Swiss behavioural surveillance system 1986-2008

Background: Second generation surveillance is a central feature of HIV/AIDS policy in Switzerland. Behavioural surveys in the general population, men having sex with men (MSM) and injecting drug users (IDU) have been regularly conducted since the early nineties. After peaking at 2144 cases in 1991, the number of new HIV cases notified to the Ministry of Health decreased in each subpopulation until 2000 (n=578) and then rose again to 735 in 2006. The recent increase is mainly due to MSM. Methods: In the general population, representative cross-sectional telephone surveys have been conducted 11 times since 1987. Surveys in convenience samples of MSM, recruited through gay newspapers and gay organisations, have been conducted 5 times since 1992. Surveys among IDU's attending needle exchange programmes have been conducted 5 times since 1993. Condom statistics, available since 1986, are included in the behavioural surveillance system. Results: In the general population aged 17-30, systematic condom use with casual partners in the last six months increased from 8.0% in 1987 to 75.8% in 2007. The proportion of MSM reporting anal intercourse with casual partners in the last 12 months increased from 61% in 1992 to 79% in 2007 (lowest value 56% in 1994) and unprotected anal intercourse with these partners increased from 14 % in 1992 to 24% in 2007 (lowest value 9% in 1994). The proportion of IDUs reporting borrowing used injection equipment decreased from 16.5% in 1993 to 8.9% in 2006. The ratio condoms released to retail/population aged 15-65 increased from 1.68 in 1986 to 3.8 in 2006. Conclusions: It has been possible to maintain a coherent behavioural surveillance system on a long-term basis, allowing for the monitoring of HIV prevention policy outcome and forseeing the development and distribution of new HIV cases in the population.

Hypolipidemic therapeutics and muscle metabolism

Summary : Lipid metabolism disorders, leading to obesity and cardiovascular diseases, are a major public health issue worldwide. These diseases have been treated by drugs and surgery, leading to tremendous costs and secondary morbidity. The aim of this thesis work is to investigate the mechanisms of actions of a new, micronutrition-based, approach to prevent obesity and cardiovascular diseases. This specific combination of micronutrients, Lipistase, incorporated into any dietary ail can be used in the daily food. Micronutrients are substances used by the living organism in small quantities to maintain physiological homeostasis. However, the human body is not able to produce them and has to obtain them from dietary sources. The combination of micronutrients investigated here, is composed of 26 compounds including trace elements, vitamins, minerals, ails and plant extracts, known to have individually a beneficial effect on lipid metabolism regulation. These specific micronutrients are used for the first time in a combinatorial mode targeting several metabolic pathways for better homeostasis control as opposed to a single target treatment, either chemical or natural. Short and long term studies, in different mouse strains, showed a significant decrease in plasma triglycerides, body weight gain and body fat mass in animals that were fed with a standard diet containing Lipistase. Additionally, a greatly reduced fat accumulation was observed in adipose tissue and liver of Lipistase-treated animals, while lipid and glucose utilization by skeletal muscle was enhanced. Moreover, the size of atherosclerotic plaques was significantly reduced in mice whose masher was treated during pregnancy and suckling, without showing any adverse effect. Finally, Lipistase has been shown to increase longevity by 20%. The control mice that did not receive Lipistase in their diet did not show all these beneficial effects. These micronutrients are used at the lowest dosage ever reported for treating Lipid disorders, resulting in far much lower costs as well as probably a higher safety. This is the first approach being very suitable for an effective large scale prevention policy for obesity and cardiovascular diseases, like iodine in dietary salt has been for goiter. Résumé : Les dysrégulations du métabolisme des lipids, à l'origine d'obésité et de maladies cardiovasculaires, sont un problème de santé publique majeur et mondial. Ces maladies impliquent des traitements médicamenteux et chirurgicaux dont le coût la morbidité secondaire sont très important. Le but de ce travail de thèse est d'étudier les mécanismes d'action d'une nouvelle approche préventive, basée sur la micronutrition. Cette combinaison spécifique de micronutriments, Lipistase, peut être incorporée dans n'importe quelle huile alimentaire et utilisée dans l'alimentation quotidienne. Les micronutrirnents sont des substances essentielles, à très faibles doses, pour le maintien de l'homéostasie physiologique des organismes vivants. Cependant, étant incapable de les synthétiser, le corps humain est dépendant en cela de l'apport alimentaire. La combinaison de micronutriments que nous avons étudié contient 26 composants, incluant des extraits de plantes, des huiles, des vitamines, des métaux et des minéraux, tous connus pour avoir individuellement des effets bénéfiques sur la régulation du métabolisme des lipides. Ces micronutriments spécifiques sont utilisés pour la première fois en mode combinatoire, ciblant ainsi plusieurs voies métaboliques pour un meilleur control de l'homéostasie, par opposition monothérapies chimiques ou naturelles. Des expériences de court et long terme, avec divers modèles de souris, ont montré une diminution significative des taux de triglycérides plasmatiques, de la prise de poids et de la masse graisseuse corporelle chez les animaux qui ont reçu Lipistase dans la nourriture standard. Une accumulation significativement moins importante des graisses a été observée dans le tissu adipeux et hépatique des souris traitées, alors que l'utilisation des lipides et glucose a été favorisée dans le muscle. En outre, la taille des plaques d'athérosclérose aété significativement réduite chez les souris dont la mère a été traitée pendant la grossesse et l'allaitement, sans montrer aucun effet indésirable. Enfin, les souris traitées par Lipistase ont vécu 20% plus longtèmps. Les souris contrôles qui n'ont pas reçu Lipistase dans la nourriture n'ont montré aucun de ces effets bénéfiques. Ces micronutriments sont utilisés au dosage le plus faible jamais rapporté pour le traitement des maladies du métabolisme lipidique, permettant ainsi un coût plus faible et surtout une meilleure sécurité. C'est une approche adéquate pour une politique de prévention de santé publique à large échelle de l'obésité et des maladies cardiovasculaires. C'est en cela et sous bien d'autres aspects, une première dans la prise en charge des maladies du métabolisme lipidique et pourrait même être pour ces dernières ce que l'iode du sel de cuisine a été pour le goitre.

A step beyond--the relevance of depressed mood and mastery in the interplay between the number of social roles and alcohol use.

OBJECTIVES: The present study examines whether depressed mood and external control mediate or moderate the relationship between the number of social roles and alcohol use. PARTICIPANTS: The analysis was based on a national representative sample of 25- to 45-year-old male and female drinkers in Switzerland. METHOD: The influence of depressed mood and external control on the relationship between the number of social roles (parenthood, partnership, employment) and alcohol use was examined in linear structural equation models (mediation) and in multiple regressions (moderation) stratified by gender. All analyses were adjusted for age and education level. RESULTS: Holding more roles was associated with lower alcohol use, lower external control and lower depressed mood. The study did not find evidence of depressed mood or external control mediating the social roles-alcohol relationship. A moderation effect was identified among women only, whereby a protective effect of having more roles could not be found among those who scored high on external control. In general, a stronger link was observed between roles and alcohol use, while depressed mood and external control acted independently on drinking. With the exception of women with high external control, the study found no link between a higher number of social roles and greater alcohol use. CONCLUSION: Our results indicate that drinking behaviours are more strongly linked to external control and depressed mood than they are to the number of social roles. The study also demonstrates that in any effective alcohol prevention policy, societal actions that enable individuals to combine more social roles play a central role.

Prévention des alcoolisations aiguës a l'adolescence: quel rôle pour le médecin de famille [Prevention of binge drinking in adolescents: do family doctors have a role to play?].

Binge drinking has nearly become the norm for young people and is thus worrying. Although alcohol use in males attracts more media attention, females are also frequently affected. A variety of preventive measures can be proposed: at the individual level by parents, peers and family doctors; at the school and community level, particularly to postpone age of first use and first episode of drunkenness; at the structural level through a policy restricting access to alcohol for young people and increasing its price. Family doctors can play an important role in identifying at risk users and individualising preventive messages to which these young people are exposed in other contexts.

Comparing impact and cost-effectiveness of primary prevention strategies for lipid-lowering.

BACKGROUND: Lipid-lowering therapy is costly but effective at reducing coronary heart disease (CHD) risk. OBJECTIVE: To assess the cost-effectiveness and public health impact of Adult Treatment Panel III (ATP III) guidelines and compare with a range of risk- and age-based alternative strategies. DESIGN: The CHD Policy Model, a Markov-type cost-effectiveness model. DATA SOURCES: National surveys (1999 to 2004), vital statistics (2000), the Framingham Heart Study (1948 to 2000), other published data, and a direct survey of statin costs (2008). TARGET POPULATION: U.S. population age 35 to 85 years. Time Horizon: 2010 to 2040. PERSPECTIVE: Health care system. INTERVENTION: Lowering of low-density lipoprotein cholesterol with HMG-CoA reductase inhibitors (statins). OUTCOME MEASURE: Incremental cost-effectiveness. RESULTS OF BASE-CASE ANALYSIS: Full adherence to ATP III primary prevention guidelines would require starting (9.7 million) or intensifying (1.4 million) statin therapy for 11.1 million adults and would prevent 20,000 myocardial infarctions and 10,000 CHD deaths per year at an annual net cost of $3.6 billion ($42,000/QALY) if low-intensity statins cost $2.11 per pill. The ATP III guidelines would be preferred over alternative strategies if society is willing to pay $50,000/QALY and statins cost $1.54 to $2.21 per pill. At higher statin costs, ATP III is not cost-effective; at lower costs, more liberal statin-prescribing strategies would be preferred; and at costs less than $0.10 per pill, treating all persons with low-density lipoprotein cholesterol levels greater than 3.4 mmol/L (>130 mg/dL) would yield net cost savings. RESULTS OF SENSITIVITY ANALYSIS: Results are sensitive to the assumptions that LDL cholesterol becomes less important as a risk factor with increasing age and that little disutility results from taking a pill every day. LIMITATION: Randomized trial evidence for statin effectiveness is not available for all subgroups. CONCLUSION: The ATP III guidelines are relatively cost-effective and would have a large public health impact if implemented fully in the United States. Alternate strategies may be preferred, however, depending on the cost of statins and how much society is willing to pay for better health outcomes. FUNDING: Flight Attendants' Medical Research Institute and the Swanson Family Fund. The Framingham Heart Study and Framingham Offspring Study are conducted and supported by the National Heart, Lung, and Blood Institute.

Female genital mutilation and its prevention: a challenge for paediatricians.

Female genital mutilation (FGM) is defined as an injury of the external female genitalia for cultural or non-therapeutic reasons. FGM is mainly performed in sub-Saharan and Eastern Africa. The western health care systems are confronted with migrants from this cultural background. The aim is to offer information on how to approach this subject. The degree of FGM can vary from excision of the prepuce and clitoris to infibulation. Infections, urinary retention, pain, lesions of neighbouring organs, bleeding, psychological trauma and even death are possible acute complications. The different long-term complications include the risk of reduced fertility and difficulties during labour, which are key arguments against FGM in the migrant community. Paediatricians often have questions on how to approach the subject. With an open, neutral approach and basic knowledge, discussions with parents are constructive. Talking about the newborn, delivery or traditions may be a good starting point. Once they feel accepted, they speak surprisingly openly. FGM is performed out of love for their daughters. We have to be aware of their arguments and fears, but we should also stress the parents' responsibility in taking a health risk for their daughters. It is important to know the family's opinion on FGM. Some may need support, especially against community pressure. As FGM is often performed on newborns or at 4-9 years of age, paediatricians should have an active role in the prevention of FGM, especially as they have repeated close contact with those concerned and medical consequences are the main arguments against FGM.

Hospital admission rates for alcoholic intoxication after policy changes in the canton of Geneva, Switzerland.

Background: In February, 2005, the canton of Geneva in Switzerland prohibited the off-premise sale of alcoholic beverages between 9pm and 7am, and banned their sale in gas stations and video stores. The aim of this study is to assess the impact of this policy change on hospital admission rates for alcoholic intoxication.Methods: An interrupted time series analysis of this natural experiment was performed with data on hospitalisations for acute alcoholic intoxication during the 2002-2007 period. The canton of Geneva was treated as the experimental group, while all other Swiss cantons were used as the control group.Results: In the experimental site, the policy change was found to have a significant effect on admission rates among adolescents and young adults. Depending on the age group, hospitalisation rates for alcoholic intoxication fell by an estimated 25-40% as the result of restricted alcohol availability.Conclusions: Modest restrictions on opening hours and the density of off-premise outlets were found to be of relevance for public health in the canton of Geneva. In light of this finding, policy makers should consider such action as a promising approach to alcohol prevention. (C) 2011 Elsevier Ireland Ltd. All rights reserved.

Attitudes of detainees and prison staff towards tobacco control policy in Switzerland: a qualitative interview study.

PURPOSE: To explore detainees and staff's attitudes towards tobacco use, in order to assist prison administrators to develop an ethically acceptable tobacco control policy based on stakeholders' opinion. DESIGN: Qualitative study based on in-depth semi-structured interviews with 31 prisoners and 27 staff prior (T1) and after the implementation (T2) of a new smoke-free regulation (2009) in a Swiss male post-trial prison consisting of 120 detainees and 120 employees. RESULTS: At T1, smoking was allowed in common indoor rooms and most working places. Both groups of participants expressed the need for a more uniform and stricter regulation, with general opposition towards a total smoking ban. Expressed fears and difficulties regarding a stricter regulation were increased stress on detainees and strain on staff, violence, riots, loss of control on detainees, and changes in social life. At T2, participants expressed predominantly satisfaction. They reported reduction in their own tobacco use and a better protection against second-hand smoke. However, enforcement was incomplete. The debate was felt as being concentrated on regulation only, leaving aside the subject of tobacco reduction or cessation support. CONCLUSION: Besides an appropriate smoke-free regulation, further developments are necessary in order to have a comprehensive tobacco control policy in prisons.

La prévention du tabagisme passif [Prevention of air pollution by indoor tobacco smoke in France]

A majority of smokers and non-smokers mind tobacco smoke. Passive smoking causes death by sudden infant death, lung cancer and coronary heart disease. 3000 to 6000 persons are killed every year in France. The lack of implementation of the Evin's law published in 1991 explains why non-smokers are not given the protection they can expect. The trend of scientific knowledge and of French and international public opinions support a growing demand for a complete protection of non-smokers with a total ban of smoking in all public or working places.

Introducing a first AIDS vaccine in Switzerland: a Policy Delphi analysis.

This preliminary exploration was limited by a number of factors. The format of the study has necessarily induced some form of selection bias of the panelists, because of the complexity of some questions, and the time required to complete the questionnaires. Several issues have not been addressed. One example could be the response to HIV infection occurring in a vaccinee. The study also did not address the difficulties related to the licensing of the vaccine. Indeed, the proposed scenario assumed that the vaccine had been registered as a starting point for the analysis. Finally, it has not been possible to conduct a sensitivity analysis, in order to evaluate how the responses would have been modified if some important characteristics of the vaccine had been modified.Very diverse evaluations were given in response to questions related with attitudes and perception of AIDS and AIDS vaccine. The possibility that vaccine availability or usage can be associated with an increased frequency in risky behaviors was spontaneously mentioned by half of the panelists. The estimation of the proportion of persons at highest risk who would choose to use this vaccine also indicated a high degree of uncertainty. This study offers important lessons. According to a broad and diverse panel of individuals, an incompletely effective AIDS vaccine would result in an additional level of complexity for the AIDS prevention strategy, rather than a simplification. The use of such a vaccine would have to be coupled with counselling. This implies a sustained emphasis on the recommendations which have been central to the STOP AIDS campaigns until now. In addition, consensual issues, as well as other issues more likely to be controversial have been identified. This should greatly help focusing the work of any committee designated to develop and implement a vaccination policy if an AIDS vaccine became available. Finally, our experience with the Policy Delphi indicates that this mode of structured communication could be usefully applied to other public health issues presenting a high visibility as well as a complex relationship with public perception.

Long term global evaluation of a national AIDS prevention strategy: the case of Switzerland.

OBJECTIVES: The Swiss Aids prevention strategy has been subject to a continuous process of evaluation for the past 12 years. This paper describes the conceptual approach, methodology, results obtained and contribution to policy-making of that evaluation.¦DESIGN: The evaluation is on-going, global with respect to all components of the strategy, and utilization-focused. Each successive phase of the evaluation has included 10-20 studies centred either on aspects of process, of outcome or of environmental context. Findings are synthesized at the end of each phase. METHODS: Both quantitative and qualitative methods are used. Studies generally have one of three functions within the overall evaluation: assessment of trends through surveys or other types of repeated studies; evaluation of specific areas through a series of studies from different viewpoints; in-depth investigation or rapid assessment through one-off studies. Various methods of triangulation are used to validate findings. RESULTS: The evaluation has allowed for: the observation of behavioural change in different populations; the availability of scientific data in controversial fields such as drug-use policy; an understanding of the diversity of public appropriation of prevention messages. Recommendations are regularly formulated and have been used by policy-makers and field workers for strategy development. CONCLUSIONS: The global approach adopted corresponds well to the evaluation requirements of an integrated long-term prevention strategy. Cost is low relative to the extent of information provided. Such an evaluation cannot however address the question of causal relationship between the strategy and observed changes. The evaluation has contributed to the development of a culture of evaluation in Swiss AIDS prevention more generally.