HIV AND AIDS IN SPAIN, 2001

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HIV AND AIDS
              IN SPAIN, 2001

 MINISTERIO
DE SANIDAD
Y CONSUMO

                                SUBSECRETARÍA DE
                                SANIDAD Y CONSUMO

                   MINISTERIO   DIRECCIÓN GENERAL DE
                   DE SANIDAD   SALUD PÚBLICA Y CONSUMO
                   Y CONSUMO
                                SECRETARÍA DEL PLAN
                                NACIONAL SOBRE EL SIDA
HIV AND AIDS
I N S PA I N , 2 0 0 1
Edited and distribuyed by:
© MINISTERIO DE SANIDAD Y CONSUMO
   CENTRO DE PUBLICACIONES
   Paseo del Prado, 18. 28014 Madrid
NIPO: 351-02-027-7
Depósito Legal: M-24045-2002
Printed:
Rumagraf, S.A.
Avda. Pedro Díez, 25. 28019 Madrid
Printed in Spain

O.T. 31484
HIV AND AIDS IN SPAIN, 2001      3

BACKGROUND

Spain is a country in southern Europe with a population of about 40 million inhabitants. In the
1990s, it was the European country most heavily affected by the HIV/AIDS epidemic, but this
situation has changed in recent years, as great progress has been made in controlling HIV
transmission, and AIDS incidence and mortality rates have been substantially reduced. The
epidemiological situation of HIV infection and AIDS in Spain at the start of the 21st century is the
result of a process of over 20 years, which can be briefly summarized in three major events:1

The rapid spread of HIV during the 1980s.

During this decade HIV infection spread widely among a large number of injecting drug users
(IDUs)2,3 in Spain, making this mechanism of transmission responsible for more than two-thirds
of cases. HIV also spread among homosexual men, although much less abruptly.4,5 The high
number of HIV-infected IDUs, most of them sexually active young adults, led to secondary
transmission of HIV by the heterosexual and perinatal route. At the start of the 1990s, more
than 100,000 HIV infections had already occurred,6 and AIDS-related mortality ranked first
among the major causes of potential years of life lost in Spain.8

The progressive control of HIV transmission since the beginning of the 1990s.

The seriousness of the situation alerted society. New prevention programs were started and
existing programs intensified, which helped to reduce risk practices. The number of young
people in the next generations started intravenous drug use gradually decreased,9 resulting in a
gradual aging of the IDU group. Added to this was a trend to replace the intravenous route of
drug use by the inhaled or smoked route.9,10 These trends led to a marked reduction in the rate
of occurrence of new HIV infections, as has been shown by serial studies of HIV seroprevalence
in IDUs,11-12 homosexual men3,5 and women who engage in sex work.13-14

The spread of highly active antiretroviral therapies since 1997.

By the mid-nineties, the highest point in the epidemic in terms of morbidity and mortality was
reached, with more than 7,000 new AIDS diagnoses and more than 5,000 deaths annually.3 Since
highly active antiretroviral therapies were introduced at the end of 1996, there has been a
considerable improvement in the immune status and prognosis of HIV-infected persons.15 This
resulted in a rapid reduction in AIDS incidence of over 60% in the next four years, and a decline
in mortality of 67% in just two years.3
4   HIV AND AIDS IN SPAIN, 2001

    STATUS OF THE EPIDEMIC IN SPAIN AT THE BEGINNING
    OF THE 21ST CENTURY

    • HIV TRANSMISSION                                                    Figure 1. Time trend of HIV diagnosis in several
                                                                                      European countries.
    General trend

                                                Diagnosis of HIV-infection per million
                                                                                         250                                            Spain*
    The various sources of information                                                          Belgium
                                                                                                Germany
    available agree in pointing out a steady            200                                     Ireland
    decline in HIV transmission rates

                                                             inhabitants
                                                                                                Switzerland
    in Spain over recent years.4-5,11-14                150                                     United Kingdom

    However, the number of new HIV
                                                        100
    diagnoses is still high, and the
    possibility of new increases in                       50
    transmission rates cannot be ruled
    out.16 In autonomous communities in                    0
    which epidemiological data on newly                     1994 1995 1996  1997     1998 1999    2000 2001
    diagnosed cases of HIV infection is                                          Year
    available, a reduction of over 70% has       *Three regions.

    been noted since the early 1990s.17
    In spite of this large decrease, an overall total of 60 new HIV infections per million inhabitants were
    diagnosed in these communities in 2001, a figure that is still very high in comparison with other
    European countries (Figure 1).7

    The risk of HIV infection is                                           Figure 2. New diagnosis of HIV-infection, according
    distributed very heterogeneously in                                    to transmission category in three Spanish regions.
    the population. In Spain, the
    situations associated with the                                                       800
    highest risk of infection are, in order                                              700
                                                                                                                                  Injecting drug users
                                                Number of HIV diagnosis

    of importance, parenteral drug use,                                                  600
                                                                                                                                  Sexual transmission
    homosexual practices between men                                                     500
    and heterosexual contact with an                                                     400
    infected partner. In spite of this,                                                  300
    risky sexual relations have been the
                                                                                         200
    leading cause of new infections in
                                                                                         100
    recent years, which is explained by
    the fact that it is the most                                                           0
                                                                                            1986   1988   1990   1992     1994   1996   1998      2000
    widespread exposure to risk in the
                                                                                                                        Year
    population (Figure 2).18
HIV AND AIDS IN SPAIN, 2001     5

Injecting drug users

Large changes have occurred in this group over the years, which have led to a rapid and marked
reduction in the number of new HIV infections.9,11-12 Of these, the most important change has
been a steady decline in the number of youths starting intravenous drug use and, consequently, in
the risk of infection by this route.19-20 In parallel to this, some former IDUs, mostly heroin users,
                                                                  have stopped consuming and many
                                                                  others have switched either partly
  Figure 3. Main route of drug administration among
                                                                  or totally from the injected to the
   persons first time attended for heroine or cocaine
                                                                  inhaled route (Figure 3).21 This
                        dependence.
                                                                  process      has     not    occurred
                                                                  simultaneously or with the same
     80        Injected    Smoked/inhaled     Sniffed
                                                                  intensity throughout Spain.10,21 The
     70
                                                                  risk of HIV infection continues to be
     60
                                                                  very high among persons who inject
Percentage

     50
                                                                  drugs, although various studies have
     40
                                                                  found moderate reductions in
     30
                                                                  prevalence       (Figure    4), 10-12,22
     20
                                                                  probably contributed to by the
     10
                                                                  spread of methadone maintenance
      0
                                                                  and needle exchange programs.9,23
                      1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

Elaborated from Treatment indicator of the Spanish Observatory on Drugs. DGPNSD.
                                                                                                          Men who have sex with men

           Figure 4.           HIV infection among injecting drug users                                   European statistics on AIDS cases
                               who were voluntarily tested.                                               show that Spain is one of the
                                                                                                          countries with the highest rates in
                 45                 Prevalence (%)           Nº of HIV+            350                    homo/bisexual         men.7      HIV
                      38,4
                 40
                                                                                   300                    seroprevalence in homo/bisexual
                             33,1
                 35                                                30,7                                   men declined in the first half of the
                                                                                   250
                                                                                         Number of HIV+

                                    28,9 27,9 28,2
Prevalence (%)

                 30                                                                                       1990s, but subsequently has
                                                      23,9    25
                 25                                                       22,2     200
                                                                                                          remained stable at around 10%
                 20                                                                150                    (Figure 5).4-5,24 In other European
                 15                                                                                       countries, there have been recent
                                                                                   100
                 10                                                                                       reports of increases in risk
                 5                                                                 50
                                                                                                          practices,25 incidence rates of
                 0                                                                 0
                                                                                                          sexually transmitted diseases,26 and
                      1992 1993 1994 1995 1996 1997 1998 1999 2000
                                                                                                          the incidence of HIV in homosexual
                                               Year
The EPI-VIH Study.                                                                                        men.27 This new trend may also be
6   HIV AND AIDS IN SPAIN, 2001

    occurring in Spain, as reflected by a              Figure 5. HIV infection among homo/bisexual men
    recent study in Madrid, which found                               voluntarily tested.
    an upward trend in HIV transmission
    since 1997 in a cohort of men with                        25                  Prevalence (%)           Nº of HIV+          250
    homosexual practices.16                                        19,6
                                                              20                                                               200

                                                                                                                                     Number of HIV+
    Recent studies have found that men                                    15,6

                                             Prevalence (%)
                                                              15                        13                                     150
    who have sex with men, male sex                                              11,1
                                                                                              10    10,3          10,4
    workers and transvestites are                             10                                            8,8          8,3   100
    groups especially susceptible to HIV;
    furthermore, it is worth noting that                      5                                                                50
    nearly half of the men in these
    groups are of Latin American                              0                                                                0
    origin.28-30                                                   1992 1993 1994 1995 1996 1997 1998 1999 2000
                                                                                             Year
                                            The EPI-VIH Study.

    Heterosexual transmission of HIV

    HIV transmission through heterosexual contacts has remained an endemic phenomenon in Spain,
    without appreciable changes. However, the level of endemicity has been relatively high compared
    to other European countries, as is revealed by comparison of the AIDS rates in this transmission
    category.7

    The marked decrease in other mechanisms of HIV transmission in Spain has caused heterosexual
    transmission to become the leading cause of infections in recent years, although this does not
    imply an increase in the number of infections by this route.

    The heterosexual population is very heterogeneous in terms of the risk of HIV infection. The
    data that probably best summarize this situation are those for seroprevalence in women
    delivering a liveborn child, which ranges from 1 to 3 per 1000, although there are differences
    between autonomous communities.24,31 Among persons who only have heterosexual exposure,
    the highest risk of HIV infection is found in those with an infected sexual partner, most of which
    are IDUs or ex-IDUs. Over the years, this group has shown infection prevalence rates of over
    5%, with no clear signs of a decrease (Figure 6).32

    In women engaging in sex work, HIV seroprevalence has fallen below 2% (Figure 7), and
    intravenous drug use has become an uncommon practice.13,14,32 A massive influx of immigrant
    women from Latin America, sub-Saharan Africa and Eastern Europe has occurred in recent
    years in this group; however, an increase in levels of infection has not been observed to
    date.28,32
HIV AND AIDS IN SPAIN, 2001     7

                       Figure 6. HIV seroprevalence among persons                          New diagnoses of HIV infection
                           with HIV infected heterosexual partner.                         reflect moderate decreases in the
                                                                                           number      of    infections    from
                       14
                                                               12,4
                                                                                           heterosexual transmission,17 which
                       12          10,6          10,6
                                                                                           agrees with the lower frequency of
                                                                      10,5   10,3
                                          9,9                                              sexual risk behaviors in the Spanish
                       10                               9,3
      Prevalence (%)

                            8,5
                        8
                                                                                    7,9    population compared to other
                                                                                           countries,33 and the continuous
                        6
                                                                                           decrease in the incidence of sexually
                        4
                                                                                           transmitted diseases during the
                        2
                                                                                           1990s.34
                        0
                            1992   1993   1994   1995   1996   1997   1998   1999   2000
                                                        Year
                                                                                           Mother-to-child transmission
       The EPI-VIH Study.
                                                                              Spain was the European country
                                                                              with the highest incidence of AIDS
                                                                              through mother-to-child transmis-
   Figure 7. HIV seroprevalence among female sex                              sion.7 The high effectiveness of
                      workers voluntarily tested.                             antiretroviral therapy in reducing
     10
                                                                              the rate of mother-to-child HIV
          8,4                                    TOTAL                        transmission led to it being
      8                                          Non  injecting drug users    proposed as a goal to virtually
                                                                              eliminate infections transmitted by
 Prevalence (%)

      6                                                                       this mechanism, for which early
                    5
                          4                                                   diagnosis of infection in all pregnant
      4
              2,5               2,4
                                      2,8                                     women is a prerequisite. In recent
      2               1,4   1,3           1,3
                                                      1,8
                                                          1,3 1,3
                                                                              years, between 500 to 1000 HIV-
                                    1                             0,9 0,8 0,7
                                              0,6 0,3                         infected women have delivered a
      0                                                                       liveborn child in Spain but, thanks to
           1992 1993 1994 1995 1996 1997 1998 1999 2000                       new treatments, it is estimated that
                                       Year
                                                                              the number of children born with
 The EPI-VIH Study.                                                           HIV infection is well below 40.31 The
                                                                              number of HIV infections and AIDS
cases in children of infected mothers has been markedly reduced (Figure 8),3 but still shows that
there is a long way to go for complete control of this mechanism of transmission.
8   HIV AND AIDS IN SPAIN, 2001

    HIV infection and immigrants                                                          Figure 8. Mother-to-child transmitted AIDS
                                                                                                      cases in Spain.
    Of the AIDS cases diagnosed in
    Spain up to 2001, less than 3%                                           AZT recomendation to
                                                                          HIV-infected pregnant women
    were persons from other countries             100
    of origin, which reflects the fact

                                                                      No. of new AIDS cases
                                                   80
    that AIDS epidemic has mainly                                                        Proteasa inhibitors
    affected the national population.3 In          60
    recent years, progressive control
                                                   40
    of HIV transmission in the Spanish
    population, together with a                    20
    growing influx of immigrants to                 0
    Spain, has caused this characteristic           1985 1987 1989 1991 1993 1995 1997 1999 2001
    of the HIV epidemic to be                                             Year
    reversed. The fact that some
    immigrants come from countries
    where HIV/AIDS is highly endemic may have some impact, but it is likely that adverse social
    conditions, leading to situations of greater vulnerability to HIV infection, such as prostitution
    or drug use, and greater difficulty to access prevention measures and health services, play a
    more important role.35-36

    As was previously described for other countries in Europe, the growing importance of immigrant
    populations in the HIV epidemic has also started to become evident in Spain. In all autonomous
    communities that have data on newly diagnosed AIDS cases, over 20% of the persons diagnosed
    with HIV infection in 2001 were
    immigrants, a percentage which has
                                             Figure 9. Number and percentage of AIDS cases in
    doubled in just two years. 37
                                                Spain in persons from other countries of origin.
    Nevertheless, HIV prevalence rates
    in immigrants who underwent                        Number of AIDS cases Percentage of all AIDS cases 10
                                               150
    voluntary testing have not been
    higher than those found in a Spanish                                                                 8                             Percentage of all cases
                                               Number of AIDS cases

    population of similar characteristics,     100
    except in women from sub-Saharan                                                                     6
    Africa and men from Latin                                                                            4
    America.28                                  50
                                                                                                                                   2
    This new trend has begun to have                                                          0                                    0
    impact on the number of AIDS cases
                                                                                                 89
                                                                                                 90
                                                                                                 91
                                                                                                 92
                                                                                                 93
                                                                                                 94
                                                                                                 95
                                                                                                96
                                                                                                97
                                                                                                98
                                                                                                99
                                                                                                00
                                                                                                01
                                                                                              19
                                                                                              19
                                                                                              19
                                                                                              19
                                                                                              19
                                                                                              19
                                                                                              19
                                                                                              19
                                                                                              19
                                                                                              19
                                                                                              19
                                                                                              20
                                                                                              20

    (Figure 9), in which there is an
    increasing proportion of persons                                                                          Year
HIV AND AIDS IN SPAIN, 2001     9

with a country of origin other than Spain, mainly Africa, Latin America and Portugal.3 Diagnosis
of HIV infection and AIDS in persons from other countries does not mean that they were
already infected when they arrived; as at least a third of immigrants diagnosed with AIDS in
Barcelona may have acquired the infection in Spain.38

• NUMBER AND CHARACTERISTICS OF PERSONS LIVING
  WITH HIV INFECTION

The key feature of the current situation of the epidemic in Spain is the existence of a high
number of persons living with HIV infection (Table 1). Advances in antiretroviral therapy have
improved survival considerably, but have been unable to achieve a cure, making HIV infection a
chronic disease. New therapies have improved the quality of life of HIV-infected persons,
although, once started, treatment must be maintained on an indefinite basis.

HIV prevalence in the general population is approximately 3 infections per one thousand
inhabitants, increasing to 6 per thousand in the 20 to 39 years age group.6,39 In line with the
general pattern of the epidemic, seroprevalence in men is three times higher than in women. In
mothers of newborns, i.e., in sexually active women of childbearing age, seroprevalence rates
range from 1 to 3 per thousand in most autonomous communities.24,31

                   Table 1. End-2001 estimates of the HIV/AIDS epidemic in Spain.

 Persons living with HIV infection                                            110,000 – 150,000
 Prevalence of HIV infection (rate per 1000 inhabitants)                                2.7 – 3.8
 Probable mechanism of infection in persons living with HIV
    Injecting drug users                                                              50% - 60%
    Men with homosexual practices                                                     15% - 25%
    Heterosexual risk                                                                 20% - 30%
 Characteristics of persons living with HIV
    Men                                                                               75% - 80%
    Women                                                                             20% - 24%
    Children (under 13 years)                                                              < 1%
 Persons developing AIDS since the start of the epidemic*                       65,000 – 75,000
 New AIDS diagnoses in 2001*                                                        2,500 – 3,000
 AIDS incidence rate in 2001 (per 100,000 inhabitants)*                                 6.3 – 7.5
 HIV/AIDS deaths since the start of the epidemic*                               40,000 – 50,000
 Persons living with HIV-hepatitis C coinfection                                60,000 – 80,000

* Estimates take into account underreporting.
10   HIV AND AIDS IN SPAIN, 2001

     Based on this seroprevalence data,       Figure 10.                 Estimated time trends of HIV epidemic in
     there are an estimated 110,000-                                               Spain.
     150,000 persons living with HIV
     infection in Spain, although probably                     140000   Persons newly infected with HIV
     more than a quarter of them have                                   HIV related deaths
                                                               120000   Persons living with AIDS
     not yet been diagnosed (Figure 10).
                                                               100000

                                              No. of persons
     In recent years, the population of
     persons living with HIV infection has                     80000
     remained relatively stable, since                         60000
     both the number of new infections                         40000
     and the number of deaths in infected
                                                               20000
     persons have fallen to low levels.40
                                                                   0
                                                                   1982 1984 1986 1988 1990 1992 1994 1996 1998 2000
     The epidemiological characteristics
     of these persons depend less on                                         Year

     new infections than on those that
     have accumulated over the course of the epidemic. These characteristics can be approximated
     by studying the number of AIDS cases diagnosed in recent years3 or the number of patients with
     HIV infection reported in hospital surveys, as both figures arise directly from the population of
     persons living with HIV infection. Based on either of these sources, we can estimate that a little
     more than half (50-60%) of HIV-infected living persons acquired the infection by sharing
     parenteral drug injection equipment, 20-30% from unprotected heterosexual practices and 15-
     25% are men who became infected through unprotected homosexual practices. The proportion
     of men to women is approximately 4:1, and the average age of these persons is from 35 to 40
     years, with a progressive trend toward aging.

     The high frequency of intravenous drug use among persons living with HIV in Spain explains why
     more than half of them are also infected by hepatitis C virus.

     • REDUCTION OF HIV/AIDS MORBIDITY AND MORTALITY

     Most persons with HIV infection will tend to progress to AIDS if the natural course of the
     disease is allowed to go unchecked, resulting in high levels of morbidity and mortality from AIDS.
     Highly active antiretroviral therapies have changed this situation, dramatically improving the
     prognosis for infected persons.41 Following their introduction in 1997, they caused very sharp
     decreases in the incidence of AIDS and mortality (Figure 11). In recent years, these decreases
     have become less pronounced, which leads us to suspect that the ceiling for their effectiveness
     may have been reached.3 In 2001, the lowest AIDS rates in the last ten years were recorded in
     Spain (5.8 new AIDS cases per 100,000 inhabitants), but despite this significant advance, they
HIV AND AIDS IN SPAIN, 2001    11

                    Figure 11. Time trend in AIDS incidence and                                         were still high compared to other
                                mortality in Spain.                                                     European countries, making Spain
                                                                                                        the second ranking country in the
                                                    Expanded AIDS case definition                       AIDS incidence rate, only surpassed
                    8000                                                        Highly active           by Portugal.7
                                 New AIDS cases                            antiretroviral therapy
                                 AIDS deaths
                                                           Antiretroviral therapies currently
Number of persons

                    6000
                                                           play a fundamental role in continuing
     4000                                                  to reduce morbidity and mortality
                                                           from HIV/AIDS and in preventing
     2000                                                  AIDS incidence and mortality from
                                                           recovering past levels, since the
        0                                                  number of HIV-infected living
         1985 1987 1989 1991 1993 1995 1997 1999 2001      persons is still very high. The main
                              Year                         factors hindering greater impact of
                                                           antiretroviral therapies are: late
diagnosis of AIDS leading to delays in the start of treatment,42 lack of patient compliance with
treatment, the emergence of resistance to antiretroviral drugs and adverse reactions requiring
prescribed treatments to be withdrawn or changed.

Delayed diagnosis of HIV infection has been shown to be an important factor in reducing the
impact of antiretroviral therapies,42,43 and probably of preventive measures as well.44 Its
importance is illustrated by the fact that of all persons diagnosed with AIDS since 1998, over
a third did not know they were infected by HIV, and this proportion exceeds 50% in AIDS
                                                             cases due to sexual transmission
                                                             (Figure 12).
       Figure 12. AIDS cases unaware of their HIV
           infection up to AIDS diagnosis, 1998-2001.        Improved life expectancy in HIV-
                                                             infected persons is providing the
  Heterosexual
                                                             opportunity for other late-
                                 59
     category                                                developing health problems to
                                                             appear. The most notable case of
 Homo/bisexual
      men                      56,3                          this is infection by hepatitis C virus,
                                                             the high frequency of which in HIV-
  Injecting drug                                             infected persons is leading to an
       users        17,3
                                                             increasing incidence of chronic liver
                                                             disease and cirrhosis.
                     TOTAL                35,6

                             0      10         20      30        40       50        60         70
                                                                                                    %
12   HIV AND AIDS IN SPAIN, 2001

     KEY FACTORS IN THE FUTURE OF THE EPIDEMIC

     The HIV/AIDS epidemic is Spain is showing a favorable course and appears headed toward
     progressive control of the epidemic. However, there are various factors that could mark the
     course of the epidemic in the near future.

     – The risk of HIV infection in the population through known transmission mechanisms persists.
       A relaxation in healthy behaviors could cause new upturns in the epidemic at any time.

     – Some HIV transmission categories, such as men with homosexual practices and persons with
       HIV-infected partners, continue to have a less favorable course and have even shown recent
       increases.

     – The existence of a considerable proportion of HIV-infected persons who have not been
       diagnosed has various implications for the course of the epidemic. They may play a significant
       role in HIV transmission and also do not benefit from antiretroviral therapies, with the
       consequent adverse effects on AIDS incidence and mortality.

     – Treatment of HIV infection is continually evolving and changes may occur which differ in their
       impact on the epidemic, such as the spread of resistant viral strains or the introduction of
       new drugs that improve on and complement previous existing drugs.

     – The demographic and social changes that are occurring in Spain as a result of immigration
       introduce new elements to be taken into account for prevention and control of the epidemic.

     – The principal element of uncertainty about the epidemic comes from the global environment,
       where HIV is very widespread and continues to progress.45 Geographical barriers do not
       prevent the spread of HIV, so while an effective vaccine remains unavailable, control of the
       epidemic will only be possible through close international cooperation.
HIV AND AIDS IN SPAIN, 2001   13

HIV AND AIDS IN SPAIN, 2001 – KEY POINTS.

HIV transmission
• HIV transmission is much lower than it was in the past, but is still high.
• The number of new infections through sexual transmission has decreased less and
  currently surpasses parenteral transmission.
• Injecting drug use, homosexual relations between men and having an infected sexual
  partner are, in order of importance, the situations associated with the highest risk of
  infection.
• Promotion of HIV testing in pregnant women helps to reduce infection through vertical
  transmission.

People living with HIV infection
• In spite of new treatments, there is still no cure for HIV infection.
• There are approximately 120,000 infected persons, a figure that has remained relatively
  stable in recent years.
• Over half of these persons acquired the infection through injecting drug use, and most have
  hepatitis C virus coinfection.

Reduction of morbidity and mortality
• AIDS incidence and mortality decreased markedly following the introduction of highly
  active antiretroviral therapies.
• This trend has recently slowed even though the incidence of AIDS is still high.
• Persons who do not know they are infected cannot benefit from treatment, which is why
  early diagnosis of infection is so important.
• AIDS is still a significant cause of mortality in young adults in Spain.

Principal uncertainties in the near future
• Difficulties in maintaining protective behaviors over the long term.
• Advances and possible problems modifying the effectiveness of antiretroviral therapy.
• Influence of migratory movements of the population on HIV infection in Spain.
14   HIV AND AIDS IN SPAIN, 2001

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      1. Castilla J, Bolea A, Suárez M, de la Fuente L. Spain. In McElrath K. HIV and AIDS: A World View.
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      2. Fernández Sierra MA, Gómez Olmedo M, Delgado Rodríguez M, et al. Infección por el virus de la
         inmunodeficiencia humana en la población española (II). Metaanálisis de las tendencias temporales y
         geográficas. Med Clin (Barc) 1990;95:366-71.
      3. Centro Nacional de Epidemiología. Vigilancia Epidemiológica del Sida en España. Situación a 31 de
         diciembre de 2001. Bol Epidemiol Semanal 2001; 10: 1-4.
      4. Del Romero J, Castilla J, García S, et al. Evolución de la prevalencia de infección por el virus de la
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         Clin (Barc) 1997;110:209-12.
      5. Centre d’Estudis Epidemiològics sobre la Sida de Catalunya. Monitoratge de la prevalença i del nivell
         de prevenció de la infecció per l’HIV en la comunitat d´homes homosexual i en usaris de drogues per
         via parenteral. Document tecnic nº 11. Barcelona: Departament de Sanitat i Seguretat Social, 2000.
      6. Downs AM, Heisterkamp SH, Brunet JB, Hamers FF. Reconstruction and prediction of the HIV/AIDS
         epidemic among adults in European Union and low prevalence countries of central and eastern
         Europe. AIDS 1997;11:649-662.
      7. European Centre for the Epidemiological Monitoring of AIDS. HIV/AIDS surveillance in Europe. End-
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      8. Castilla J, Martínez de Aragón MV, Gutiérrez A, Llácer A, Belza MJ, Ruiz C et al. Impact of HIV
         mortality among young men and women in Spain. Int J Epidemiol 1997;26:1346-51.
      9. Plan Nacional sobre Drogas. Memoria 2000. Madrid: Delegación del Gobierno para el Plan Nacional
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     10. De la Fuente L, Bravo MJ, Lew C, et al. Prevalencia de infección por el virus de la inmunodeficiencia
         humana y de conductas de riesgo entre consumidores de heroína en Barcelona, Madrid y Sevilla: un
         ejemplo de centrar los estudios en consumidores y no sólo en usuarios por vía intravenosa. Med Clin
         (Barc) 1999;113:646-51.
     11. Hernández-Aguado I, Aviñó MJ, Pérez-Hoyos S, et al. Human immunodeficiency virus (HIV) infection
         in parenteral drug users: evolution of epidemic over 10 years. Int J Epidemiol 1999;28:335-340.
     12. Sopelana P, Carrascosa C, García-Benito P. Evolución de la prevalencia de la infección por el VIH-1 en
         los drogodependientes de la Comunidad de Madrid (1985-1996). Med Clin (Barc) 1998;111:257-8.
     13. Ballesteros J, Clavo P, Castilla J, et al. Low seroincidence and decrease in seroprevalence among
         female prostitutes in Madrid [letter]. AIDS 1999; 13:1143-4.
     14. Vioque J, Hernández-Aguado I, Fernández García E, et al. Prospective cohort study of female sex
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HIV AND AIDS IN SPAIN, 2001         15

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HIV AND AIDS
              IN SPAIN, 2001

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