using national data from 20,361 hospitalizations occurring between 2009 and 2014 in 41 public hospitals in Portugal; b) For the period 2009-2018, we analysed the outcomes of HIV prevention programmes in Portugal which included: financial support to private non-for-profit organisations; syringe exchange programme; HIV rapid testing; and distribution of preventive materials; c) For the period 2005-2017, we analysed Portuguese HIV/AIDS surveillance data, using descriptive analysis and linear regression models to test for trends in new HIV and AIDS diagnoses and late HIV diagnoses; d) We examined and compared a set of HIV indicators in Cyprus, Greece, Portugal and Spain, countries which received economic assistance from the European Union during the financial crisis. Results: This study found that length of stay of HIV/AIDS patients in Portuguese public hospitals between 2010 and 2014 was significantly shorter compared to 2009, and that a number of variables, including being female, urgent admission, in-hospital mortality, pneumocystis pneumonia, hepatitis C, and hospital's current ratio contributed to the decrease of HIV/AIDS patients’ length of stay between 2009 and 2014. Findings also showed that, despite transitory spending cuts in 2012-13, the Portuguese HIV/AIDS Programme was able to improve its efficiency and sustain its core activities, thanks to prioritisation of spending in HIV testing expansion and a strong engagement with civil society organisations. The analysis of HIV trends between 2005 and 2017 has shown a significant decline in new HIV infections in all groups, except in men who have sex with men, where a non-significant increase trend was observed. Late diagnosis remains common in all transmission groups, except in MSM, while foreign acquisition of HIV is relevant among foreign-born persons, except in people who inject drugs. The comparative analysis with other three Southern European countries that received economic bailout assistance shows that Portugal is the only country that implemented both PrEP and HIVST. Portugal met the UNAIDS 90-90-90 targets for HIV treatment in 2017. Conclusion: Results from this study show that financial constraints experienced in Portugal have not hampered the country’s progress towards eliminating AIDS by 2030, making Portugal an interesting case study in the European context

Linkage to care following HIV diagnosis in Europe

Background: Attendance for clinical care promptly after diagnosis with human immunodeficiency virus (HIV) is important; delayed linkage to care and treatment has implications for the health of the individual and the public. In this thesis, I have explored entry into care in the World Health Organization European Region with an aim to inform and optimise public health monitoring. Methods: I utilised data from the literature and HIV surveillance data from Europe and England, Wales and Northern Ireland (EW&NI) to describe linkage to care and risk factors for poor linkage. I carried out a key informant survey of national HIV surveillance focal points to understand the context within which linkage occurs in Europe and investigate the current capacity of countries to monitor linkage to care for public health purposes. Results: Overall, 38/53 countries from Europe were able to contribute routinely collected CD4 data to this, the first European estimate of linkage to care; 80% of included HIV diagnoses made between 2014 and 2016 were ever linked to care, 73%-92% within three months of diagnosis. However, linkage varied widely by region. Several groups were identified as being at higher risk of delayed linkage to care: people who acquired HIV through injecting drug use or heterosexual contact (Europe), people of younger age at diagnosis (Western Europe), migrants (Western Europe), people who had a higher first CD4 count (Western Europe) and people diagnosed outside of sexual health clinics (EW&NI). The survey identified a number of barriers to using surveillance data to monitor linkage to care, but ultimately validated the use of CD4 as a proxy for care entry. Conclusion: The findings of this thesis have implications for public health action and have informed the development of monitoring of linkage to care at the European Centre for Disease Prevention and Control and Public Health England

Spatial dependence of body mass index and exposure to night-time noise in the Geneva urban area

In this study, we calculated the night-noise mean (SonBase 2014, compatible with the EU Environmental Noise Directive) for the 5 classes obtained after computation of Local Indicators of Spatial Association (LISA; Anselin et al 1995) on the BMI of the participants in the Bus Santé study, a cohort managed by the Geneva University Hospitals (N=15’544; Guessous et al 2014). We expected the mean of dBs to be significantly higher in the group showing spatial dependence of high BMI values (high-high class). We ran an ANOVA and multiple T-tests to compare the dB means between LISA clusters. The approach was applied to the participants of the whole State Geneva cohort, and to a reduced set of individuals living in the urban environment of the municipality of Geneva only

Preventing overweight and improving parenting skills from birth to age 3 years: preliminary results

Background. Parenting has been associated with child weight status. This study aims to evaluate the effects on parenting skills and BMI-SDS of the BBOFT+ overweight prevention program, compared to care-as-usual (CAU). Method. In a cluster-randomized trial, 2500 parents participated. Parent-reported weight and length were used. Parenting was measured with subscales control and reinforcement of the parenting strategies for eating and activity scale (PEAS) and the warmth subscale from the Child Rearing Questionnaire. Results. The first univariate analyses show that at age 15 months, no statistically significant differences in BMI- SDS, parental control, reinforcement or warmth were found between the BBOFT+ and the CAU group. Further cluster analyses need to be conducted. Results from age 36 months will be presented during the conference, which will include all subscales of the PEAS and an assessment of parenting styles. Conclusion. The intervention does not seem to have an effect on BMI-SDS or parenting

Healthy snacks consumption and the Theory of Planned Behaviour. The role of anticipated regret

Two empirical studies explored the role of anticipated regret (AR) within the Theory of Planned Behavior (TPB) framework (Ajzen, 1991), applied to the case of healthy snacks consumption. AR captures affective reactions and it can be defined as an unpleasant emotion experienced when people realize or imagine that the present situation would be better if they had made a different decision. In this research AR refers to the expected negative feelings for not having consumed healthy snacks (i.e., inaction regret). The aims were: a) to test whether AR improves the TPB predictive power; b) to analyze whether it acts as moderator within the TPB model relationships. Two longitudinal studies were conducted. Target behaviors were: consumption of fruit and vegetables as snacks (Study 1); consumption of fruit as snacks (Study 2). At time 1, the questionnaire included measures of intention and its antecedents, according to the TPB. Both the affective and evaluative components of attitude were assessed. At time 2, self-reported consumption behaviors were surveyed. Two convenience samples of Italian adults were recruited. In hierarchical regressions, the TPB variables were added at the first step; AR was added at the second step, and the interactions at the last step. Results showed that AR significantly improved the TPB ability to predict both intentions and behaviours, also after controlling for intention. In both studies AR moderated the effect of affective attitude on intention: affective attitude was significant only for people low in AR

Refugee, Migrant and Ethnic Minority Health

International migration, particularly to Europe, has increased in the last few decades, making research on aspects of this phenomenon, including numbers, challenges, and successes, particularly vital. This Special Issue highlights this necessary and relevant area of research. It presents 37 articles including studies on diverse topics relating to the health of refugees and migrants. Most articles (28) present studies focusing on European host countries. The focus on Europe is justified if we take into consideration the increased number of refugees and migrants who have come to Europe in recent years. However, there are also articles which present studies from countries in other continents. The topics discussed in the Issue include healthcare utilization, infectious diseases, mother and child health, mental health, and chronic diseases. Finding from the included articles indicate that further development of guidelines and policies at both local and international levels is needed. Priorities must be set by encouraging and funding in-depth research that aims to evaluate the impact of existing policies and interventions. Such research will help us formulate recommendations for the development of strategies and approaches that improve and strengthen the integration of migrants and refugees into the host countries

Influence of household behaviour and perception on Malaria control and prevention in Zamfara State North West Nigeria

Household behaviour has been established as a fundamental element in health preventive practices. Malaria control paradigm focuses mostly on the medical and health approach. Household behaviour has been to a large extent do not take into account. Household behaviour, not only plays a critical role in the influence of malaria prevalence, but these behaviours and attitudes can also play a role in its control and management. The objective of this study is to investigate the influence of household behaviour and perception on malaria control and prevalence in Zamfara state North West Nigeria. The study used a mixed methodology of quantitative and qualitative research. For the quantitative, a total of 409 respondents participated in the study. Statistical Package for Social Science (SPSS) and smart PLS 2.0 is use for the quantitative analysis. For the qualitative, 20 people participated as respondents. Thematic analysis was used for qualitative analysis. Result from the PLS analysis supported the entire three hypothesis. Specifically, the finding from hypothesis one shows that there is a significant relationship between behaviour on fumigation and malaria control. Furthermore, results from hypothesis two indicate that there is a connection between household behaviour on waste disposal and malaria control. The result from the hypothesis three reveals that there is a relationship between household malaria perception and malaria control. A finding from the qualitative study reveals that household behaviour has the influence to available and effective malaria control measures in Nigeria. Part of the result also shows that available and effective control measures influence household behaviour. The findings of the study were supported by the literature and theories. In general the study provides further proofs on the influence of household behaviour on malaria control and prevention with particular reference to Zamfara state in North West Nigeria. Household behaviour should be considered as an important concept for malaria control and prevention