**4.5.2 Alcohol and drug use**

As the alcohol and recreational drug use seems to be connected to an increase in unprotected sexual practices, the use of alcohol and drug before or during sex was included in the questionnaire.

With regard to alcohol use is concerned (Fig. 13), a significant percentage of respondents in the overall sample stated that they had used alcohol before or during sex in the last 6 months. The percentage of subjects reach 82.9% in Bratislava, 54.2% in Verona, 85.0% in Prague, 66.0% in Barcelona, 64.3% in Bucharest, while the level is of 72.3% in Ljubljana. With regards to the alcohol use before or during their last sexual encounter, percentages are lower compared with the last 6 months. The levels of alcohol use are in this case high in Prague (56.0%), Bucharest (46.3%), Bratislava (45.2%), Barcelona (43.0%), while rates lower than 40% were found only in Ljubljana and Verona (32.2% and 23.2% respectively).

With regard to drug use (see Fig. 14), drug use before or during sex in the last 6 months seems to be widely present in the sample. In Ljubljana the percentage reaches 58.8%, in Barcelona 57.1%, in Prague 52.7%. Low percentages are reported in Bucharest (33.2%), Verona (34.3%) and Bratislava (44.5%). Here again the proportion of people using drugs during sex was significantly higher among HIV positive (68.5%) than negative (44.9%) people (P<0.001).

The SIALON Project: Report on HIV Prevalence

reliable information on epidemic patterns.

events and creating a list of all possible time-space units.

from the target population.

among MSM of over 25.

Treponema seroprevalence and HIV infection.

and Risk Behaviour Among MSM in Six European Cities 225

with the scientific literature, it increases the possibility of involving a variety of participants

In implementing this method, the formative research is a crucial step of the process. The initial identification and selection of all gay venues (bars, discos, saunas, cruising venues, sex-shops, sex-clubs, special events) is a key factor for including all possible places and

Moreover, it should be pointed out that in this project different ways of recruiting MSM, such as internet, chat rooms and so on, were excluded. In actual fact, these virtual settings seem to play a very important role in the process of socialising and finding potential sexual partners among MSM. Nevertheless, the selection of "real" gay venues allowed to collect both behavioural data (questionnaire) and biological data (oral fluid sample). In this way, it was possible to triangulate behavioural data, risk factors, and HIV prevalence and to obtain

With regard to oral fluid sample collection, this procedure has clear advantages in terms of simplifying both the data collection and the diagnostic processes in community settings, compared to venopuncture. Oral fluid testing proved to be an ideal tool for surveillance and epidemiological purposes in outreach settings among high-risk and hard to reach populations, namely MSM. The acceptability of this biological data collection procedure in

Furthermore, the SIALON project methodology included several epidemiological approaches: first of all, the Second Generation Surveillance System philosophy, which strongly suggests the combination of both behavioural and biological data and the regular replication of surveillance survey. Secondly, the implementation of UNGASS indicators, which proved to be very useful in focusing on specific topics such as access to prevention (testing and prevention programmes), high risk behaviours and HIV prevalence. Indicators related to HIV testing, prevention programs, condom use, and understanding of how to protect against HIV infection, revealed how many MSM are unaware of their HIV status and

This very approach seems to be a crucial activity in order to develop, pilot and validate

In terms of the data collected, the highest rates of HIV seroprevalence were found in Southern European cities, namely Barcelona and Verona. This could be partly attributed to the older samples and therefore to longer exposure to risk, since HIV prevalence was higher

The highest rates of syphilis prevalence were also found in Barcelona and Verona. In general, data confirms that a correlation exists between STI, previous syphilis, IgG anti-

Alarming findings included undiagnosed HIV infections. Over half the respondents were unaware of their HIV positive status. This proportion was slightly lower only in Barcelona, but very high (nearly 80%) in Ljubljana and Bucharest. Moreover, nearly one third of MSM found to be HIV-positive through oral fluid samples reported a negative HIV test result over the last 12 months, so the undiagnosed infections were recent. This figure was highest in

gay settings is proven by the number of samples collected in all sites confirmed.

fail to practice behaviour that could protect them from infection.

Bucharest (over 50%) and lowest in Bratislava (less than 20%).

multi-faceted epidemiological approaches in monitoring HIV epidemic.

Fig. 13. Alcohol use before or while having sex in the last six months and in the last sexual intercourse

Fig. 14. Drug use before or while having sex in the last six months

#### **5. Conclusions**

In terms of the methodology, the use of TLS as a sampling method proved to be efficient and easily applicable especially in cities where gay scenes are highly developed and, in line

Fig. 13. Alcohol use before or while having sex in the last six months and in the last sexual

85.0 56.0 82.9 45.2 66.0 43.0 46.3 64.3 72.3 32.2 54.2 23.2 <sup>0</sup>

Prague Bratislava Barcelona Bucharest Ljubljana Verona

alcohol last 6 months alcohol last time

52.7 44.5 57.1 33.2 58.8 34.3

Prague Bratislava Barcelona Bucharest Ljubljana Verona Country

In terms of the methodology, the use of TLS as a sampling method proved to be efficient and easily applicable especially in cities where gay scenes are highly developed and, in line

intercourse

%

Fig. 14. Drug use before or while having sex in the last six months

%

**5. Conclusions** 

with the scientific literature, it increases the possibility of involving a variety of participants from the target population.

In implementing this method, the formative research is a crucial step of the process. The initial identification and selection of all gay venues (bars, discos, saunas, cruising venues, sex-shops, sex-clubs, special events) is a key factor for including all possible places and events and creating a list of all possible time-space units.

Moreover, it should be pointed out that in this project different ways of recruiting MSM, such as internet, chat rooms and so on, were excluded. In actual fact, these virtual settings seem to play a very important role in the process of socialising and finding potential sexual partners among MSM. Nevertheless, the selection of "real" gay venues allowed to collect both behavioural data (questionnaire) and biological data (oral fluid sample). In this way, it was possible to triangulate behavioural data, risk factors, and HIV prevalence and to obtain reliable information on epidemic patterns.

With regard to oral fluid sample collection, this procedure has clear advantages in terms of simplifying both the data collection and the diagnostic processes in community settings, compared to venopuncture. Oral fluid testing proved to be an ideal tool for surveillance and epidemiological purposes in outreach settings among high-risk and hard to reach populations, namely MSM. The acceptability of this biological data collection procedure in gay settings is proven by the number of samples collected in all sites confirmed.

Furthermore, the SIALON project methodology included several epidemiological approaches: first of all, the Second Generation Surveillance System philosophy, which strongly suggests the combination of both behavioural and biological data and the regular replication of surveillance survey. Secondly, the implementation of UNGASS indicators, which proved to be very useful in focusing on specific topics such as access to prevention (testing and prevention programmes), high risk behaviours and HIV prevalence. Indicators related to HIV testing, prevention programs, condom use, and understanding of how to protect against HIV infection, revealed how many MSM are unaware of their HIV status and fail to practice behaviour that could protect them from infection.

This very approach seems to be a crucial activity in order to develop, pilot and validate multi-faceted epidemiological approaches in monitoring HIV epidemic.

In terms of the data collected, the highest rates of HIV seroprevalence were found in Southern European cities, namely Barcelona and Verona. This could be partly attributed to the older samples and therefore to longer exposure to risk, since HIV prevalence was higher among MSM of over 25.

The highest rates of syphilis prevalence were also found in Barcelona and Verona. In general, data confirms that a correlation exists between STI, previous syphilis, IgG anti-Treponema seroprevalence and HIV infection.

Alarming findings included undiagnosed HIV infections. Over half the respondents were unaware of their HIV positive status. This proportion was slightly lower only in Barcelona, but very high (nearly 80%) in Ljubljana and Bucharest. Moreover, nearly one third of MSM found to be HIV-positive through oral fluid samples reported a negative HIV test result over the last 12 months, so the undiagnosed infections were recent. This figure was highest in Bucharest (over 50%) and lowest in Bratislava (less than 20%).

The SIALON Project: Report on HIV Prevalence

**7. References** 

and Risk Behaviour Among MSM in Six European Cities 227

Integrata Verona) Monika Habekova (NRC HIV/AIDS Slovak Univeristy, Bratislava) Alex Horky (Czech Youth Queer Organisation) Jaroslav Jedlicka (NIPH, Prague) Kostantinos Kampourakis (Act-up Hellas, Athens) Igor Krampac (Regional Public Health Institute Maribor, Slovenia) Massimiliano Lanzafame (Azienda Ospedaliera Universitaria Integrata Verona, Infectious Diseases Unit) Emanuela Lattuada (Azienda Ospedaliera Universitaria Integrata Verona) Roberta Martini (International Health and Social Affairs, Veneto Region) Massimo Mirandola (Azienda Ospedaliera Universitaria Integrata Verona, Verona) Zeno Menegazzi (Arcigay Pianeta Urano, Verona) Silvana Menichelli (Regional Centre for Health Promotion, Verona) Gianmichele Moise (STD Centre, Gorizia) Sabrina Montante (Veneto Region) Rafael Muñoz Castro (STOP SIDA, Barcelona) Daniela Negri (Veneto Region) Georgios Nikolopoulos (HCDCP, Athens) Irina Nita (ACCEPT, Bucharest) Paolo Patanè (Arcigay, Italy) Daniela Pitigoi (Matei Bals Institute, Bucharest) Peter Porubsky (Czech Aids Help Society) Ivo Prochazka (Czech Aids Help Society, Prague) Alexandru Rafila (Matei Bals Institute, Bucharest) Dunia Ramarli (Azienda Ospedaliera Universitaria Integrata Verona, Department of Pathology, Section of Immunology) David Rivett (independent consultant specialising in Health Promotion and Education) Miran Solinc (SKUC Magnus, Ljubljana) Danica Staneková (NRC HIV/AIDS Slovak University, Bratislava) Dzamila Stehlikova (NIPH, Prague) Barbara Suligoi (ISS, Rome) Igor Toskin (Department of Reproductive Health & Research WHO, Geneva) Lev Zohrabyan (Regional Support Team, Europe and Central Asia UNAIDS, Moscow) Elisabetta Tonolli (Azienda Ospedaliera Universitaria Integrata Verona, Department of Pathology, Section of Microbiology) Ruggero Ughetti (Regional Centre for Health Promotion, Verona) (Hana Zakoucka (NIPH, Prague)

Alessandro Zan (Arcigay Veneto) Alin Robert Zoltan (ACCEPT, Bucharest)

19(4), 2005, pp. 294-301, ISSN 0213-9111, Spanish

Suppl. 1, 2007, pp. 39-47, ISSN 0033-3549

*guidelines*. UNAIDS-WHO, retrieved from:

http://www.unaids.org

Dodds, J.D.; Mercey, D.E.; Parry, J.V.; Johnson, A.M. (2004). Increasing risk behaviour and

Stockholm: European Centre for Disease Prevention and Control, 2010 Folch, C.; Casabona, J.; Munoz, R.; Zaragoza, K. (2005). [Trends in the prevalence of HIV

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Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization

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http://www.who.int/hiv/pub/surveillance/guidelines/en/index.html

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(WHO) (2009). *Monitoring the Declaration of Commitment on HIV/AIDS: guidelines on construction of core indicators: 2010 reporting*. Geneva: UNAIDS 2009, available from:

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The risk of HIV infection was assessed with a major focus on unprotected anal intercourse (UAI). Two respondents out of ten reported having had UAI with an occasional partner the last time they had sex, while four out of ten reported having had UAI in the last 6 months with this kind of partner or partners. The percentages of UAI with an occasional partner were highest in Bucharest, Prague and Bratislava both for the last sexual encounter and for encounters over the previous 6 months. In line with this finding, in these cities MSM reported less use of a condom for anal intercourse the last time they had anal sex. Young MSM exhibited the riskiest behaviour, as the highest rates of UAI with occasional partners, both last time and in the last 6 months, were found amongst young people under 25 years old. As expected, UAI with a steady partner was more frequent than with an occasional partner, in the overall sample and in all the cities.

Finally, the association between HIV risk and alcohol and drug use was confirmed. At least one third of respondents had used drugs before or during sex over the last six months and half the respondents had used alcohol. This proportion was above half in Ljubljana, Barcelona and Prague for drugs, and higher than 80% in Prague and Bratislava.

This data suggests the (i) the need for health promotion and prevention messages particularly focused on sexual behaviour and alcohol and drug use (ii) the need for prevention and information programmes for STIs given that the presence of an STIs increases the risk of HIV infection (iii) the need for policies and strategies promoting VCT among hard to reach populations such as MSM, especially young MSM.
