Temporal trend of HIV infection: an update of the HIV surveillance system in Lazio, Italy, 1985-2000

BACKGROUND: After the introduction of the highly active antiretroviral therapies, data from AIDS surveillance systems are less useful to describe the HIV epidemic, while HIV surveillance could give more detailed information to provide data for HIV prevention and care programmes. We report the results of the HIV surveillance system update in Lazio, Italy, from 1985 through 2000. METHODS: New diagnoses of HIV infection were identified through a linkage procedure on the total reports, and underreporting was estimated through a link between the HIV surveillance system and the Hospital Information System of Lazio. RESULTS: As of December 2000, 20,912 new diagnoses of HIV occurred in Lazio. New diagnoses have decreased steadily since 1992. The male/female ratio decreased during the study period, while the number of foreign-born cases increased. Sexual transmission became the main modality of exposure for men in 1996 and for women in 1992. In 2000 the proportion of men infected by sexual transmission reached 54.0% versus 15.2% of those infected by intravenous drug use, whereas the proportion of women was 58.9% and 8.6% respectively. The sensitivity of the system has slightly decreased. CONCLUSION: HIV infection is increasing in women and immigrants; people are being infected more frequently by sexual transmission than intravenous drug use.     

A national surveillance system for newly acquired HIV infection in Australia. National HIV Surveillance Committee.

OBJECTIVES. The purpose of this study was to describe the establishment of a national surveillance system for newly acquired human immunodeficiency virus (HIV) infection and present the first 3 years' results. METHODS. All new cases of diagnosed HIV infection were reported to the national HIV surveillance center through state and territory health authorities. Information sought on each case included evidence of whether the infection had been newly acquired, defined by the diagnosis of HIV seroconversion illness or by the report of a negative or indeterminate HIV antibody test result occurring within the 12 months prior to diagnosis of infection. RESULTS. Of 3602 reported cases of HIV infection in adults and adolescents newly diagnosed in Australia between 1991 and 1993, 11.4% were identified as newly acquired. The majority (85%) of cases of newly diagnosed HIV infection occurred among men who reported homosexual contact, and 15% of these cases were identified as newly acquired. Average age at diagnosis was 31 years for cases of newly acquired infection and 34 years for other cases. CONCLUSIONS. Surveillance for newly acquired HIV infection has been established at a national level in Australia and provides valuable information for planning primary HIV prevention programs.     

HIV infection in the Women's Jail, Orange County, California, 1985 through 1991.

The incidence and prevalence of human immunodeficiency virus (HIV) infection among injection drug users, prostitutes, and other women seeking confidential testing in the Orange County Women's Jail were assessed from 1985 to 1991. A total of 4616 voluntary tests were completed on 3051 women, and 865 women were tested repeatedly. Eighty-two women tested positively, a ratio of 1.8 positives per 100 tests or 2.7% of all persons tested. Cumulative HIV prevalence increased from 2.5% to 2.7% between 1985 and 1991, increased by age, and showed racial differences. Of women with multiple tests, 29 seroconverted. Incidence declined from 5.7 to 1.4 cases per 100 person-years of observation between 1985 and 1991. The overall rate of seroconversion was 1.6 per 100 person-years of observation.     

The National Surveillance System for Sexually Transmitted Diseases in Italy. STD Surveillance Working Group.

Sexually transmitted diseases (STDs) have increased in importance in recent decades as a result of their wider dissemination, the emergence of new etiologic agents, and changes in sexual behaviors. In Italy, gonorrhea and syphilis are among the 71 diseases for which reporting is legally mandated. Despite these legal requirements, however, considerable underreporting has been documented. The need for more reliable data has led to the establishment of a formal sentinel surveillance system for STDs. The Italian National STD Surveillance Network, which involves 47 reporting centers, was established in 1990. A total of 5,049 patients were reported during the pilot study and the first 6 months of surveillance. For men, the most frequently reported diseases were genital warts and nongonococcal urethritis; for women, the most frequent diagnoses were nonspecific vaginitis and genital warts. The objectives of this system are threefold: a) to obtain a rapid and accurate assessment of the occurrence and spread of STDs; b) to identify trends in disease occurrence; and c) to monitor changes over time by geographic area.     

Behavioral surveillance among people at risk for HIV infection in the U.S.: the National HIV Behavioral Surveillance System

The Centers for Disease Control and Prevention, in collaboration with 25 state and local health departments, began the National HIV Behavioral Surveillance System (NHBS) in 2003. The system focuses on people at risk for HIV infection and surveys the three populations at highest risk for HIV in the United States: men who have sex with men, injecting drug users, and high-risk heterosexuals. The project collects information from these three populations during rotating 12-month cycles. Methods for recruiting participants vary for each at-risk population, but NHBS uses a standardized protocol and core questionnaire for each cycle. Participating health departments tailor their questionnaire to collect information about specific prevention programs offered in their geographic area and to address local data needs. Data collected from NHBS will be used to describe trends in key behavioral risk indicators and evaluate current HIV prevention programs. This information in turn can be used to identify gaps in prevention services and target new prevention activities with the goal of reducing new HIV infections in the United States.     

Underreporting of AIDS cases in Lazio,Italy

One of the most important aspect of any surveillance system is completeness. We conducted an evaluation of the completeness of the AIDS surveillance system (SSAIDS) of Lazio region. We estimated the underreporting of AIDS cases in SSAIDS of Lazio in the period 1996-1998 through a linkage with the regional Hospital Information System (HIS) for the same years. A logistic regression model was used to estimate the relative risk (Odds Ratios--OR) of being unreported by demographic and clinical characteristics. A total of 56 cases had not been reported in the period 1996-1998, corresponding to 3.6% of underreporting. The risk of not being reported was associated with undetermined value of CD4 at diagnosis of AIDS (OR 15.40), unknown modality of exposure (OR 3.15) and with AIDS defining illness at diagnosis (ADI) as mycobacteriosis (OR 11.65), encephalopaties (OR 4.47) and toxoplasmosis (OR 8.67). Differences were also observed by clinical centre of diagnosis. In conclusion, the degree of underreporting is lower in our region than in other countries and the SSAIDS has a high completeness in Lazio. In agreement with other studies, underreporting is more frequent for cases with undermined value of CD4 at diagnosis of AIDS and unknown modality of exposure. The results regarding ADI need further investigation.     

Socioeconomic status and survival of persons with AIDS before and after the introduction of highly active antiretroviral therapy. Lazio AIDS Surveillance Collaborative Group

We estimated the AIDS survival by neighborhood socioeconomic status before (1993-1995) and after (1996-1997) the introduction of highly active antiretroviral therapy in Rome, Italy, in a retrospective cohort of persons with AIDS followed through July 31, 1998. Participants included 1,474 persons with AIDS residing in Rome who were diagnosed in 1993-1997. We calculated hazard ratios (HRs) of death for two diagnostic periods (before and after highly active antiretroviral therapy was introduced) by neighborhood socioeconomic status categorized into four levels (level I = highest socioeconomic status), using the Cox model and adjusting for gender, age, intravenous drug use, CD4 cell count at diagnosis, AIDS-defining disease, and hospital of diagnosis. Thirty-four per cent of persons with AIDS (N = 503) had survived as of mid-1998. For persons with AIDS diagnosed in 1993-1995, we found little difference in the risk of death by neighborhood socioeconomic status. For 1996-1997, the risk of death was greater for persons with lower neighborhood socioeconomic status, especially for levels III and IV [HR = 2.81 (95% confidence interval = 1.38-5.76), and HR = 2.55 (95% confidence interval = 1.27-5.14), respectively, compared with level I]. Stratified analyses showed that the greatest difference was found for women and drug users. In conclusion, even in a country with universal health coverage that provides therapy at no cost, differences in survival of persons with AIDS have emerged by neighborhood socioeconomic status since highly active antiretroviral therapy was introduced. Inequalities in health-care access or in medical management, or poor adherence to treatment, could explain the observed heterogeneity.     

Incidence of measles in Italy in the 1985-1994 period

Measles notifications in Italy underestimate the actual incidence by a factor of ten, as it is ascertained by seroepidemiological investigation. In the decade 1980-89, 45,000 measles cases were notified, on average, per year. Since 1988 mass vaccination campaigns were implemented in several Italian regions. The strategy aimed to offer the prophylaxis actively to all children aged 13 months to 8-12 year for whom a sure recollection of measles was absent. The study has aimed to evaluate the impact of the strategy that worked in the period 1989-91, on the standardised average annual incidence of measles notification, comparing the periods 1985-89 and 1990-94. A reduction of 45% resulted all over Italy. On the contrary the incidence of chickenpox notifications has increased, indicating that the notification system did not worse.     

Paediatric, invasive pneumococcal disease in Switzerland, 1985-1994. Swiss Pneumococcal Study Group

BACKGROUND: Cost effective use of new vaccines against pneumococcal disease in children requires detailed information about the local epidemiology of pneumococcal infections. METHODS: Data on 393 culture-confirmed cases of invasive pneumococcal infection in children (<17 years) hospitalized in Swiss paediatric clinics were collected retrospectively for the years 1985-1994. RESULTS: Meningitis (42%) was most frequent, followed by pneumonia (28%) and bacteraemia (26%). The overall annual incidence was 2.7 cases per 100000 children <17 years old and 11 cases per 100000 children <2 years old. Annual incidence rates were stable over the study period. Lethality was high for meningitis (8.6%) and bacteraemia (8.9%). A history of basal skull fracture was reported in 3.3% of children with pneumococcal meningitis. Residence in a rural region was associated with an increased risk of pneumococcal infection (relative risk = 1.45, 95% confidence interval: 1.01-2.00). CONCLUSIONS: Paediatric, invasive pneumococcal disease seems to be less frequent in Switzerland than in other European and non-European countries. This may be due to differences in diagnostic strategies and lower frequency of risk factors such as the use of day care. Children with a history of basal skull fracture are at increased risk for pneumococcal meningitis. Further investigation of the association of invasive pneumococcal infection with rural residence and the use of antibiotics for upper respiratory tract infections might give new insight into the dynamics of Streptococcus pneumoniae infection and the development of antibiotic resistance.     

Epidemiology of HIV infection in Italy

AIDS surveillance systems, which have provided for many years useful information on HIV epidemic dynamics, are no longer useful for estimating the evolution of the HIV epidemic due to the effect of anti-retroviral treatments that have strongly improved survival of HIV-infected persons. To obtain reliable data on the HIV epidemic, some Italian provinces and regions (Lazio, Veneto, Friuli Venezia-Giulia, Trento, Modena) have set up local surveillance systems of the new HIV diagnoses. Aggregated data collected by these systems since 1988, show that the rapid spread of the infection in the eighties has been followed by a progressive decrease in the number of new diagnoses during the nineties; in more recent years this trend has levelled-off. The composition of cases by exposure category has greatly changed over time: in 1988 75.2% of cases were injecting drug users, whereas in 2000 58.5% of cases acquired the infection through sexual contacts. HIV incidence for the considered areas decreased from 19.2 per 100.000 inhabitants in 1992, to 6.7 per 100.000 inhabitants in 2000. Median age at diagnosis increased over time, from 27 years in 1988 to 34 years in 2000. The changed pattern of the HIV epidemic in Italy stresses the need of a nation-wide surveillance system for HIV infections aimed at allocation of adequate economic resources and planning specific prevention programmes.     

北京市2005-2012年男男性行为者同伴推动抽样法HIV监测分析

目的 探索采用同伴推动抽样法（Respondent-Driven Sampling,RDS）开展MSM HIV监测的可行性及该人群HIV感染趋势分析。方法 2005-2012年每年4-10月采用RDS法在北京征募MSM开展调查,了解目标人群人口学特征、艾滋病相关危险行为以及HIV和梅毒感染状况。结果 2005-2012年各调查427,540,607,614,616,602,579和600名MSM。HIV感染率由2005年的4.2%（95% CI：1.9～7.0）上升至2012年的10.1%（95% CI：7.2～13.2,P=0.02）。外地户籍、25岁以上和高中及以下教育水平MSM HIV感染率人群估计分别从3.3%（95% CI：1.8～5.4）、6.4%（95% CI：2.2～9.5）和5.5%（95% CI：2.2～8.9）升至2012年的10.7%（95% CI：7.8～14.6,P=0.04）、7.6%（95% CI：5.4～10.3,P=0.04）和10.4%（95% CI：7.2～14.3,P=0.04）。25岁及以下者和高中以上文化程度者HIV感染率分别自2009和2007年起开始上升,从1.7%（95% CI：0.4～3.1）和1.1%（95% CI：0.2～1.7）升至13.7%（95% CI：7.2～20.4）和9.1%（95% CI：4.7～13.8）,未达显著性水平。最近6个月有2～9名男性伴者HIV感染率由2005年的4.0%（95% CI：1.0～8.0）上升至2012年的12.6%（95% CI：8.7～16.7,P=0.02）。结论 RDS是一种稳定性较高的隐匿人群抽样方法,可用于长期监测。2005-2012年北京市MSM人群HIV感染率呈上升趋势,应重点关注MSM人群中的年轻人及高学历者。     

HIV seroconverters: using surveillance to characterise people with incident HIV infection in Victoria, Australia

This paper describes a cohort of people living in Victoria, Australia, diagnosed with incident HIV infection and identified through routine HIV surveillance. All HIV diagnoses notified to the Victorian HIV Registry between January 1997 and September 1998 were included. Infections were classified as incident if there was a prior negative test and/or seroconversion illness within 12 months of the first positive HIV test. During the study period there were 277 notifications received of which 70 (25%) were incident infections (seroconversions). People with incident infection were aged 36 years (+/- 10), from an Anglo background (76%) and living in Melbourne (91%). Seroconverters were more likely to have acquired their infection in Victoria (76%), through male-to-male sexual contact (86%), and from casual or anonymous partners (67%). Cohorts of individuals with incident HIV infection provide a valuable resource for understanding the dynamics of HIV acquisition and natural history of the infection.     

河南口岸1989～2001年HIV感染监测

目的 掌握河南口岸出入境人员中HIV的流行情况,采取有效的预防控制措施。方法 对30例HIV感染者从不同年度、人群、职业、年龄、传播途径分析。结果 HIV感染者中,1989年检出10例,为输入性病例;1995～2001年检出20例,为国内出入境人员;感染者中年龄最小的18岁,最大的54岁;人群分布中以劳务输出人员居多,其次为外籍人员;传播途径以静脉采血及性传播为主要传播途径。结论 应加强血源管理并做好出入境人员的传染病监测预警工作。     

HACCP and food hygiene in hospitals: knowledge, attitudes, and practices of food-services staff in Calabria, Italy. Collaborative Group.

OBJECTIVES: To determine adherence to Hazard Analysis and Critical Control Points (HACCP) methods and to evaluate knowledge, attitudes, and practices of food-services staff with regard to food hygiene in hospitals. DESIGN: A survey. PARTICIPANTS: Hospital medical directors and food-services staff of 36 hospitals in Calabria, Italy. METHODS: A questionnaire about hospital characteristics, food-services organization, and measures and procedures for the control and prevention of foodborne diseases was sent to medical directors; a questionnaire about demographic and practice characteristics, knowledge, attitudes, and behaviors about control and prevention of foodborne diseases was sent to food-services staff. Multiple logistic regression analysis was performed. RESULTS: Only 54% of the 27 responding hospitals were using the HACCP system and, of those using HACCP, 79% adopted a food-hygiene-practice manual; more than one half already had developed written procedures for food storage, personal hygiene, cleaning and disinfection; one half or less performed microbiological assessment of foods and surfaces. Of the 290 food-services staff who responded, 78.8% were aware of the five leading foodborne pathogens; this knowledge was significantly higher among those with a higher educational level and those who worked in hospitals that had implemented the HACCP system. Younger staff and those who had attended continuing educational courses about food hygiene and hospital foodborne diseases had a significantly higher knowledge of safe temperatures for food storage. A positive attitude toward foodborne-diseases prevention was reported by the great majority, and it was significantly higher in older respondents and in those working in hospitals with a lower number of beds. Only 54.9% of those involved in touching or serving unwrapped raw or cooked foods routinely used gloves during this activity; this practice was significantly greater among younger respondents and in those working in hospitals using HACCP. CONCLUSION: Full implementation of the HACCP system and infection control policies in hospital food services is needed.     

HIV infection during pregnancy: the Sentinel Surveillance Project, Brazil, 2002

OBJECTIVE: To evaluate the actual coverage of HIV infection detection during pregnancy at national level. METHODS: The actual coverage of HIV testing during pregnancy was defined as the proportion of women who attended prenatal care visits (at least one visit), ordering HIV testing and knowledge of test result before delivery. The coverage was estimated by sampling procedures based on the 2002 Sentinel Surveillance Study data. Actual coverage Inequalities were assessed by: country regions; population size of the municipality where delivery took place; and mother's schooling. RESULTS: The actual coverage of HIV testing during pregnancy was 52%. Huge sociogeographic inequalities are seen between the Northeastern (24%) and Southern regions (72%); illiterate mothers (19%) and those with complete basic education (64%); mothers who delivered in small municipalities (36%) and those who delivered in municipalities with more than 500,000 inhabitants (66%). Ministry of Health recommendations were fully followed by only 27% pregnant women. CONCLUSIONS: The study results show a need for actions aiming at increasing HIV detection coverage during pregnancy, and indicate that HIV/STD programs should be intensified with joint strategies between the National AIDS Program and infant-maternal programs.