SIALON II

In line with the most recent communication on combating HIV/AIDS in the European Union and neighbouring countries (2009-2013), the overall objective of the SIALON project was to carry out and promote combined and targeted prevention complemented by a meaningful surveillance among a specific hard to reach population, namely Men who have Sex with Men (MSM).

This was not only a research project but also a capacity building project which provided a large network of institutions with a shared tool able to integrate a second-generation surveillance system activity in a common framework for prevention strategies among MSM.

Specifically, the aim of the project was to carry out:

• a prevention needs assessment and prevention actions with the involvement of the MSM community
• innovative surveillance and HIV/STI testing methodologies for hard to reach populations (Time Location Sampling, Respondent Driven Sampling).

Thanks to the participation of UNAIDS and WHO, the strategies and materials developed in the context of the SIALON II project were shared with two non-EU neighbouring countries (Armenia and Moldova).

As one of the main objectives of the project was to promote capacity building in STI surveillance and targeted prevention, the methodologies (Protocols, United Nations General Assembly Special Session UNGASS-GARP indicators, epidemiological algorithms) and prevention strategies were shared with the above countries, promoting different experiences in capacity building and HIV prevention/surveillance strategies targeting MSM.

Starting in November 2011, SIALON II ran for three years and was coordinated by the Regional Coordination Centre for European Project Management (CReMPE), Verona University Hospital, Veneto Region, Italy.

Specific objectives of SIALON II were:

• To pilot the implementation of a bio-behavioural survey using Time-Location Sampling (TLS) and Respondent-Driven Sampling (RDS)
• To estimate Ab-anti-HIV serum prevalence among MSM in the data collection sites though TLS in 10 European countries (Belgium, Bulgaria, Germany, Italy, Poland, Portugal, Slovenia, Spain, Sweden, UK; N=5,200)
• To estimate Ab-anti-HIV, Syphilis, HBV-HVC serum prevalence among MSM in the data collection sites through RDS in four European countries (Italy, Lithuania, Romania, and Slovakia; N=1,600)
• To identify, describe and analyse sexual risk behaviour patterns, prevention needs and sexual health in the MSM population through a survey modelling the relationship between risk behaviour, socio-ecological or contextual factors and biological samples
• To pilot the algorithm for the following testing procedure, both in terms of technical procedures and in terms of acceptability from the point of view of the target population: rapid test for HIV-Syphilis in MSM population in the context of a surveillance system.

Research team UK: Dr Nigel Sherriff; Dr Christina Panton; Ross Boseley (Terrence Higgins Trust); Glynis Flood [Coordinated in Europe by Dr Massimo Mirandola of the Regional Coordination Centre for European Project Management (CReMPE) in Verona, Italy.]

Civil Society Partnership: Collaboration with local Gay NGOs

Local Gay NGOs in all the partner countries have been actively involved in the Sialon II from the outset in order to ensure adequacy with social , cultural context and views of the target group. The project has provided these local NGOs with the opportunity to establish a dialogue not only with the institutional representatives in their countries but also with their counterparts in other countries participating in the project.

Institutional partnerships; Collaboration with UNAIDS and WHO

Through the SIALON II project, a very fruitful channel of communication has been established with both UNAIDS and WHO. This collaboration has evolved into a formal working relationship in the context of SIALON II and the project protocol was submitted for the WHO review process. After having been reviewed by the WHO Research Project Review Panel (RP2-WHO), it was finally approved by the Research Ethics Review Committee (WHO-ERC) on the 27 February 2013.

Moreover, the collaboration with WHO foresees the development of capacity building and know how through both training and on-site coaching under the active supervision and in collaboration with UNAIDS and WHO in European and Eastern neighbouring countries.

Collaboration with ECDC

Building on the experience of SIALON, SIALON II created a network of institutions working with the ECDC to implement new tools for STI surveillance in support of comprehensive, integrated HIV/STI prevention strategies.

The associated partners of the SIALON project were:

AOUI - Azienda Ospedaliera Universitaria Integrata, Verona - Italy ; IHMT - Instituto de Higiene e Medicina Tropical, Lisboa - Portugal;IGTIP - Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol; ICO - Institut Catala d'Oncologia Barcelona - Spain; INBI - Institutul National De Boli Infectioase Prof. Dr. Matei Balș, Bucuresti - Romania; ISS - Istituto Superiore di Sanità, Rome - Italy; ITG - Prins Leopold Instituut voor Tropische Geneeskunde Antwerpen - Belgium; NCIPD - National Centre of Infectious and Parasitic Diseases Sofia - Bulgaria; NIPH - National Institute of Public Health, Ljubljana - Slovenia; NIZP-PZH - National Institute of Public Health - National Institute of Hygiene, Warszawa, Poland; RKI - Robert Koch-Institut, Berlin - Germany; SMI - Smittskyddinstitutet, Solna, Stockholm - Sweden; SMU - Slovak Medical University, Bratislava - Slovakia; ULAC - Centre for Communicable Diseases and AIDS, Vilnius - Lithuania; University of Brighton, Brighton - United Kingdom

The collaborating partners of the Sialon project were:
ACCEPT, Bucuresti - Romania; ANDOS - Associazione Nazionale contro le Discriminazioni per Orientamento Sessuale, Roma - Italy; ARCIGAY - Associazione LGBT Italiana, Bologna - Italy; ASMEDA, Vilnius - Lithuania; DHA - Deutsche AIDS-Hilfe
Berlin - Germany; DOM SVETLA (Lighthouse), Bratislava - Slovakia; GAT, Lisboa, Portugal; Hein & Fiete, Hamburg - Germany; HWB - Association Health Without Borders, Sofia - Bulgaria; INMI - Istituto Nazionale Malattie Infettive, Roma - Italy; Lambda Warszawa Association, Warszawa, Poland; Rainbowhouse Brussels, Bruxelles - Belgium; SENSOA, Antwerpen, Belgium; SKUC Magnus, Ljubljana - Slovenia; STOP SIDA, Barcelona, Spain; THT - Terence Higgins Trust (South), London - United Kingdom; TJA - Tolerantisko Jaunimo Asociacija, Vilnius - Lithuania

SIALON and SIALON II have developed a client friendly method of gathering biological and social data in MSM communities that can be used by a wide audience range. Policy and decision makers can make use of the data to design policies and strategies for building comprehensive approaches to addressing the immediate and long term prevention treatment and care services for MSM.

Health care services can use the SIALON and SIALON II method for building local and regional representations of the health care needs of MSM throughout the health system. The SIALON II methodology could be applied in any country. One of the two different sampling methodologies (Time and Location Sampling and Respondent Driven Sampling) can be chosen as an appropriate method for collecting biological and social data in MSM communities in each local context, according to SIALON II experience.

Furthermore, the SIALON II study demonstrates how Global AIDS Response Progress (GARP) and the European Centre for Disease Prevention and Control (ECDC) indicators can be used to provide a key measure for basic monitoring of HIV.

Reports were published in 2016. The SIALON II final report presents the findings from this large-scale bio-behavioural survey implemented across 13 European countries. This project was set within a context of rising HIV infections among MSM in many countries across Europe. The survey is without precedence in Europe in terms of its size and from the point of view of the practical implementation of the WHO – Joint United Nations Programme on HIV/AIDS (UNAIDS) Second Generation Surveillance System (SGSS) approach and behavioural surveillance recommendations from the ECDC.

Data from the SIALON II survey have provided a wealth and diversity of insights regarding access to prevention programmes and testing in each partner country, sexual behaviour and health. In terms of HIV prevalence, data suggested a range between 2 per cent and 20 per cent, with higher prevalence among individuals older than 25 years of age. A relevant proportion (ranging between 12 per cent and 88 per cent) of participants were unaware of being HIV-positive.

On the one hand, the findings confirm the already identified trend of rising infection among MSM in Europe. On the other hand, the data reveal some alarming findings with regard to prevention, treatment and support to MSM and underline the disparities within Europe.

The high number of MSM who were tested for the first time in the context of this survey, in particular in the Eastern European survey cities and the high estimates of HIV positive participants unaware of their real serum-status, seem to suggest critical conditions in terms of future increase of the HIV epidemic. The situation seems to be particularly concerning in Eastern European cities, where a low level of condom use is reported, as well as a high level of perceived discrimination.

The lack and/or delay in diagnosis is also a crucial factor in general. In several cities, the treatment coverage is less than optimal among individuals who know they are HIV positive indicating potential challenges in linkage to care and continuity of care.

This scenario reflects the marked diversity of the societal and political contexts of the countries involved, in particular with respect to the social and legal conditions for sexual minority emancipation. This will obviously have an impact on both surveillance and prevention activities and needs to be taken into consideration in the definition of policy in this area. This means that in addition to concrete measures such as increased condom distribution networks and promotion of testing and treatment, policy actions must also address the social determinants of high risk behaviour and low uptake of testing for HIV and other STIs such as homophobia and stigma.

Similarly, the segmentation and the complexity of the MSM population which this survey has contributed to identifying, point to the need to design targeted HIV prevention and health promotion interventions by subgroups.

To conclude, the findings of SIALON II survey represent a valid contribution to the pool of epidemiological research that has been has undertaken to date in the area of HIV/STI prevention among MSM. However, at the same time, the results also point to the urgent need for continued and more widespread data collection (in line with the SGGS) to better understand the marked differences in prevention needs across Europe and among sub-populations of MSM and hence to better define more effective and efficient prevention strategies.

Publications and outputs

Gios, L, Massimo, M, Toskin, I, Marcus, U, Dudareva-Vizule, S, Sherriff, NS, Breveglieri, M, Furegato, M, Folch, C, Ferrer, L, Montoliu, A, Nöstlinger, C, Vanden Berghe, W, Kühlmann-Berenzon, S, Velicko, I, Dias, S, Suligoi, B, Regine, V, Stanekova, D, Rosińska, M, Caplinskas, S, Klavs, I, Alexiev, I, and Rafila, A (2016) Bio-behavioural HIV and STI surveillance among men who have sex with men in Europe: the SIALON II project protocols. BMC Public Health.

Folch, C, Ferrer, L, Montoliu, A, Muñoz, R, Staneková, D, Smoleň, M, Tibaj, P, Záhradník, P, Sherriff, NS. et al (2016) SIALON II City Profiles: Recommendations on HIV prevention gaps and opportunities for health promotion among men who have sex with men. Verona: Department of Pathology, Verona University Hospital.

Mirandola, M, Gios, L, Sherriff, NS, Toskin, I, Marcus, U, Schink, S, Suligoi, S, Folch, C, Rosińska, M (2016) (Eds) SIALON II: Capacity building in combining targeted prevention with meaningful HIV surveillance among MSM: Report on a bio-behavioural survey among MSM in 13 European cities. Verona: Department of Pathology, Verona University Hospital.

Media coverage

Sherriff, NS (2015) Making gay business the frontline in the fight against HIV, 30 October 2015.

Sherriff, NS, Panton, C, Boseley, R, Gios, L, Mirandola, M, and the SIALON II network (2015) SIALON II in Brighton: Working collaboratively with gay businesses to conduct second generation HIV surveillance and prevention activities among MSM. Brighton and Hove Sexual Health News, Spring 2015.

SIALON II Project: BBC South East TV News (report), 31 May 2013.

SIALON II Project: BBC Radio Sussex, 31 May 2013, by Neil Pringle.

“HIV tests offered at Brighton and Hove gay venues”, 31 May, 2013, BBC News

“Brighton and Hove gay venues to now offer HIV tests”, 7 June, 2013, Brighton and Hove Independent.

“Swabs at gay venues in Brighton and Hove help crucial research into HIV”, 2 June, 2013, The Argus.

“HIV testing at gay venues”, 31 May 2013, Reproductive Health Matters.

“Brighton: Gay businesses take part in HIV mouth swab project”, 31 May 2013. Pink News.