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INSTITUTO DE SALUD CARLOS III CENTRO NACIONAL DE EPIDEMIOLOGÍA

Sinesio Delgado, 6 - 28029 MADRID Teléf.: 91 387 78 02- Fax: 91 387 78 15/16

MINISTERIO DE SANIDAD Y CONSUMO Secretaría del Plan Nacional sobre el Sida

Paseo Del Prado 18-20. 28071 Madrid http://www.msc.es/Diseno/enfermedadesLesiones/enfermedades_transmisibles.htm

PROJECT EPI-VIH Evolution of HIV prevalence in the patients of ELEVEN CENTRES of sexual transmission diseases and/or HIV diagnosis, 1991-2004.

Participating centres: Centro de Diagnóstico y Prevención de ETS de Sevilla. Centro de ETS de Granada. Centro de ETS "Costa del Sol" de Málaga. Unidad de ETS de Gijón. Centro Dermatológico de Tenerife. Programa de Prevención del SIDA y ETS del Ayuntamiento de Madrid. Centro Sanitario Sandoval, Servicio Regional de Salud de la Comunidad de Madrid. Unidad de Prevención y Educación Sanitaria sobre SIDA de Murcia. Unidad ETS-SIDA. Centro de Salud Área II. Cartagena. Centro de la Dirección Territorial de Álava. Centro de Información y Prevención del Sida de Valencia. Coordination: Centro Nacional de Epidemiología, Instituto de Salud Carlos III. Secretaría del Plan Nacional sobre Sida. Financiatión: FIPSE (Fundación formada por el Ministerio de Sanidad y Consumo, Abbott Laboratories, Boehringer Ingelheim, Bristol Myers Squibb, GlaxoSmithKline, Merck Sharp and Dohme, and Roche), exp. 3076/99.

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PROJECT OBJECTIVES -

Describe the evolution of HIV sero prevalence in persons who carried out the voluntary tests between the years 1991 and 2004 in ten centres located in ten different cities in Spain. Analyse the sero prevalence with respect to risk factors, sex and age.

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Describe the characteristics of the persons who were analysed in these centres for HIV and their evolution in a time period.

-

Describe the characteristics of the persons who were diagnosed as HIV infected.

MATERIAL AND METHODS Design: Descriptive study of sero prevalence. The information collected was concurrent and the analysis has been retrospectively set out. Period: The study analyses the period 1991 - 2004, although the complete participation of all the centres covers the period 1997 - 2004. Centres: the participation of centres was voluntary and was subjected to the disposal of computerised data on the total of persons analysed for HIV during the study period. It was also demanded that the data be collected with comparable criteria.

Period Sandoval Gijón Vitoria Montesa Murcia Cartagena Tenerife Sevilla Granada Málaga Valencia Total

1991-2004 1991-2004 1997-2004 1997-2004 1996-2004 1991-2004 1991-2004 1991-2004 1994-2004 1991-2004 1991-2004 1991-2004

Persons on 1st visit in the period 1991-2004 24.815 (41,2%) 4.529 (7,5%) 1.232 (2,0%) 2.418 (4,0%) 1.020 (1,7%) 1.410 (2,3%) 6.168 (10,2%) 12.456 (20,7%) 4.491 (7,4%) 1.743 (2,9%)

Persons on 1st visit year 2004 2.481 (37,3%) 449 (6,7%) 213 (3,2%) 487 (7,3%) 107 (1,6%) 112 (1,7%) 807 (12,1%) 1.249 (18,8%) 621 (9,3%) 123 (1,8%)

60.282 (100%)

6.649 (100%)

Criteria of patient inclusion: Patients who carried out the voluntary HIV test for the first time in any one of the participating centres. Doubtful or unconfirmed results were not considered, nor were the successive repetitions of the HIV test in the same patient. Analysis variables. Sero prevalence was calculated by dividing the positive confirmed results among the total of the HIV tests carried out. To effect this analysis no identifying information of persons was used or transmitted.

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RESULTS Characteristics of the analysed persons In the eleven centres participating in this analysis information was compiled on a total of 109.442 persons who presented themselves to carry out the HIV test for the first time between 1991 and 2004. As the initiation of the activity was not simultaneous in all of the centres, during the first years the numbers of patients analysed were fewer. The number of patients analysed annually has increased progressively from 4.862 in 1991 to 9.107 in 2004 (Figure 1). Throughout the period the most numerous groups of patients have been those referred to as exposed to heterosexual risk factors, without having practiced prostitution or IDUs. Over these years the request for HIV tests has diminished among persons with antecedents of injecting drugs (IDUs) these have passed from 31% of the persons analysed in 1991 to 2% in 2004. The number of tests in women who practice prostitution has increased in the same period and passed from 4% to 16%. The rest of the categories have experienced fewer changes. This modification in the type of patient has meant an increase in the percentage of women among those requesting the HIV test that has passed from 34% in 1991 to 43% in 2004 (Figure 2).

Figure 1. HIV tests carried out on patients who consult on their first visit.

10000

UDIs

Homosexuales

Prostitutas

Heterosexual

Otros

9000 8000 7000 6000 5000 4000 3000 2000 1000 0

19 91 19 92 19 93 19 94 19 95 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03 20 04

Nº de personas analizadas

11000

Año

4

Figure 2. Distribution by categories of exposure of the persons analysed for HIV.

5% 2%

8%

18% 32%

18%

UDI Homosexual

25%

Prostitución Hombre hetero

16%

Mujer hetero Otros

19% 4%

19%

Año 1991 N = 4.862

34%

Año 2004 N = 9107

The average age in the IDUs has increased from 26 years old in 1991 to 33 in 2400. In the remainder of the categories the age averages have remained relatively stable. (Table 1).

Characteristics of the persons diagnosed with the infection of HIV In all, 8.999 persons have been diagnosed with the infection of HIV, the characteristics of these patients are subjected to the type of patient who consults in these centres. In 1991 71% of the persons diagnosed were IDUs, but from then on their numbers have fallen to a 15% of the total of those diagnosed (Table 1). This decrease has not been seen as being replaced by increases in the diagnosis of other risk categories, and has carried with it a fall in the total number of infections diagnosed annually up till 2002. From this year on a slight increase has been detected in the number of diagnosed patients, particularly among heterosexual women and homosexual men. (Table 1). In general in the year 2004 only a quarter part of the number of infections of those diagnosed in 1991 were diagnosed (Figure 3) and in the conjunction of categories of transmission the percentage of homosexual men reached 51%. (Figure 4).

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Figure 3. Evolution of the number of new diagnosis in HIV patients who consult on their first visit.

Nº de personas analizadas

1000 900

UDIs

Homosexuales

Prostitutas

Heterosexual

Otros

800 700 600 500 400 300 200 100

19 91 19 92 19 93 19 94 19 95 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03 20 04

0

Año

Figure 4. Distribution by categories of exposure of the persons infected with HIV

1% 2% 6% 0%

12,0%

3,3%

14,9%

UDI Homosexual

20%

Prostitución

12,4%

Hombre hetero Mujer hetero Otros

6,2%

71% 51,0%

Año 1991 N = 974

Año 2004 N = 241

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Evolution of sero prevalence of HIV in the period 1991-2004

The sero prevalence of HIV in the conjunction of patients has decreased in a marked way from 20% in 1991 and 2,5% in 2002, maintaining itself with oscillations (table 1) and this being the predominant tendency in the majority of categories of transmission. Among IDUs the sero prevalence has decreased from 44,6% in 1991 to 18,8% in 2004, although it continues to be high (Figure 5). In homosexual men it has passed from 20,4% in 1991 to 8% in 2000 and later to maintain itself stable around 7,5% (Figure 6). The prevalence in women who practice prostitution has suffered oscillations although in conjunction a decrease can be noted from 3% in 1992 to 1%, which has been maintained in 2000 -2004. This fall can be explained to a great extent because fewer women prostitutes are IDUs. The fall is from 20% of those analysed in 1991 to only 0,5% in 2004. However the prevalence has also fallen among prostitutes not IDUs from 1,6% in 1991 to 1,0% in 2004 (Figure 7). The sero prevalence in HIV positive persons in sexual couples has fluctuated around 10% being the only exposure category that does not show a clear descending tendency. . (Figure 8). In the first years, the sero prevalence of HIV among women that only referred to heterosexual risk exposure, without practising prostitution, was far higher than to those of men of equal category, but in later years both have fallen with the differences disappearing, except in 2002 when an increase was observed in the prevalence in heterosexual men. (Figure 10). Finally it can be said that following a favourable evolution in the majority of categories of transmission, over the past years a standstill has been observed in several of them.

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18,8 400

8

7,7 7,2 7,8 7,4

100

5

50

2004

2003

2002

2001

2000

1999

0 1991

0

2004

2003

2002

2001

2000

1999

1998

1997

0 1996

0 1995

100 1994

5 1993

200

1992

10

150

10,2 10,2 9,9 9,8

10

1998

15

300

200 12,1 12,5

1997

15,3

16

15

1996

20,8

20

250

1995

25

500

23,2

Nº de VIH+

19,2

1994

27,3 24,1

20

Prevalencia (%)

Año

Año

Figura 7. Seroprevalencia de VIH en mujeres que ejercen la prostitución que acudieron a realizarse la prueba 12

Figura 8. Seroprevalencia de VIH en personas con pareja heterosexual infectada por el VIH, que acudieron a realizarse la prueba

10,1

16 14,9

5,7 4,7 3,2 1 1 1,1 1

4 2

Año

Figura 9. Seroprevalencia de VIH en personas con riesgo heterosexual (excluidos UDI y prostitución), que acudieron a realizarse la prueba 8 7

Hombres

Mujeres

6 4,7 3,7

2

2,1

3,2

1,9

1,9

2,1

2,2

2,5

2,5

2,2 1,9

1,4

1,41,4

1,4 1,1

2000

3,2 2,6

1999

4

1

1,3 1,5

1

1,11,2

1

1,3

1998

1997

1996

1995

1994

1993

1992

0 1991

Porcentaje de infectados

Año

2003

2002

2001

2000

1999

1998

1991

Año

1997

0

2004

2003

2002

2001

2000

1999

1998

1997

1996

1995

1994

1993

1992

1991

0

6

1996

1,6

8,7

7,3

6

1995

1

8,5 7,3

8

2004

1,7

2,1 1,6 1,4 1 0,9 0,90,9 1,1 1 1,1 1 0,7

9,7

1994

2

1,6

2,2

10,3 9,1

2003

2

3,4

10,9

10

1993

4

12

13,5 11,9

11,5

2002

6

14

14

2001

8

No UDVP

1992

TOTAL

Porcentaje de infectados

10

2004

600

30,6

300 20,4

1993

28,3

30

25

700

1992

33,6 34,1 33,1

35

Nº de VIH+

Porcentaje de infectados

Prevalencia (%)

38

10,5

Porcentaje de infectados

800

41,3

40

Número de VIH+

44,6

1991

Porcentaje de infectados

45

Figura 6. Infección por VIH en hombres homosexuales, no UDI, que acudieron a realizarse la prueba

Número de VIH+

Figura 5. Infección por VIH en usuarios de drogas inyectadas (UDI) que acudieron a realizarse la prueba

Table 1. Results of the HIV tests in patients on their first visit according to the category of transmission and year of tests. Category

Year

Analysed

IDU

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

1547 1367 1057 922 704 716 629 494 294 249 216 216 164 191 945 1264 1422 1357 1311 1183 1178 1183 1071 1121 1255 1232 1413 1661

690 565 402 310 240 237 178 151 71 68 45 33 38 36 193 243 227 164 164 121 120 117 105 90 97 89 110 123

44,6 41,3 38,0 33,6 34,1 33,1 28,3 30,6 24,1 27,3 20,8 15,3 23,2 18,8 20,4 19,2 16,0 12,1 12,5 10,2 10,2 9,9 9,8 8,0 7,7 7,2 7,8 7,4

Average age 26,4 26,8 27,3 27,8 28,3 29,4 29,7 29,9 31,1 31,0 32,1 32,5 33,7 32,8 30,2 29,6 30,1 29,5 29,5 29,5 30,2 30,0 29,6 30,1 29,8 29,3 29,9 30,7

1991

192

3

1,6

29,9

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

293 358 401 417 632 681 754 1062 1519 1880 1904 1622 1502

10 7 7 4 10 5 12 10 13 18 19 16 15

3,4 2,0 1,7 1,0 1,6 0,7 1,6 0,9 0,9 1,0 1,0 1,0 1,0

29,3 30,2 29,9 29,8 29,3 28,9 29,3 28,1 28,0 27,6 27,3 27,6 27,9

Men Homosexuals

Women who practice prostitution

Positive Prevalence

(continue...)

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Category Men Heterosexual

Women Heterosexual

Others

TOTAL

Year Analysed 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001

926 1321 1584 1777 1756 1963 2043 2161 2174 2067 2338 2523 2663 3047 876 1262 1639 1624 1597 1699 1766 1852 1716 1762 1837 1846 1955 2240 376 479 577 541 627 574 639 592 439 438 374 265 309 466 4862 5986 6637 6622 6412 6767 6936 7036 6756 7156 7900

Positive 18 34 33 34 37 43 29 47 30 22 23 37 30 30 61 59 60 52 51 42 45 35 24 24 23 18 24 29 9 20 15 20 18 9 4 7 6 2 3 3 5 8 974 931 744 587 514 462 381 369 246 219 209

Prevalence 1,9 2,6 2,1 1,9 2,1 2,2 1,4 2,2 1,4 1,1 1,0 1,5 1,1 1,0 7,0 4,7 3,7 3,2 3,2 2,5 2,5 1,9 1,4 1,4 1,3 1,0 1,2 1,3 2,4 4,2 2,6 3,7 2,9 1,6 0,6 1,2 1,4 0,5 0,8 1,1 1,6 1,7 20,0 15,6 11,2 8,9 8,0 6,8 5,5 5,2 3,6 3,1 2,6

(... continuation) Average age 30,6 31,1 31,2 31,3 30,8 60,9 30,8 30,7 30,7 30,6 31,5 30,9 31,8 32,5 27,4 27,8 28,1 28,0 28,3 27,6 28,0 27,9 28,2 28,4 28,2 28,7 28,5 29,1 28,8 29,3 29,5 29,2 28,9 29,6 29,4 28,4 29,8 29,3 30,0 30,1 30,0 30,5 28,5 28,9 29,4 29,4 29,4 29,5 29,6 29,4 29,4 29,4 29,5

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10 2002 2003 2004

7986 8126 9107

199 223 241

2,5 2,7 2,6

29,3 29,8 30,5

Conclusions:

Heterosexual exposure risks have been the most frequent motive for requests for the HIV tests.

The demand for HIV tests on the part of IDUs has decreased markedly. While that of persons of heterosexual risk practices, including women who practice prostitution has increased.

HIV diagnosis has decreased by a quarter part since 1991 to 2004 and the HIV infections attributed to sexual transmission have widely overtaken those related to the IDUs.

The HIV prevalence during the period 1991 -2004 has decreased in the majority of categories of exposure although in the past years the descending tendency is at a standstill.

As from 2002 a change in tendency has been detected with an increase in the number of diagnoses of infection and an oscillation in the prevalence of HIVA. The transcendence of this change of tendency will have to be evaluated over the coming years.

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PARTICIPANTS OF THE GROUP EPI-VIH Centro Sanitario Sandoval, IMSALUD, Madrid Jorge del Romero Guerrero Carmen Rodríguez Martín. Juan Ballesteros Martín Petunia Clavo Escribano Soledad García Pérez Sonsoles del Corral del Campo Mª Angeles Neila Paredes Natividad Jerez Zamora Centro de ETS de Sevilla Isabel Pueyo Rodríguez María Antonia Mendo Gastalver Milagros Rubio Narváez Centro Dermatológico de Tenerife Eduardo García-Ramos Alonso Carlos de Armas González Jesús Rodríguez-Franco Castro Mª Adelaida Gutiérrez León Lourdes Capote Pestano Luis Haro Domingo Núñez Gallo Unidad de ETS de Gijón José Antonio Varela Uría Carmen López Sánchez Centro de ETS de Granada José Manuel Ureña Escribano Juan Bautista Egea Martínez Carmen Gracia Sánchez-Román Esperanza Castro López Ana María Calzas Urrutia Manuel Lorente Programa de Prevención del SIDA y ETS, Ayuntamiento de Madrid Francisco Javier Bru Gorraiz Concepción Colomo Gómez Raquel Martín Pozas Alicia Comunión Artieda

Centro de ETS "Costa del Sol" de Málaga Mª Victoria Aguanell Marfil Francisco Montiel Alcántara Antonio Manuel Burgos del Pino Unidad de Prevención y Educación Sanitaria sobre SIDA de Murcia José Joaquín Gutiérrez García Josefa Ballester Blasco Francisco Pérez Riquelme Juan Ramón Ordoñana Martín Unidad ETS-SIDA. Centro de Salud Área II. Cartagena Jordi Balaguer Josefa Durán Iniesta Dirección Territorial de Álava Luís Mª Sáez de Vicuña Jesús Ortueta CIPS de Valencia J. Ignacio Alastrué Loscos Concha Santos Rubio Teresa Tasa Zapater Universidad de Albacete Mª José Belza Egozcue Instituto de Salud Pública de Navarra Jesús Castilla Centro Nacional de Epidemiología (Instituto de Salud Carlos III) y Secretaría del Plan Nacional sobre Sida Isabel Noguer Alicia Barrasa Mª Paz Sobrino

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