Prevalence and risk factors for HPV seropositivity and anogenital DNA positivity among men who have sex with men: a repeated cross-sectional study.

OBJECTIVES: This study aimed to assess associations of potential risk factors with human papillomavirus (HPV) seropositivity among men who have sex with men (MSM) and compare these to risk factors for anal and penile (HPV) deoxyribonucleic acid (DNA)-positivity in the same study population. METHODS: Seropositivity and anal and penile HPV DNA-positivity were determined for seven high-risk HPV genotypes for MSM aged 16-24 years participating in Papillomavirus Surveillance among STI clinic Youngsters in the Netherlands (PASSYON) 2009-2021. Logistic regression models were conducted to assess risk factors for seropositivity, anal and penile HPV DNA-positivity. RESULTS: Overall, 1019 MSM were included. HPV-16 and -18 were most common for serology, and anal and penile HPV DNA-positivity. Although no clear similarities were observed for most risk factors for HPV seropositivity and anal or penile DNA positivity, receptive anal intercourse (RAI) was the strongest associated risk factor for both seropositivity ('RAI ever' adjusted odds ratio [aOR] 3.50, 95% confidence interval [CI] 1.56-7.88; 'RAI previous 6 months' aOR 2.17, 95% CI 1.44-3.26) and anal DNA-positivity ('RAI previous 6 months' aOR 1.67, 95% CI 1.09-2.56). CONCLUSIONS: Our study is suggestive of site-specific immune response after HPV infection; RAI might lead to anal HPV infections and consequently to seroconversion. Finally, as the two genotypes that are most oncogenic and preventable by all HPV vaccines were most common, our results underline the importance of gender-neutral vaccination.

Availability and accessibility of HIV self-tests and self-sample kits at community pharmacies in the Netherlands.

BACKGROUND: In 2016 the WHO declared HIV self-testing and self-sampling an effective and safe test option that can reduce testing barriers. HIV self-tests and self-sampling kits (HIVST/HIVSS) are available for purchase at Dutch community pharmacies since 2019. We investigated the availability and accessibility of HIVST/HIVSS in community pharmacies, and factors associated with test availability. METHODS: An online survey among all Dutch community pharmacies (n = 1,987) was conducted between April and June 2021. Availability of HIVST/HIVSS and experiences of pharmacists with the test offer were analyzed with descriptive statistics. The association of pharmacy and pharmacists' characteristics with HIVST/HIVSS availability was explored by logistic regression analysis. RESULTS: In total, 465 pharmacists completed the questionnaire. Of the responding pharmacists, 6.2% (n = 29) offered HIVST/HIVSS. The majority (82.8%) sold between 0 and 20 tests per year. In total, pharmacies sold an estimated 370 HIVST/HIVSS per year. Pharmacies having HIVST/HIVSS available were less often located in moderately-urbanized to rural neighborhoods (OR 0.35, 95%CI 0.16-0.77 versus highly-urbanized), and were less often located in moderate-to-low SES neighborhoods (OR 0.40, 95%CI 0.18-0.88 versus high-SES). Reasons for not offering HIVST/HIVSS by pharmacists were no or little demand (69.3%), and not being familiar with these tests (17.4%). 52% of the pharmacists provided information about testing to test buyers. Reported options to improve the test offer were giving advice about (performing) the test to test buyers (72.4%), placing tests visible on the counter (51.7%), and advertisement (37.9%). CONCLUSION: HIVST/HIVSS have a limited practical availability in Dutch community pharmacies since their introduction in 2019, especially in lower-urbanized and lower-SES areas. Further research is needed to explore how to expand access to HIVST/HIVSS through community pharmacies in the Netherlands, and how to tailor it to the needs of pharmacy clients.

Spontaneous clearance of asymptomatic anogenital and pharyngeal Neisseria gonorrhoeae: a secondary analysis from the NABOGO trial.

INTRODUCTION: Spontaneous clearance of asymptomatic Neisseria gonorrhoeae (NG) does occur, but data are scarce. We aimed to assess spontaneous clearance among patients with asymptomatic anal, pharyngeal, vaginal and urethral NG infections who participated in the New AntiBiotic treatment Options for uncomplicated GOnorrhoea (NABOGO) trial. In addition, we assessed the determinants associated with spontaneous clearance. METHODS: The NABOGO trial (Trial registration number: NCT03294395) was a randomised controlled, double-blind, single-centre trial assessing non-inferiority of ertapenem, gentamicin and fosfomycin to ceftriaxone for treatment of uncomplicated gonorrhoea. For asymptomatic NABOGO participants, we collected pre-enrolment and enrolment visit samples before trial medication was given. Spontaneous clearance was defined as a positive pre-enrolment nucleic acid amplification test (NAAT) result, followed by a negative NAAT at enrolment. We compared the median time between pre-enrolment and enrolment visits for patients who cleared spontaneously and for those who did not. Determinants of spontaneous clearance were assessed using logistic regression. RESULTS: Thirty-two of 221 (14.5%) anal NG infections cleared spontaneously, 17 of 91 (18.7%) pharyngeal, 3 of 13 (23.1%) vaginal and 9 of 28 (32.1%) urethral NG infections. The median time between the pre-enrolment and enrolment visit was longer for patients who cleared their pharyngeal infection spontaneously compared with those who did not (median 8 days (IQR=7-11) vs 6 days (IQR=4-8), p=0.012); no determinants of clearance at other sites were identified. Overall, patients with more days between the pre-enrolment and enrolment visit were more likely to clear spontaneously (adjusted OR=1.06 per additional day, 95% CI 1.01 to 1.12). No association between location of NG infection and spontaneous clearance was found. CONCLUSIONS: A significant proportion of asymptomatic patients cleared their NG infections spontaneously. Given these results, treatment of all NG infections after a one-time NAAT may be excessive, and more research on the natural history of NG is needed to improve antibiotic stewardship.

Efficacy of ertapenem, gentamicin, fosfomycin, and ceftriaxone for the treatment of anogenital gonorrhoea (NABOGO): a randomised, non-inferiority trial.

BACKGROUND: Neisseria gonorrhoeae causes gonorrhoea, a common sexually transmitted infection. Emerging strains resistant to first-line ceftriaxone threaten N gonorrhoeae management. Hence, alternative treatments are needed. We aimed to evaluate the efficacy of ertapenem, gentamicin, and fosfomycin as alternative treatments for anogenital N gonorrhoeae. METHODS: In a randomised, controlled, double-blind, non-inferiority trial (three experimental groups and one control group) at the Centre for Sexual Health in Amsterdam, Netherlands, we included adults aged 18 years or older, with anorectal or urogenital gonorrhoea. With random permuted blocks, participants were randomly assigned (1:1:1:1) to receive intramuscular 500 mg ceftriaxone (control group), intramuscular 1000 mg ertapenem, intramuscular 5 mg/kg gentamicin (maximum 400 mg), or oral 6 g fosfomycin. The primary outcome was the proportion of participants with a negative nucleic acid amplification test of the predefined primary infected site, 7-14 days after treatment. The primary analysis was per protocol (ie, excluding those lost to follow-up). The modified intention-to-treat analysis included all randomly assigned patients with anogenital gonorrhoea considering those lost-to-follow-up as treatment failure. Non-inferiority was established if the lower Hochberg-corrected 95% CI for difference between the experimental and control groups was greater than -10%. For the analysis of adverse events, we included all participants who received medication. The trial was registered at ClinicalTrials.gov (NCT03294395) and is complete. FINDINGS: Between Sept 18, 2017, and June 5, 2020, from 2160 patients invited to participate, we assigned 346 (16%) participants to receive either ceftriaxone (n=103), ertapenem (n=103), gentamicin (n=102), or fosfomycin (n=38). The fosfomycin group was terminated early after interim analysis revealed less than 60% efficacy. In the primary per-protocol analysis, 93 (100%) of 93 patients in the ceftriaxone group, 86 (99%) of 87 patients in the ertapenem group, 79 (93%) of 85 patients in the gentamicin group, and four (12%) of 33 patients in the fosfomycin group cleared N gonorrhoeae (risk difference vs ceftriaxone -0·01 [95% CI -0·08 to 0·05] for ertapenem and -0·07 [-0·16 to -0·01] for gentamicin). Thus, ertapenem proved non-inferior to ceftriaxone. In mITT analysis, risk differences versus ceftriaxone were -0·08 (-0·17 to 0·003) for ertapenem and -0·11 (-0·21 to -0·04) for gentamicin. We observed a higher proportion of patients with at least one adverse event in the ertapenem group (58 [56%] of 103) and fosfomycin group (36 [95%] of 38) versus the ceftriaxone group (24 [23%] of 103). INTERPRETATION: Single-dose 1000 mg ertapenem is non-inferior to single-dose 500 mg ceftriaxone in gonorrhoea treatment. Yet, 5 mg/kg gentamicin (maximum 400 mg) is not non-inferior to ceftriaxone. Ertapenem is a potential effective alternative for anogenital N gonorrhoeae infections and merits evaluation for ceftriaxone-resistant infections. FUNDING: ZonMw and GGD-Amsterdam. TRANSLATION: For the Dutch translation of the abstract see Supplementary Materials section.

Incident urogenital and anorectal Chlamydia trachomatis in women: the role of sexual exposure and autoinoculation: a multicentre observational study (FemCure).

BACKGROUND: Anorectal infections with Chlamydia trachomatis (CT) are common in women visiting STI outpatient clinics. We here evaluated the risk posed by sexual exposure and by alternate anatomical site infection for incident anorectal and urogenital CT. METHODS: Prospective multicentre cohort study, FemCure. Participants were treated for CT, and after 4, 6, 8, 10 and 12 weeks, they self-collected anorectal and urogenital samples (swabs) for CT-DNA testing. We calculated the proportion with incident CT, that is, CT incidence (at weeks 6-12) by 2-week time-periods. Compared with no exposure (A), we estimated the risk of incident CT for (B) sexual exposure, (C) alternate site anatomic site infection and (D) both, adjusted for confounders and expressed as adjusted ORs with 95% CIs. RESULTS: We analysed data of 385 participants contributing 1540 2-week periods. The anorectal CT incidence was 2.9% (39/1343) (95 CI 1.8 to 3.6); 1.3% (A), 1.3% (B), 27.8% (C) and 36.7% (D). The ORs were: 0.91 (95% CI 0.32 to 2.60) (B), 26.0 (95% CI 7.16 to 94.34) (C), 44.26 (95% CI 14.38 to 136.21) (D).The urogenital CT incidence was 3.3% (47/1428) (95% CI 2.4 to 4.4); 0.7% (A), 1.9% (B), 13.9% (C) and 25.4% (D). The ORs were: 2.73 (95% CI 0.87 to 8.61) (B), 21.77 (95% CI 6.70 to 70 71) (C) and 49.66 (95% CI 15.37 to 160.41) (D). CONCLUSIONS: After initial treatment, an alternate anatomical site CT infection increased the risk for an incident CT in women, especially when also sex was reported. This may suggest a key role for autoinoculation in the re-establishment or persistence of urogenital and anorectal chlamydia infections.

Determinants associated with viable genital or rectal Chlamydia trachomatis bacterial load (FemCure).

BACKGROUND: Chlamydia trachomatis (CT) is routinely diagnosed by nucleic acid amplification tests (NAATs), which are unable to distinguish between nucleic acids from viable and non-viable CT organisms. OBJECTIVES: We applied our recently developed sensitive PCR (viability PCR) technique to measure viable bacterial CT load and explore associated determinants in 524 women attending Dutch sexual health centres (STI clinics), and who had genital or rectal CT. METHODS: We included women participating in the FemCure study (Netherlands, 2016-2017). At the enrolment visit (pre-treatment), 524 were NAAT positive (n=411 had genital and rectal CT, n=88 had genital CT only and n=25 had rectal CT only). We assessed viable rectal and viable genital load using V-PCR. We presented mean load (range 0 (non-viable) to 6.5 log10 CT/mL) and explored potential associations with urogenital symptoms (coital lower abdominal pain, coital blood loss, intermenstrual bleeding, altered vaginal discharge, painful or frequent micturition), rectal symptoms (discharge, pain, blood loss), other anatomical site infection and sociodemographics using multivariable regression analyses. RESULTS: In genital (n=499) CT NAAT-positive women, the mean viable load was 3.5 log10 CT/mL (SD 1.6). Genital viable load was independently associated with urogenital symptoms-especially altered vaginal discharge (Beta=0.35, p=0.012) and with concurrent rectal CT (aBeta=1.79; p<0.001). Urogenital symptoms were reported by 50.3% of women; their mean genital viable load was 3.6 log10 CT/mL (vs 3.3 in women without symptoms). Of 436 rectal CT NAAT-positive women, the mean rectal viable load was 2.2 log10 CT/mL (SD 2.0); rectal symptoms were reported by 2.5% (n=11) and not associated with rectal viable load. CONCLUSION: Among women diagnosed with CT in an outpatient clinical setting, viable genital CT load was higher in those reporting urogenital symptoms, but the difference was small. Viable genital load was substantially higher when women also had a concurrent rectal CT. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov NCT02694497.

Community-based HIV testing in The Netherlands: experiences of lay providers and end users at a rapid HIV test checkpoint.

BACKGROUND: The AIDS Healthcare Foundation (AHF-Checkpoint) in The Netherlands offers rapid HIV testing for key populations by lay providers. We explored the experiences and needs of lay providers and end users of HIV testing at AHF-Checkpoint, taking into account the WHO 5C-(consent, confidentiality, counselling, correct-results, connection-to-care) criteria for HIV test services. METHODS: Qualitative evaluation with 15 semi-structured interviews conducted during 2020 with ten lay providers and five gay or bisexual end users. Recorded interviews were thematically analysed, taking data triangulation into account. RESULTS: Four domains were identified: (1) accessibility of HIV testing, (2) quality of test procedures, (3) bridging (transitional care), and (4) future strategies for service delivery. AHF-Checkpoint fills a gap for key populations including LGBTQ and refugees, who experience HIV testing barriers at sexual health centres or general practices. The level of trust between lay providers and end users was highly valued by end users. They appreciated the low threshold to test at no costs, and the absence of waiting lists or triaging. Needs expressed by lay providers included more preparedness for emotionally charged situations, and extra training to improve STI knowledge. End users expressed a need for a full STI test package. Of the 5Cs, consent, counselling, and correct results were realised but confidentiality was sometimes difficult to achieve at pop-up locations, and referral barriers for confirmation testing (connection-to-care) were occasionally experienced by lay providers during weekends. CONCLUSION: AHF-Checkpoint was described as a convenient and easily accessible service by end users and lay providers. Of the WHO 5Cs, connection-to-care could be optimised to ensure HIV confirmation and STI testing through a liaison approach with professionals from the regular healthcare sector.

Recently acquired HIV infections and associated factors among men who have sex with men diagnosed at Dutch sexual health centres.

INTRODUCTION: Surveillance for recent HIV infections was implemented at Dutch sexual health centres (SHCs) for planning and evaluation of HIV prevention initiatives. The study objective is twofold: (1) to explore trends in recent HIV infections and associated socio-demographic and behavioural risk factors among men who have sex with men (MSM )attending SHCs, to gain insight into subgroups at risk for acquiring HIV and(2) to illustrate how comparison with different reference groups affect associations with these risk factors. METHODS: Residual plasma or serum samples from MSM newly HIV diagnosed at SHCs in 2014-2017 were tested with an avidity assay. Multinomial regression was used to analyse risk factors for recent HIV infections among MSM with established HIV infections among MSM and with HIV-negative MSM as reference groups. RESULTS: Of newly diagnosed MSM, 33% were classified as recent HIV infection with avidity testing. Combining HIV-negative test results with avidity outcomes resulted in 54% recent infections. Recent infection was associated with having an STI in the past, multiple partners and condom use for both reference groups of MSM. Additionally, relative to the HIV-negative MSM, recent infection was associated with education and having a non-Western origin. In contrast, relative to MSM with established HIV infections, recent infection was associated with Western origin. CONCLUSION: Our results suggest ongoing but declining transmission of HIV and high uptake of HIV testing among MSM visiting SHCs. The identification of risk factors for recent infections can help healthcare professionals to target subgroups eligible for PrEP or condom use promotion. Differentiation by the reference group in explanatory models for recent infections is important as different risk factors were identified. Likely, associations relative to HIV-negative MSM follow those of acquiring HIV infection in general, whereas the comparison with the established HIV infection reference rather reflects the frequent testing behaviour of subgroups of MSM.

Decreased Time to Viral Suppression After Implementation of Targeted Testing and Immediate Initiation of Treatment of Acute Human Immunodeficiency Virus Infection Among Men Who Have Sex With Men in Amsterdam.

BACKGROUND: Men who have sex with men (MSM) with acute human immunodeficiency virus (HIV) infection (AHI) are a key source of new infections. To curb transmission, we implemented a strategy for rapid AHI diagnosis and immediate initiation of combination antiretroviral therapy (cART) in Amsterdam MSM. We assessed its effectiveness in diagnosing AHI and decreasing the time to viral suppression. METHODS: We included 63 278 HIV testing visits in 2008-2017, during which 1013 MSM were diagnosed. Standard of care (SOC) included HIV diagnosis confirmation in < 1 week and cART initiation in < 1 month. The AHI strategy comprised same-visit diagnosis confirmation and immediate cART. Time from diagnosis to viral suppression was assessed for 3 cART initiation periods: (1) 2008-2011: cART initiation if CD4 < 500 cells/µL (SOC); (2) January 2012-July 2015: cART initiation if CD4 < 500 cells/µL, or if AHI or early HIV infection (SOC); and (3a) August 2015-June 2017: universal cART initiation (SOC) or (3b) August 2015-June 2017 (the AHI strategy). RESULTS: Before implementation of the AHI strategy, the proportion of AHI among HIV diagnoses was 0.6% (5/876); after implementation this was 11.0% (15/137). Median time (in days) to viral suppression during periods 1, 2, 3a, and 3b was 584 (interquartile range [IQR], 267-1065), 230 (IQR, 132-480), 95 (IQR, 63-136), and 55 (IQR, 31-72), respectively (P < .001). CONCLUSIONS: Implementing the AHI strategy was successful in diagnosing AHI and significantly decreasing the time between HIV diagnosis and viral suppression.

Evaluation of the Hepatitis C Testing Strategy for Human Immunodeficiency Virus-Positive Men Who Have Sex With Men at the Sexually Transmitted Infections Outpatient Clinic of Amsterdam, the Netherlands.

INTRODUCTION: As the incidence of hepatitis C virus (HCV) infections remains high among human immunodeficiency virus (HIV)-positive men who have sex with men (MSM) an HCV testing strategy was introduced at the sexually transmitted infections (STI) clinic in Amsterdam in 2017. We aimed to evaluate this HCV testing strategy. METHODS: The HIV-positive MSM and transgender women (TGW) were eligible for HCV testing (anti-HCV and HCV ribonucleic acid) at the STI clinic if they did not visit their HIV clinician in the 3 months before the consultation and had not been tested for HCV at the STI clinic in the previous 6 months. All eligible individuals were administered the 6 questions on risk behavior of the HCV-MSM observational study of acute infection with hepatitis C (MOSAIC) risk score; a risk score of 2 or greater made a person eligible for testing. RESULTS: From February 2017 through June 2018, 1015 HIV-positive MSM and TGW were eligible for HCV testing in 1295 consultations. Eleven active HCV infections (HCV ribonucleic acid positive) were newly diagnosed (positivity rate, 0.9%; 95% confidence interval [CI], 0.4-1.5%). Sensitivity and specificity of the HCV-MOSAIC score for newly diagnosed active HCV infections were 80.0% (95% CI, 49.0-94.3%) and 53.7% (95% CI, 50.8-56.5%), respectively. If an HCV-MOSAIC score of 2 or greater were used to determine whom to test, 46.6% of individuals currently tested for HCV would be eligible for testing. CONCLUSIONS: Using the new HCV testing strategy, HCV testing was done in 1295 consultations with HIV-positive MSM and TGW in 17 months. We newly diagnosed 11 active HCV infections. The HCV-MOSAIC risk score could reduce the number of tests needed, but some active HCV infections will be missed.

The impact of STI test results and face-to-face consultations on subsequent behavior and psychological characteristics.

Sexually transmitted infection (STI) testing without face-to-face counselling is increasingly offered at sexual health centers (SHC), and ordering self-sampling tests online is becoming more popular. However, the impact of testing without counselling on behavior is unknown. We examine the impact of STI testing with and without consultation and the combined effect of a positive test result and treatment consultation, on behavioral and psychological characteristics over time. Data from a longitudinal study among heterosexual SHC visitors aged 18-24 years was used. The impact of a test consultation (participants who tested chlamydia negative with vs. without consultation) and treatment consultation/positive test result (participants who tested chlamydia positive vs. negative), was assessed by comparing behavioral and psychological characteristics before testing (baseline), and at three-week and six-month follow-up, using generalized estimating equation models. Changes after testing were similar between participants who tested chlamydia negative with and without test consultation, namely decreased risk perception, shame, number of partners, and increased knowledge. However, participants who tested chlamydia positive reported stronger increases in health goals and intentions towards condom use, and stronger decreases in the number of partners and stigma, compared to participants who tested negative. Furthermore, condom use increased in chlamydia positive, and decreased in chlamydia negative participants. A treatment consultation/positive test result had a risk-reducing impact on behavioral and psychological characteristics, whereas the impact of a test consultation was limited. Since the majority of young heterosexuals test chlamydia negative, alternative interventions (e.g., online) achieving risk-reducing behavior change targeted to individuals who tested negative are needed.

Types of Group Sex and Their Association with Different Sexual Risk Behaviors Among HIV-Negative Men Who Have Sex with Men.

The current study sought to identify types of group sex acts among HIV-negative men who have sex with men (MSM) and assess their association with different sexual risk behaviors using cross-sectional data of group sex acts reported during 6 waves (2015-2018) of the Amsterdam MSM Cohort Study. Latent class analysis was performed to identify group sex types based on size, familiarity with partners, location, planning, and drug use. Associations between group sex types and sexual behaviors were evaluated using logistic regression with generalized estimating equations, employing the sample mean as a reference. Data at the level of group sex acts were analyzed, while correcting variance estimations for repeated measurements within MSM. A total of 392 MSM engaged in group sex ≥ 1 times, totaling 1033 group sex acts. Four types of group sex emerged: familiar (29%), intimate (27%), impromptu (36%), and party (8%). Familiar group sex (characterized by high proportions of mostly known partners, occurring in private places and involving drug use) had an increased adjusted odds of risky fingering (aOR 1.6, 95%CI 1.3-2.0) and of risky fisting and/or use of sex toys (aOR 2.3, 95%CI 1.6-3.1). Intimate group sex (characterized by high proportions of threesomes, occurring in private places, and not involving drug use) had a decreased adjusted odds of risky fisting and/or use of sex toys (aOR 0.6, 95%CI 0.4-0.9). Impromptu group sex (characterized by high proportions of spontaneity, mostly unknown partners, and taking place in public places) had a decreased adjusted odds of risky fisting and/or use of sex toys (aOR 0.5, 95%CI 0.3-0.7) and of condomless anal intercourse (CAI) (OR 0.6, 95%CI 0.5-0.8). Party group sex (characterized by high proportions of larger groups, mostly unknown partners, and being planned) had an increased adjusted odds of risky fisting and/or use of sex toys (aOR 1.6, 95%CI 1.0-2.7) and of CAI (aOR 1.5, 95%CI 1.1-2.1). The identified types of group sex reflect different dynamics and characteristics, with some types riskier for STIs and others riskier for HIV. HIV and STI prevention efforts could be tailored accordingly. For example, in certain type of public sex environments (e.g., cruising parks), traditional HIV and STI prevention efforts, such as promoting of condom use and PrEP, might be sufficient. However, in other settings (e.g., private parties), where group sex is more likely to be planned and where behaviors such as fisting, sharing of sex toys, and CAI are more likely to take place, which carry different levels of risk for HIV and STI transmission, including that of Hepatitis C, different approaches might be needed, such as broader HIV and STI prevention education efforts or targeting the organizers of group sex events.

Participation, retention, and associated factors of women in a prospective multicenter study on Chlamydia trachomatis infections (FemCure).

Prospective studies are key study designs when attempting to unravel health mechanisms that are widely applicable. Understanding the internal validity of a prospective study is essential to judge a study's quality. Moreover, insights in possible sampling bias and the external validity of a prospective study are useful to judge the applicability of a study's findings. We evaluated participation, retention, and associated factors of women in a multicenter prospective cohort (FemCure) to understand the study's validity.Chlamydia trachomatis (CT) infected adult women, negative for HIV, syphilis, and Neisseria gonorrhoeae were eligible to be preselected and included at three sexually transmitted infection (STI) clinics in the Netherlands (2016-2017). The planned follow-up for participants was 3 months, with two weekly rectal and vaginal CT self-sampling and online questionnaires administered at home and at the clinic. We calculated the proportions of preselected, included, and retained (completed follow-up) women. Associations with non-preselection, noninclusion, and non-retention (called attrition) were assessed (logistic and Cox regression).Among the 4,916 women, 1,763 (35.9%) were preselected, of whom 560 (31.8%) were included. The study population had diverse baseline characteristics: study site, migration background, high education, and no STI history were associated with non-preselection and noninclusion. Retention was 76.3% (n = 427). Attrition was 10.71/100 person/month (95% confidence interval 9.97, 12.69) and was associated with young age and low education. In an outpatient clinical setting, it proved feasible to include and retain women in an intensive prospective cohort. External validity was limited as the study population was not representative (sampling bias), but this did not affect the internal validity. Selective attrition, however (potential selection bias), should be accounted for when interpreting the study results.

Web-Supported Social Network Testing for HIV Among Men Who Have Sex With Men With a Migration Background: Protocol for a Mixed Methods Pilot Study.

BACKGROUND: Of newly diagnosed HIV positive men who have sex with men (MSM) in the Netherlands, 29% have a non-Western migration background (MSM-NW). Among MSM-NW, HIV positivity rates are high (0.8%-2.0%), as is the proportion of late stage infections (39%). Factors such as HIV and sexual orientation-related stigma may form barriers for timely testing. Innovative approaches for HIV testing are needed to better reach MSM-NW. Social network testing (SNT) for HIV is an evidence-supported approach where peer recruiters identify persons (network associates) who could benefit from testing in their social or sexual networks. Web-supported SNT might be particularly promising for reaching people who may not be reached by regular care. OBJECTIVE: The purpose of this paper is to describe the design of our pilot PREVENT (Peer-Empowered Voluntary Extended Network Testing). In this pilot, we will explore whether SNT using HIV self-tests is feasible and acceptable among MSM-NW in the Netherlands and whether it reaches those who were never or not recently tested for HIV (>1 year ago). METHODS: The project aims to include 50 to 60 MSM and MSM-NW peers who will distribute 4 to 5 oral HIV self-tests each aiming to reach 200 network associates (NAs). Enrollment of peers includes 4 steps: (1) fostering interest in becoming a peer by health care professionals at sexual health clinics, HIV treatment clinics, and community settings; (2) sending peer contact information to the peer coordinator; (3) registering peers and giving program instructions by the peer coordinator and referring to the Web-based training at time2test; and (4) receiving precoded HIV self-tests for distribution in the peers' networks. NAs who receive the self-test will log in with their test package code in the time2test application for step-by-step test instructions. After testing is complete, NAs receive tailored follow-up information depending on their test result. RESULTS: Between January and May 2019, 10 STI clinics and 7 HIV treatment clinics started recruiting peers. Results of the PREVENT pilot are expected in December 2020. CONCLUSIONS: This is the first Web-supported peer-driven SNT pilot using HIV self-tests in the Netherlands and one of the first in Europe. Implementation is considered successful if it reaches MSM-NW who were never or not recently tested for HIV. Additionally, it may encourage conversations within the networks about risk behavior and barriers to HIV testing, potentially contributing to the Joint United Nations Programme on HIV/AIDS goal of zero HIV infections. TRIAL REGISTRATION: Netherlands Trial Registry NL7424; https://www.trialregister.nl/trial/7424. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/14743.

Longitudinal Patterns of Sexually Transmitted Infection Risk Based on Psychological Characteristics and Sexual Behavior in Heterosexual Sexually Transmitted Infection Clinic Visitors.

BACKGROUND: Great heterogeneity in sexually transmitted infections (STI) risk exists, and investigating individual-level characteristics related to changes in STI risk over time might facilitate the development and implementation of effective evidence-based behavior change interventions. The aim of this study was to identify longitudinal patterns of STI risk based on psychological and behavioral characteristics. METHODS: A longitudinal study was conducted among heterosexual STI clinic visitors aged 18 to 24 years. Latent classes based on behavioral and psychological characteristics at baseline, and transitions from 1 latent class to another at 3-week, 6-month, and 1-year follow-up, were identified using latent transition analysis. RESULTS: Four latent classes were identified that could be differentiated by psychological and behavioral characteristics and STI risk: overall low-risk (10%), insecure high-risk (21%), condom-users (38%), and confident high-risk (31%). Although the majority of the total study population did not move to another latent class over time, the size of the overall low-risk group increased from 10% at baseline to 30% after 1 year. This was mainly due to transitions from the insecure high-risk, condom-users, and confident high-risk class at 3-week follow-up to the overall low-risk class at 6-month follow-up. CONCLUSIONS: Distinct subgroups among heterosexual STI clinic visitors can be differentiated from each other by multiple psychological and behavioral characteristics, and these characteristics reflecting the risk of acquiring STI are consistent over the course of 1 year in most individuals. An integral approach, adapting behavioral interventions to match multiple psychological and behavioral characteristics of high-risk subgroups, might be more effective in controlling STI transmission.

Comparison of collection methods for molecular detection of α-herpes viruses and Treponema pallidum, including evaluation of critical transportation conditions.

The detection of herpes simplex viruses and Treponemal pallidum from genital lesions requires efficient sampling of genetic material for a reliable molecular diagnosis. From 460 patients attending the Public Health clinic, two swabs (dry cotton swabs and Eswabs) per patient were collected in alternating order from the same lesion. Additionally, three storage conditions of Eswabs up to 28 days were evaluated to assess the stability of DNA over time. Out of the 830 PCRs performed, 20 (2.4%) PCRs were discordant between the two swabs. No significant differences were observed between the two sample types. HSV1 and HSV2 could be reliably detected from Eswabs up to 28 days when kept at room temperature. A single swab from a genital lesion is sufficient for reliable diagnosis of α-herpes viruses and Treponemal pallidum, for which both a dry cotton swab or Eswab could be used.

A Multidimensional Approach to Assessing Infectious Disease Risk: Identifying Risk Classes Based on Psychological Characteristics.

Prevention of infectious diseases depends on health-related behavior, which is often influenced by psychological characteristics. However, few studies assessing health-related behavior have examined psychological characteristics to identify risk groups, and this multidimensional approach might improve disease risk assessment. We aimed to characterize subgroups based on psychological characteristics and examine their influence on behavior and disease risk, using chlamydia as a case study. Selected participants (heterosexuals aged 18-24 years and females aged 18-24 years who had sex with both men and women) in a Dutch longitudinal cohort study (the Mathematical Models Incorporating Psychological Determinants: Control of Chlamydia Transmission (iMPaCT) Study) filled out a questionnaire and were tested for chlamydia (2016-2017). Latent class analysis was performed to identify risk classes using psychological predictors of chlamydia diagnosis. Two classes were identified: class 1 (n = 488; 9% chlamydia diagnosis) and class 2 (n = 325; 13% chlamydia diagnosis). The proportion of participants with high shame, high impulsiveness, and lower perceived importance of health was higher in class 2 than in class 1. Furthermore, persons in class 2 were more likely to be male and to report condomless sex compared with class 1, but the number of recent partners was comparable. Thus, risk classes might be distinguished from each other by psychological characteristics beyond sexual behavior. Therefore, the impact of the same intervention could differ, and tailoring interventions based on psychological characteristics might be necessary to reduce chlamydia prevalence most effectively.

Hepatitis A incidence, seroprevalence, and vaccination decision among MSM in Amsterdam, the Netherlands.

BACKGROUND: Several outbreaks of Hepatitis A virus (HAV) were recently documented among men who have sex with men (MSM) in Europe. We investigated the HAV incidence among MSM in Amsterdam, the Netherlands; and HAV seroprevalence and HAV vaccination decision among MSM visiting the Sexually Transmitted Infection (STI) clinic in Amsterdam. METHODS: Using surveillance data from 1992 to 2017 of MSM with acute HAV in Amsterdam, we estimated the incidence by calendar year and age. We explored HAV seroprevalence by calendar year and age, determinants for HAV seropositivity, and opting-in/out for HAV vaccination using data collected among MSM that visited the STI clinic between 2006 and 2017 and were included in a nationwide Hepatitis B virus (HBV) vaccination programme. Offering HAV vaccination at the STI clinic differed over three consecutive periods: not offered, offered for free, or offered for 75 euros. Logistic regression analyses were used to explore determinants. RESULTS: HAV incidence increased in 2016/17 after 4 years of absence and peaked in MSM around 35 years of age. Among MSM visiting the STI clinic, HAV seroprevalence was 37% (95%CI = 35-40%), which was constant over the period 2006-2017, and increased with age (p < 0.001). Determinants for HAV seropositivity in multivariable analysis were: older age (p < 0.001), originating from an HAV endemic country (p < 0.001), and being HBV seropositive (p = 0.001). MSM opted-in more frequently when HAV vaccination was offered for free versus paid (89% versus 11%, respectively; p < 0.001). Younger MSM were less inclined to vaccinate when payment was required (p = 0.010). Post-hoc analyses showed that 98% versus 46% of MSM visiting the Amsterdam STI clinic would be protected against HAV infection if HAV vaccination was offered for free or for 75 euros, respectively. CONCLUSIONS: The MSM population of Amsterdam is vulnerable to a new HAV outbreak. We strongly recommend that MSM have access to free hepatitis A vaccination.

Treatment Effectiveness of Azithromycin and Doxycycline in Uncomplicated Rectal and Vaginal Chlamydia trachomatis Infections in Women: A Multicenter Observational Study (FemCure).

BACKGROUND: Rectal infections with Chlamydia trachomatis (CT) are prevalent in women visiting a sexually transmitted infection outpatient clinic, but it remains unclear what the most effective treatment is. We assessed the effectiveness of doxycycline and azithromycin for the treatment of rectal and vaginal chlamydia in women. METHODS: This study is part of a prospective multicenter cohort study (FemCure). Treatment consisted of doxycycline (100 mg twice daily for 7 days) in rectal CT-positive women, and of azithromycin (1 g single dose) in vaginally positive women who were rectally untested or rectally negative. Participants self-collected rectal and vaginal samples at enrollment (treatment time-point) and during 4 weeks of follow-up. The endpoint was microbiological cure by a negative nucleic acid amplification test at 4 weeks. Differences between cure proportions and 95% confidence intervals (CIs) were calculated. RESULTS: We analyzed 416 patients, of whom 319 had both rectal and vaginal chlamydia at enrollment, 22 had rectal chlamydia only, and 75 had vaginal chlamydia only. In 341 rectal infections, microbiological cure in azithromycin-treated women was 78.5% (95% CI, 72.6%-83.7%; n = 164/209) and 95.5% (95% CI, 91.0%-98.2%; n = 126/132) in doxycycline-treated women (difference, 17.0% [95% CI, 9.6%-24.7%]; P < .001). In 394 vaginal infections, cure was 93.5% (95% CI, 90.1%-96.1%; n = 246/263) in azithromycin-treated women and 95.4% (95% CI, 90.9%-98.2%; n = 125/131) in doxycycline-treated women (difference, 1.9% [95% CI, -3.6% to 6.7%]; P = .504). CONCLUSIONS: The effectiveness of doxycycline is high and exceeds that of azithromycin for the treatment of rectal CT infections in women. CLINICAL TRIALS REGISTRATION: NCT02694497.

Stable Low Hepatitis C Virus Antibody Prevalence Among HIV-Negative Men Who Have Sex With Men Attending the Sexually Transmitted Infection Outpatient Clinic in Amsterdam, 2007 to 2017.

BACKGROUND: In response to the increased hepatitis C virus (HCV) prevalence recently found among participants of the Amsterdam preexposure prophylaxis demonstration project, we evaluated HCV prevalence over time and the performance of the HCV-MOSAIC risk score for detection of HCV infection in HIV-negative men who have sex with men (MSM) attending the Amsterdam sexually transmitted infection (STI) clinic. METHODS: In October 2016, HIV-negative MSM were tested for anti-HCV and HCV RNA and completed the HCV-MOSAIC risk score. Anti-HCV prevalence was compared with that found in cross-sectional studies at the Amsterdam STI clinic (2007-2017). The time trend in HCV prevalence was modeled via logistic regression. The performance of the HCV-MOSAIC risk score, adjusted to identify prevalent HCV infection, was evaluated by calculating sensitivity and specificity. RESULTS: Of 504 HIV-negative MSM tested in October 2016, 5 were anti-HCV positive (1.0%, 95% confidence interval [CI], 0.4%-2.3%) and all were HCV RNA negative. Sensitivity and specificity of the adjusted HCV-MOSAIC risk score for prevalent infection were 80.0% (95% CI, 37.6%-96.4%) and 56.1% (95% CI, 51.7%-60.4%), respectively. The overall anti-HCV prevalence among 3264 HIV-negative MSM participating in cross-sectional studies at the Amsterdam STI clinic (2007-2017) was 0.8% (95% CI, 0.5%-1.2%) and did not change over time (P = 0.55). CONCLUSIONS: Anti-HCV prevalence among HIV-negative MSM attending the Amsterdam STI clinic in October 2016 was 1.0% and remained stable over time. We would therefore not recommend routine HCV screening of HIV-negative MSM at the STI clinic. However, given the increased prevalence among MSM using preexposure prophylaxis, periodic monitoring of HCV prevalence remains important.