Refining Timely Diagnosis of Early Syphilis by Using Treponema pallidum PCR or IgM Immunoblotting Next to Conventional Serology for Syphilis.

Treponema pallidum subsp. pallidum is a fastidious spirochete and the etiologic agent of syphilis, a sexually transmitted infection (STI). Syphilis diagnoses and disease staging are based on clinical findings and serologic testing. Moreover, according to most international guidelines, PCR analysis of swab samples from genital ulcers is included in the screening algorithm where possible. It has been suggested that PCR might be omitted from the screening algorithm due to low added value. As an alternative to PCR, IgM serology might be used. In this study, we wanted to establish the added value of PCR and IgM serology for diagnosing primary syphilis. Added value was defined as finding more cases of syphilis, preventing overtreatment, or limiting the extent of partner notification to more recent partners. We found that both PCR and IgM immunoblotting could aid the timely diagnosis of early syphilis in ~24% to 27% of patients. PCR has the greatest sensitivity and can be applied to cases with an ulcer with suspected reinfection or primary infection. In the absence of lesions, the IgM immunoblot could be used. However, the IgM immunoblot has better performance in cases with suspected primary infection than in reinfections. The target population, testing algorithm, time pressures, and costs should determine whether either test provides sufficient value to be implemented in clinical practice.

Mpox vaccination willingness, determinants, and communication needs in gay, bisexual, and other men who have sex with men, in the context of limited vaccine availability in the Netherlands (Dutch Mpox-survey).

Introduction: In the 2022 multicountry mpox (formerly named monkeypox) outbreak, several countries offered primary preventive vaccination (PPV) to people at higher risk for infection. We study vaccine acceptance and its determinants, to target and tailor public health (communication-) strategies in the context of limited vaccine supply in the Netherlands. Methods: Online survey in a convenience sample of gay, bisexual and other men who have sex with men, including transgender persons (22/07-05/09/2022, the Netherlands). We assessed determinants for being (un)willing to accept vaccination. We used multivariable multinominal regression and logistic regression analyses, calculating adjusted odds ratios (aOR) and 95 percent confidence-intervals. An open question asked for campaigning and procedural recommendations. Results: Of respondents, 81.5% (n = 1,512/1,856) were willing to accept vaccination; this was 85.2% (799/938) in vaccination-eligible people and 77.7% (713/918) in those non-eligible. Determinants for non-acceptance included: urbanization (rural: aOR:2.2;1.2-3.7; low-urban: aOR:2.4;1.4-3.9; vs. high-urban), not knowing mpox-vaccinated persons (aOR:2.4;1.6-3.4), and lack of connection to gay/queer-community (aOR:2.0;1.5-2.7). Beliefs associated with acceptance were: perception of higher risk/severity of mpox, higher protection motivation, positive outcome expectations post vaccination, and perceived positive social norms regarding vaccination. Respondents recommended better accessible communication, delivered regularly and stigma-free, with facts on mpox, vaccination and procedures, and other preventive options. Also, they recommended, "vaccine provision also at non-clinic settings, discrete/anonymous options, self-registration" to be vaccinated and other inclusive vaccine-offers (e.g., also accessible to people not in existing patient-registries). Conclusion: In the public health response to the mpox outbreak, key is a broad and equitable access to information, and to low-threshold vaccination options for those at highest risk. Communication should be uniform and transparent and tailored to beliefs, and include other preventive options. Mpox vaccine willingness was high. Public health efforts may be strengthened in less urbanized areas and reach out to those who lack relevant (community) social network influences.

How aware are swingers about their swing sex partners' risk behaviours, and sexually transmitted infection status?

BACKGROUND: Swingers are members of a heterosexual couple who, as a couple, have sex with others. They constitute a hidden subpopulation that is at risk for sexually transmitted infections (STIs). This study aimed to determine swingers' level of awareness about the STI risk (indicators: bisexual behaviour, number of sex partners, and STI status) of their swing sex partners (i.e. alters). METHODS: In this cross-sectional study, data were collected from a convenience sample of swingers who visited our STI clinic. The sample consisted of 70 participants (i.e. egos) and their 299 swing sex partners (i.e. alters) who had undergone an STI test at our clinic. We compared network data (i.e. information that egos provided about alters) and data stored in the electronic patient record (EPR) in our clinic (i.e. information provided by alters themselves). We assessed the agreement (correct estimation, overestimation and underestimation) between the network data and EPR data using chi-squared tests. RESULTS: Egos underestimated the bisexual behaviours of 37% of their male alters and overestimated the number of sex partners of 54 and 68% of their male and female alters, respectively. Egos correctly estimated the STI statuses of only 22% of the alters who had an STI during the past six months. CONCLUSIONS: The participating swingers underestimated the bisexual behaviours of their male swing sex partners, overestimated their number of sex partners, and underestimated their positive STI status. Underestimating their alters' STI statuses can cause swingers to underestimate their own STI risk and fail to implement preventive measures. The latter finding has implications for STI prevention. Therefore, more attention should be paid to swingers in general and the promotion of actual partner notification and STI testing among swingers in specific.

Do swingers self-identify as swingers when attending STI services for testing? A cross-sectional study.

OBJECTIVES: Swingers, that is, members of a heterosexual couple who, as a couple, had sex with other couples and/or singles within the swinger's subculture, are a hidden population with substantial rates of sexually transmitted infections (STIs) and high-risk sexual behaviour. Information on swingers' self-identification to be a swinger, their risk perception and attitudes about STI testing and safe sex will help to reveal swingers who are hidden while in care, to address them with targeted strategies. METHODS: We used data from a convenience sample of 289 swingers from our Dutch STI clinic patient registry between 2009 and 2012 (median age 45 years; 49% women; STI positivity 13%, no condom in vaginal sex: 57%). Participants filled in a self-administered questionnaire on sexual behaviour and answered statements about self-identification, risk perception and attitudes about STI testing and safe sex. RESULTS: Of all participating registered swingers, 56% self-identified as a swinger. Safe sex was reportedly deemed important (77%). Overall, 72%, 62% and 56% reported that STI testing, partner notification and condom use is the norm in the swinger community. The latter was reported more often by self-identified swingers compared with non-self-identified swingers. Self-identified swingers further swinged more often, had more partners and more often swinged at home parties than non-self-identified swingers. CONCLUSIONS: About half of STI clinic attending swingers whose sexual behaviour agrees with the definition of swinging are neutral/do not identify themselves to be a swinger. As many STI clinics internationally not specifically ask clients about their swinging behaviour, swingers may be a missed target population in care. Implementation of routine questions addressing behaviour (thus not only asking whether someone is a swinger) in STI clinics is feasible and facilitated by swingers' positive norm towards STI prevention and testing. Implementing routine swinger questions contribute to effective STI services including appropriate testing, counselling and partner notification.

Drug use, sexual risk behaviour and sexually transmitted infections among swingers: a cross-sectional study in The Netherlands.

OBJECTIVES: Recreational drug use has been found to be associated with high-risk sexual behaviour and with sexually transmitted infections (STI). This study is the first to assess the prevalence of drug use among swingers (heterosexuals who, as a couple, practise mate swapping or group sex, and/or visit sex clubs for couples), and its association with high-risk sexual behaviour and STI. METHODS: We recruited individuals who self-identified as swingers and visited our STI clinic (from 2009 to 2012, South Limburg, The Netherlands). Participants (n=289; median age 45 years; 49% female) filled in a self-administered questionnaire on their sexual and drug use behaviour while swinging, over the preceding 6 months. We assessed associations between sexual behaviour, drug use and STI diagnoses (Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), syphilis, HIV and hepatitis B) using logistic regression analyses. RESULTS: Overall, the prevalence of CT and/or NG was 13%. No other STIs were observed. Seventy-nine percent of swingers reported recreational drug use (including alcohol and use of erectile dysfunction drugs); 46% of them reported multiple drug use. Recreational drug use excluding alcohol and erectile dysfunction drugs (reported by 48%) was associated with high-risk behaviours in men and women. Drug use was independently associated with STI in female swingers, especially those who practice group sex. CONCLUSIONS: High rates of multiple drug use, as well as risky sexual behaviour and STIs among swingers, warrant paying more attention to this key population in prevention and care, as they are a risk group that is generally under-recognised and underserved in care.

Standard symptom- and sexual history-based testing misses anorectal Chlamydia trachomatis and neisseria gonorrhoeae infections in swingers and men who have sex with men.

BACKGROUND: Currently, individuals at risk for sexually transmitted diseases (STDs) are tested extragenitally only if indicated, most often when there is a history of self-reported symptoms or self-reported anal sex. The sensitivity of such selective symptom- and sexual history-based testing for detection of anorectal STD has not been determined. METHODS: All men having sex with men (MSM) and swingers (heterosexual couples who have sex with other heterosexual couples and their self-identified heterosexual sex partners) attending our STD clinic (consults: n = 1690) from January 2010 until February 2011 were universally tested for urogenital, anorectal, and oropharyngeal Chlamydia trachomatis and Neisseria gonorrhoeae infections (STD). We compared STD prevalence at anorectal site based on universal versus selective testing. RESULTS: Sensitivity of selective symptom- and sexual history-based testing for anorectal STD was 52% for homosexual MSM, 40% for bisexual MSM, 43% for bisexual male swingers, 40% for heterosexual male swingers, and 47% for female swingers. CONCLUSIONS: Universal testing of STD clinic clients who were MSM and swingers yielded more than half of all anorectal STD infections and is more sensitive for identifying anorectal STD infections compared with selective testing. Universal testing may be a more effective strategy for interrupting the ongoing transmission in high-risk sexual networks.

Improving sexual health for HIV patients by providing a combination of integrated public health and hospital care services; a one-group pre- and post test intervention comparison.

BACKGROUND: Hospital HIV care and public sexual health care (a Sexual Health Care Centre) services were integrated to provide sexual health counselling and sexually transmitted infections (STIs) testing and treatment (sexual health care) to larger numbers of HIV patients. Services, need and usage were assessed using a patient perspective, which is a key factor for the success of service integration. METHODS: The study design was a one-group pre-test and post-test comparison of 447 HIV-infected heterosexual individuals and men who have sex with men (MSM) attending a hospital-based HIV centre serving the southern region of the Netherlands. The intervention offered comprehensive sexual health care using an integrated care approach. The main outcomes were intervention uptake, patients' pre-test care needs (n=254), and quality rating. RESULTS: Pre intervention, 43% of the patients wanted to discuss sexual health (51% MSM; 30% heterosexuals). Of these patients, 12% to 35% reported regular coverage, and up to 25% never discussed sexual health topics at their HIV care visits. Of the patients, 24% used our intervention. Usage was higher among patients who previously expressed a need to discuss sexual health. Most patients who used the integrated services were new users of public health services. STIs were detected in 13% of MSM and in none of the heterosexuals. The quality of care was rated good. CONCLUSIONS: The HIV patients in our study generally considered sexual health important, but the regular counselling and testing at the HIV care visit was insufficient. The integration of public health and hospital services benefited both care sectors and their patients by addressing sexual health questions, detecting STIs, and conducting partner notification. Successful sexual health care uptake requires increased awareness among patients about their care options as well as a cultural shift among care providers.

Older and swinging; need to identify hidden and emerging risk groups at STI clinics.

BACKGROUND: Identification of STI risk groups is essential for optimal prevention and medical care. Until now, swingers--that is, heterosexual couples who are practising mate swapping, group sex, visit sex clubs for couples, are not considered as a specific risk group for STI in healthcare services and prevention. OBJECTIVE: To compare STI prevalence rates in swingers with that in other risk groups. METHODS: At the STI clinic, South Limburg, The Netherlands, whether an attendee is a swinger has been systematically registered since 2007. STI clinic surveillance data were analysed to assess the swingers' share of consultations and STI diagnoses--here Chlamydia trachomatis (CT) and/or Neisseria gonorrhoea (NG). RESULTS: Of 8971 consultations, 12% comprised swingers (median age 43 years, IQR 38-48). Overall, STI prevalence was highest in youth, men who have sex with men (MSM) and swingers. Older swingers had a CT prevalence of 10% and an NG prevalence of 4%. The share in STI diagnoses in the older age group (>45 years) comprised 55% for swingers and 31% for MSM. CONCLUSIONS: Swingers comprise a substantial proportion of STI consultations. They are a mainly older age group and form an important part of STI diagnoses. While other risk groups for STI, such as young heterosexuals and MSM, are systematically identified at STI healthcare facilities and provided with appropriate services, this is generally not the case for swingers. Swingers, like other groups with risk behaviours, need to be identified and treated as a risk group in STI prevention and care.