Changes in the prevalence of self-reported sexually transmitted bacterial infections from 2010 and 2017 in two large European samples of men having sex with men-is it time to re-evaluate STI-screening as a control strategy?

BACKGROUND/OBJECTIVES: Many European countries reported increased numbers of syphilis, gonorrhoea and chlamydia diagnoses among men who have sex with men (MSM) in recent years. Behaviour changes and increased testing are thought to drive these increases. METHODS: In 2010 and 2017, two large online surveys for MSM in Europe (EMIS-2010, EMIS-2017) collected self-reported data on STI diagnoses in the previous 12 months, diagnostic procedures, STI symptoms when testing, number of sexual partners, and sexual behaviours such as condom use during the last intercourse with a non-steady partner in 46 European countries. Multivariate regression models were used to analyse factors associated with diagnoses of syphilis, gonorrhoea/chlamydia, and respective diagnoses classified as symptomatic and asymptomatic. If applicable, they included country-level screening rates. RESULTS: Questions on STI diagnoses and sexual behaviours were answered by 156,018 (2010) and 125,837 (2017) participants. Between 2010 and 2017, overall diagnoses with gonorrhoea/chlamydia and syphilis increased by 76% and 83% across countries. Increases were more pronounced for asymptomatic compared to symptomatic infections. The proportion of respondents screened and the frequency of screening grew considerably. Condomless anal intercourse with the last non-steady partner rose by 62%; self-reported partner numbers grew. Increased syphilis diagnoses were largely explained by behavioural changes (including more frequent screening). Gonorrhoea/chlamydia increases were mainly explained by more screening and a change in testing performance. A country variable representing the proportion of men screened for asymptomatic infection was positively associated with reporting symptomatic gonorrhoea/chlamydia, but not syphilis. DISCUSSION/CONCLUSION: The positive association of country-level screening rates with the proportion of symptomatic infections with gonorrhoea/chlamydia may indicate a paradoxical effect of screening on incidence of symptomatic infections. Treatment of asymptomatic men might render them more susceptible to new infections, while spontaneous clearance may result in reduced susceptibility. Before expanding screening programmes, evidence of the effects of screening and treatment is warranted.

High Rate of Repeat Sexually Transmitted Diseases Among Men Who Have Sex With Men in South Africa: A Prospective Cohort Study.

We observed a high rate of incident sexually transmitted diseases within 55 days (median) of follow-up (78% retention) among symptomatic men who have sex with men (n = 78) in South Africa (188 per 100 person-years; 95% confidence interval, 1.2-2.7); 16 newly acquired and 10 with persistent positivity. This highlights the need to strengthen prevention efforts, whereas introduction of diagnostics is urgently warranted.

Chemsex among men - a questionnaire study. / Chemsex blant menn ­ en spørreundersøkelse.

BAKGRUNN: Formålet med undersøkelsen var å kartlegge forekomsten av rusmiddelbruk under sex (chemsex) blant et utvalg av mannlige pasienter ved Olafiaklinikken i Oslo, en poliklinikk for seksuelt overførbare infeksjoner. Vi ønsket også å se hvilke variabler innen psykisk helse, seksuelt overførbare infeksjoner og seksualatferd som var assosiert med chemsex for menn som har sex med menn og menn som har sex med kvinner. MATERIALE OG METODE: Studien var anonym og spørreskjemabasert blant mannlige pasienter ved poliklinikken i perioden 1.7.2016-20.10.2016. RESULTATER: Svarprosenten var 96 (1 050 fikk utdelt skjema, 1 013 ble inkludert). Av disse rapporterte 144 (14 %) bruk av chemsex i løpet av det siste året - 87 (17 %) menn som har sex med menn og 57 (12 %) menn som har sex med kvinner. Av de som hadde hatt chemsex, oppga flere menn som har sex med menn hivinfeksjon, at de hadde hatt syfilis, over ti sexpartnere og hadde deltatt på sexfest det siste året. Flere menn som har sex med kvinner oppga psykiske plager. FORTOLKNING: Det bør utredes nærmere hvordan helsevesenet best kan møte chemsexbrukernes behov. Spesielt er det viktig med informasjon om skadereduksjonstiltak og støtte til de som ønsker å slutte eller redusere bruken av chemsex.

Impact of insurance coverage on HIV transmission potential among antiretroviral therapy-treated youth living with HIV.

OBJECTIVE: To identify the prevalence of high HIV transmission potential in a cohort of youth living with HIV (YLWH), and determine the impact of insurance coverage on potential for HIV transmission. DESIGN: Retrospective cohort study of antiretroviral therapy (ART)-treated YLWH at a US adolescent HIV clinic, 2002-2015. METHODS: The primary exposure was presence or absence of insurance, defined as private, public or pharmacy-only coverage. The primary outcome was high HIV transmission potential, defined as time-concurrent incident bacterial sexually transmitted infections (STI) (gonorrhea, chlamydia or syphilis) and HIV RNA greater than 1500 copies/ml. Marginal structural models adjusting for baseline demographic covariates, prior history of STI and time-varying retention in care assessed the relationship between insurance status and HIV transmission potential. RESULTS: Participants (n = 240) were followed for a median of 22 (IQR 8.1-49) months after ART initiation, and were predominately African-American men and transgender women who have sex with men, with a median age at HIV diagnosis of 19 years (IQR 17-21). We identified 37 (15%) participants with at least one episode of high HIV transmission potential. Insurance coverage was associated with a greater than 50% lower odds of high HIV transmission potential (aOR 0.46, 95% CI 0.26-0.84), and history of STI at or before entry to HIV care conferred more than three-fold higher odds of high transmission potential (aOR 3.21, 95% CI 1.55-6.63). CONCLUSION: We found 15% of YLWH to have episodic high HIV transmission potential despite receiving ART. Insurance coverage, including pharmacy-only benefits, was protective against transmission risk, suggesting a pivotal role for universal ART coverage in treatment as prevention.

[Chlamydia: from population screening to individual repeated screening]. / Chlamydia: du dépistage de la population au dépistage individuel répété.

Chlamydia trachomatis is a frequent sexually transmitted infection especially in young adults and adolescents. Its complications can impair a woman's reproductive potential. chlamydia control has several challenges. These include asymptomatic infections; a long duration of untreated infections; re-infections and partner treatments. Any person with infection is at high risk of re-infection. Repeated screening would decrease, at an individual level, the risk of complications. General practitioners, gynaecologists and centres for sexual health could participate in Chlamydia screening for asymptomatic infections, in Switzerland, the cost of the laboratory test is fixed by national tariff regulations. The cost is high and prohibitive for many, especially adolescents and young adults and needs to be lowered.

Are social organizational factors independently associated with a current bacterial sexually transmitted infection among urban adolescents and young adults?

This study explored the relationship between the social organization of neighborhoods including informal social control and social cohesion and a current bacterial sexually transmitted infection (STI) among adolescents and young adults in one U.S. urban setting. Data for the current study were collected from April 2004 to April 2007 in a cross-sectional household study. The target population included English-speaking, sexually-active persons between the ages of 15 and 24 years who resided in 486 neighborhoods. The study sample included 599 participants from 63 neighborhoods. A current bacterial STI was defined as diagnosis of a chlamydia and/or gonorrhea infection at the time of study participation. Participants reported on informal social control (i.e. scale comprised of 9 items) and social cohesion (i.e. scale comprised of 5 items) in their neighborhood. In a series of weighted multilevel logistic regression models stratified by gender, greater informal social control was significantly associated with a decreased odds of a current bacterial STI among females (AOR 0.53, 95% CI 0.34, 0.84) after controlling for individual social support and other factors. The association, while in a similar direction, was not significant for males (AOR 0.73, 95% CI 0.48, 1.12). Social cohesion was not significantly associated with a current bacterial STI among females (OR 0.85, 95% CI 0.61, 1.19) and separately, males (OR 0.98, 95% CI 0.67, 1.44). Greater individual social support was associated with an almost seven-fold increase in the odds of a bacterial STI among males (AOR 6.85, 95% CI 1.99, 23.53), a finding which is in contrast to our hypotheses. The findings suggest that neighborhood social organizational factors such as informal social control have an independent relationship with sexual health among U.S. urban youth. The causality of the relationship remains to be determined.

HIV screening in commercially insured patients screened or diagnosed with sexually transmitted diseases or blood-borne pathogens.

BACKGROUND: The Centers for Disease Control strongly recommends HIV screening for all patients who present to health care settings with sexually transmitted diseases (STD) or blood-borne pathogens exposure. The objective of this study is to assess the rates and determinants of HIV screening in a national sample of commercially insured patients screened or diagnosed with an STD or hepatitis B or C. METHODS: We used Poisson regression model with a robust error variance to assess the determinants of HIV screening using administrative claims data from health plans across 6 states (n = 270,423). RESULTS: The overall HIV screening rate of patients who were diagnosed or screened for STDs or hepatitis was low (32.7%); rates were lowest for patients presenting with epididymitis or granuloma inguinale (<10%). Patients aged 25 to 34 years were more likely to be screened than other age groups. Females were significantly less likely to be screened for HIV (prevalence ratio = 0.90; 95% CI = 0.89, 0.91) than males. Patients living in states where no written HIV informed consent was required were significantly more likely to be screened than those living in states where written HIV informed consent was specifically required. CONCLUSIONS: HIV screening rates were low and varied by STD categories. Females and younger and older patients were at increased risk of no HIV screening. Requiring specific written informed consent for HIV screening resulted in less HIV screening. Interventions are urgently needed to increase the HIV screening rate among this at-risk population.

Is screening for pharyngeal Chlamydia trachomatis warranted in high-risk groups?

A recent survey reported that 36% of UK genitourinary medicine clinics offer testing for pharyngeal Chlamydia trachomatis (CT). Screening at this site is targeted at high-risk groups attending our centre, including female sex workers (FSWs) and male sex workers (MSWs). A total of 2406 patients were screened between November 2006 and October 2007. A retrospective case-note review was performed for positive cases. The prevalence of pharyngeal CT was 1.9% in both men and women. The mean number of sexual partners reported in the preceding three months was 168 and 56 for FSWs and MSWs, respectively. Lack of consistent condom use and high numbers of sexual partners identify this population as potential core transmitters of infection. While the British Association of Sexual Health and HIV (BASHH) guidelines do not recommend routine screening for pharyngeal CT, there may be a role in selected high-risk populations.

Asymptomatic sexually transmitted infections in HIV-infected men who have sex with men: prevalence, incidence, predictors, and screening strategies.

Sexually transmitted infections (STIs) have increased among men who have sex with men (MSM) and are associated with unsafe sex practices, intrinsic morbidity, and enhanced genital shedding and transmission of HIV. Screening for asymptomatic STIs is recommended as part of the HIV prevention efforts, however, optimal screening strategies among HIV-infected MSM have not been well defined. In this study, conducted from April 2004 to September 2006, 212 HIV-infected MSM from two urban HIV clinics were screened for asymptomatic STIs. Testing for Neisseria gonorrhea and Chlamydia trachomatis from pharynx, rectum, and urine, as well as serologic testing for syphilis were performed initially, and then after 6 and 12 months. A self-administered questionnaire was used to assess possible predictors of incident asymptomatic STIs. A cost analysis was performed to assess different screening strategies for detecting incident STIs. The baseline prevalence of STIs was 14% (n = 29; 95% confidence interval [CI] 9%-19%) and the incidence of new infections was 20.8 cases per 100 person years (95% CI 14.8-28.4 cases per 100 person years). Younger age, higher CD4 cell count, and marijuana use were associated with increased risk of acquiring an asymptomatic STI. The laboratory cost to detect one positive STI did not significantly differ between once- and twice-yearly screening. However, almost half of all incident STIs were detected at the 6-month screening visit, potentially resulting in an increased duration of infectivity if these cases remained undiagnosed. In conclusion, prevalent and incident asymptomatic STIs are common among HIV-infected MSM. Our data support current Center for Disease Control and Prevention STI guidelines that recommend routine screening at increased frequency for HIV-infected MSM.

Epidemiology of male same-sex behaviour and associated sexual health indicators in low- and middle-income countries: 2003-2007 estimates.

OBJECTIVES: To conduct a systematic review of published and unpublished data from research and public health information systems on the prevalence of male-to-male sex in the total male population; as well as among men who have sex with men (MSM), data on prevalence of heterosexual activity and heterosexual unions; prevalence of condom use with male and female partners; and prevalence of HIV infection and other sexually transmitted infections (STIs). METHODS: Key indicators were defined (a) among men in the general population: prevalence of sex with a man ever and last year; (b) among MSM: prevalence of heterosexual experiences ever and last year; proportion of male-female transgenders; proportion of sex workers; prevalence of HIV and other STIs, condom use in last sexual encounter; consistent condom use with men last year; never used a condom with a man. With help from key informants, study searches were conducted in Pubmed, LILLACS, institutional databases, conference records and other sources. Methodology and quality of information were assessed, and the best data available for 2003-7 were selected. Indicator estimates from each study were used to propose regional estimate ranges. RESULTS: A total of 83 new entries were entered into the database in addition to the previous 561, totalling 644. Of these, 107 showing 2003-7 data were selected. Many new studies came from sub-Saharan Africa, portraying hidden HIV epidemics among MSM. The most frequently reported estimate was HIV infection, with high estimate ranges in most of the regions, except for Middle East and North Africa and Eastern Europe. The next most frequently reported was lifetime frequency of heterosexual sex, showing that roughly 50% of MSM ever had sex with a woman. The small number of newer studies reporting prevalence of "sex with a man in last 12 months" between 2003 and 2007, did not warrant enough new evidence to revise our 2005 size estimates for MSM populations. CONCLUSIONS: A considerable number of new studies with estimates of relevance to understanding sexual behaviour and HIV among MSM were identified, with an encouraging amount of new data coming from sub-Saharan Africa. However, limitations in the quality, utility and comparability of available information persist. At least three measures could be promoted for use in surveillance and academic studies: standardised indicators for MSM studies; standardised operational definitions of, and instructions to describe, variables; and standardised research designs and data gathering strategies. A prerequisite for this all is intense advocacy to ensure a social climate in which research into such matters is prioritised, resources are made available as needed and the human rights of MSM are respected.

The cost-effectiveness of screening men for Chlamydia trachomatis: a review of the literature.

BACKGROUND: An important consideration in determining whether to implement or continue a program to screen men for chlamydia is its cost-effectiveness. A review of the literature on the cost-effectiveness of screening men for chlamydia could potentially provide guidance. METHODS: An Ovid Medline search was conducted for articles published between 1990 and July 2007 using terms for cost, chlamydia, and male. This search returned 175 articles; 25 were retained after eliminating those not relevant to cost-effectiveness studies of male chlamydia screening. We added 4 articles that were in-press or are published in this issue, for a total of 29. These articles were examined for common themes and their results summarized. RESULTS: The reviewed studies examined both proactive and opportunistic screening and included screening of risk groups and of the general population. Some older studies included enzyme immunoassays; more recent studies featured nucleic acid amplification assays. Six studies used dynamic transmission models. Fourteen studies analyzed male and female chlamydia screening interventions. Several contained sufficient data to examine the cost-effectiveness of male screening compared with female screening. Male screening was preferred to expanded female screening in 1 study. In other studies, combined male and female screening programs were cost-saving. CONCLUSIONS: Studies comparing chlamydia screening in men with chlamydia screening in women may be the most useful for guidance to programs. The studies which compare the 2 generally have found that screening men from the general population is not preferred to screening women from the general population, although 1 study found that screening of men from risk groups can be cost-effective compared with screening women from the general population.

Condoms for sexually transmissible infection prevention: politics versus science.

The present review assesses the protection that condoms offer against sexually transmissible infections (STI) and the impact that social, political and religious opinion in the USA has had in the past 8 years on promoting condoms for safer sex. Condoms offer protection against most STI. However, the degree of protection depends on correct and consistent use, the type of sexual activity and the biological characteristics of different infections. Cross-sectional and case-control studies and other observational data provide the majority of evidence for STI prevention. Condoms provide a high level of protection against those infections that are transmitted mainly via infected secretions, including HIV, gonorrhoea, chlamydia and trichomoniasis. Protection against those infections transmitted via skin and mucous membrane contact, including Herpes simplex virus infection and human papilloma virus, appears to be less. The Bush administration, driven by conservative political, social and religious elements in the USA, has mounted a concerted campaign to undermine the role of the condom in health-promotion activities in the USA and overseas by undervaluing and misrepresenting scientific data, and through a sustained and well-funded promotion of abstinence-only education. However, this has lead to considerable controversy and disillusionment with abstinence-only education, both at home and abroad, and there is now incontrovertible evidence that abstinence-only programs are ineffectual.

Incident sexually transmitted infections among persons living with diagnosed HIV/AIDS in New York City, 2001-2002: a population-based assessment.

OBJECTIVE/GOAL: To describe the incidence of 3 bacterial sexually transmitted infections (STIs) among persons living with human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) (PLWHA) in New York City (NYC) and to identify predictors for STI acquisition. STUDY DESIGN: The surveillance registry of PLWHA diagnosed with HIV through December 31, 2000, and reported to the NYC Department of Health and Mental Hygiene was matched with the surveillance registry of persons diagnosed with other STIs during 2001-2002. Incident STIs were defined as cases of gonorrhea, chlamydia, or early syphilis acquired after HIV diagnosis. RESULTS: Among 62,264 NYC PLWHA, 1466 (2.4%) had an incident STI diagnosed during 2001-2002. Two-year cumulative STI incidence was highest among PLWHA who were men (2.6%), non-Hispanic white (3.2%), aged 13-24 years (8.4%), men who have sex with men (4.5%), and persons living with HIV (non-AIDS) (4.1%). Predictors of STI acquisition among PLWHA varied substantially by STI type. CONCLUSIONS: This population-based surveillance registry cross-match reveals that high-risk sexual practices occur among specific segments of the NYC PLWHA population. To decrease associated morbidity and prevent the secondary spread of HIV and STIs, prevention efforts should focus on PLWHA who continue to engage in high-risk sexual activity.

[Chlamydia trachomatis infections--a time for action?]. / Chlamydia-trachomatis-Infektionen--Zeit zum Handeln?

Infection with Chlamydia trachomatis is the most common sexually transmitted disease in the world. In women it mainly occurs before the age of 25 years, while in men it can still be diagnosed till the age of 35 years. In Western Europe the prevalence of a Chlamydia trachomatis infection has been estimated, according to WHO data, as between 2.7% (Italy) and 8.0% (Island). A general screening strategy is now being discussed in Germany. A non-diagnosed and non-treated Chlamydia trachomatis infection and the resulting health problems have not only severe consequences for the individual but also results in major epidemiological and socio-economic public health problems. This issue is not only of extreme importance in health policy, but has also a major impact in family policy, especially in view of the declining birth rates and the demographic changes.

The cost effectiveness of screening for genital Chlamydia trachomatis infection in Australia.

BACKGROUND: In Australia, there is no published study on the cost effectiveness of screening for chlamydia. The aim of this study was to examine the cost effectiveness of a hypothetical screening programme for chlamydia based on annual opportunistic testing of all women 25 years of age or younger consulting a general practitioner, compared with no screening. METHODS: A decision-analytic modelling approach was used to determine the incremental cost effectiveness ratio (ICER) of screening compared with no screening over 25 years. The analysis measured Australian health-care costs and benefits were assessed in terms of quality-adjusted life years (QALYs). RESULTS: The analysis resulted in a cost per QALY of 2968 dollars for screening. One-way sensitivity analyses on all variables, and multi-way sensitivity analyses on some variables, showed a wide range for the cost effectiveness, from dominance (where screening is effective and saves money overall) to an ICER of 67,715 dollars per QALY. CONCLUSIONS: The results indicate that annual opportunistic screening for chlamydia in women under 25 is a potentially worthwhile undertaking. However, the analysis also highlights uncertainties around the natural history of chlamydia and the effectiveness of chlamydia screening. Given these uncertainties, the need for further primary data collection in these areas becomes apparent.

The burden and determinants of reproductive tract infections in India: a population based study of women in Goa, India.

BACKGROUND/OBJECTIVE: Reproductive tract infections (RTI) present major health, social, and economic problems in developing countries. Our objective was to describe the prevalence and risk factors of RTIs in a population based sample of women aged 18-45 years. METHOD: 2494 women of 3000 randomly selected from the population defined by a primary health centre catchment area consented to participate. Participants were interviewed regarding complaints and risk factors. Laboratory specimens were collected for the diagnosis of RTIs. Analyses of risk factors were carried out separately for the outcomes of sexually transmitted infections: chlamydia, gonorrhoea, trichomoniasis; and endogenous infections: bacterial vaginosis (BV) and candida. RESULTS: Endogenous infections were relatively common (BV 17.8%; candida 8.5%), and sexually transmitted infections (STI) were infrequent (4.2%). Factors indicative of poverty and marginalisation were associated with STIs and BV. Gender disadvantage, particularly spousal violence, was associated with BV, while concern about a husband's extramarital relationships, an indicator of sexual risk, was associated with STI. Husband's discharge was strongly associated with STI, and a non-white vaginal discharge was associated with both STI and BV. Condom use and oral contraceptive use were associated with a reduced risk of BV. CONCLUSIONS: Most of the population burden of RTIs is attributed to endogenous infections. Socioeconomic deprivation and gender disadvantage are associated with raised risk for BV, while the risk factors for STIs indicated that disadvantaged women were likely to be infected by their husbands.