High prevalence of sexually transmitted infections in HIV-infected men during routine outpatient visits in the Netherlands.

BACKGROUND: In the Netherlands, no guidelines exist for routine sexually transmitted infection (STI) screening of human immunodeficiency virus (HIV)-infected men having sex with men (MSM). We assessed prevalence and factors associated with asymptomatic STI. METHODS: MSM visiting HIV outpatient clinics of academic hospitals were tested for Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), syphilis, and hepatitis B and C infection. Prevalence and risk factors were studied using logistic regression. RESULTS: In total, 659 MSM were included between 2007 and 2008. STI were found in 16.0% of patients, mostly anal CT and syphilis. One new hepatitis B and 3 new hepatitis C infections were identified. In multivariate analyses, any STI (syphilis, CT, or NG) was associated with patient's age below 40 years (odds ratio [OR]: 2.5, 95% confidence interval [CI]: 1.3-5.0), having had sex with 2 or more sexual partners (OR 2.1, 95% CI: 1.2-3.5), the use of the same sexual toys with a sexual partner (OR 2.2, 95% CI: 1.0-4.9), and enema use before sex (OR: 2.3, 95% 1.2-4.2). Syphilis was independently associated with fisting with gloves versus no fisting (OR: 4.9, 95% CI: 1.7-13.7) and with rimming (OR: 5.0, 95% CI: 1.7-15.0). CT or NG were associated with age below 45 years (age 40-44 years: OR: 2.4, 95% CI: 1.1-5.3; age <40 years: OR: 2.4, 95% CI: 1.1-5.4), enema use before sex (OR: 2.4, 95% CI: 1.3-4.4) and drug use during sex (OR: 2.4, 95% CI: 1.4-4.0). CONCLUSIONS: High-risk sexual behavior was very common, and 16% of HIV-infected MSM in HIV care had an asymptomatic STI, mostly anal CT and syphilis. Development of STI screening guidelines is recommended.

High performance and acceptability of self-collected rectal swabs for diagnosis of Chlamydia trachomatis and Neisseria gonorrhoeae in men who have sex with men and women.

BACKGROUND: Identification of sexually transmitted infections (STI) is limited by the infrequent assessment of rectal STI. This study assesses usability of self-collected rectal swabs (SRS) in diagnosing rectal Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG). METHODS: In 2006 to 2007, clients of the Amsterdam and South Limburg STI outpatient clinics reporting receptive anal intercourse were asked to fill out a questionnaire and provide SRS. A standard provider-collected rectal swab (PRS) was also taken, and both were tested for CT and NG by a nucleic acid amplification tests. SRS performance was compared with PRS as to agreement, sensitivity, and specificity. RESULTS: Prevalence of rectal CT was 11% among the 1458 MSM and 9% among the 936 women. Rectal NG prevalence was 7% and 2%. In 98% of both MSM and women, SRS and PRS yielded concordant CT test results, for NG agreement was 98% for MSM and 99.4% for women. SRS performance for CT and NG diagnosis was good in both groups and was comparable for both study regions. Slightly more (57% of MSM, 62% of women) preferred SRS to PRS or had no preference; 97% would visit the STI clinic again if SRS was standard practice. CONCLUSIONS: Because anal sex is a common practice for MSM and women, and anal STI are frequently present, rectal screening should be an essential part of an STI consultation. SRS is a feasible, valid, and acceptable alternative for MSM and women attending STI clinics, and hence should be considered for other settings as well.

Online-mediated syphilis testing: feasibility, efficacy, and usage.

OBJECTIVES: To determine the feasibility and efficacy of an online-mediated syphilis screening among men who have sex with men. METHODS: We developed a Web site that offered information about syphilis and motivated users to download a referral letter with which they could test for syphilis in a nonclinical setting. A week after the blood test, participants could retrieve their results online. To assess the feasibility and efficacy of the Web site we followed the users through the online procedure and compared the percentage of syphilis infected men detected online with those diagnosed at the local sexually transmitted infection (STI) clinic, during the same time frame. The trial was divided into an initial period of online advertising (4 months) and no advertising (11 months) to examine how advertisements affect usage. RESULTS: During 15 months, 898 visitors downloaded a referral letter. Of these, 93 (10%) men tested and 96% (90 of 93) obtained their test results online. Through the Web site we found a significantly higher percentage of men who needed treatment for syphilis compared with the STI clinic (50% online vs. 24% STI clinic, P <0.01). Of the Online users who tested positive 33% (3 of 10) had never visited the STI clinic before. In the bannered period there was a monthly average of 15 testers compared with 3 per month in the nonbannered period. CONCLUSION: Online-mediated testing for syphilis is feasible and was more successful in detecting men who have sex with men with an early or late syphilis infection than standard procedures. However, longer promotion periods are needed to generate more usage of the online service.

Low HIV-testing rates and awareness of HIV infection among high-risk heterosexual STI clinic attendees in The Netherlands.

OBJECTIVES: Since 1999, HIV testing is routinely offered to all attendees of the sexually transmitted infections (STI) outpatient clinic in Amsterdam, the Netherlands. This study evaluates whether this more active HIV-testing policy increased uptake of HIV testing and awareness of an HIV-positive serostatus among heterosexual attendees. METHODS: In addition to routine data collected at each STI consultation, data from half-yearly HIV surveys were used from 1994 to 2004. During each survey period, 1000 consecutive attendees are enrolled voluntary and anonymously for HIV testing and are interviewed on previous HIV testing and outcome. Trends in and predictors for uptake of HIV testing as offered during routine STI consultation were analysed by logistic regression. Trends in awareness of an HIV-positive serostatus as obtained from the anonymous HIV surveys were likewise analysed. RESULTS: The percentage of heterosexual attendees opting for an HIV test during consultation increased from 13% in 1996 to 56% in 2004. However, the proportion of individuals aware of their HIV infection did not change over time and only a minority (19%) of the 108 attendees found HIV-positive in the anonymous surveys were aware of their HIV infection. Persons being or visiting a commercial sex worker, having a non-Dutch ethnicity, lacking health insurance and having an STI diagnosed were less likely to opt for an HIV test. CONCLUSIONS: Although heterosexual attendees increased their uptake of HIV testing during STI consultation over time, uptake of testing by attendees at risk for HIV infection, such as those infected with an STI, remained low. As a result, the percentage of persons aware of their HIV infection remained low, posing a risk for their individual health and for ongoing HIV transmission. Current testing strategies, therefore, misses the group that most needs testing. Based on these results, 'opt-out' HIV testing is now the standard procedure at the Amsterdam STI clinic.

Low HIV-testing rates among younger high-risk homosexual men in Amsterdam.

OBJECTIVE: To investigate HIV-testing behaviour and HIV prevalence among homosexual visitors of a sexually transmitted infection (STI) outpatient clinic, and to investigate determinants of unknown HIV status, and of HIV testing separately for men with unknown and negative HIV status. DESIGN: Cross-sectional survey conducted from March 2002 to December 2003 among homosexual men with negative or unknown HIV status visiting the Amsterdam STI clinic. METHODS: A convenience sample of 1201 men with negative or unknown HIV status answered a written questionnaire about history of HIV testing, sexual risk behaviour and behavioural determinants (non-response, 35%). Information was matched to the STI registration system. Associations were determined using logistic regression. RESULTS: 817 men reported a negative HIV status, and 384 reported an unknown HIV status. The overall HIV prevalence among the 523 men who tested at new STI consultation was 2.8%. The proportion of men with unknown HIV status was relatively high among those diagnosed with infectious syphilis and those reporting unprotected anal intercourse with a casual partner. Their testing rates at new STI clinic visit were lower. Among men with an unknown HIV status, those aged <30 years and reporting risky sexual behaviour tested the least (OR 0.13, 95% CI 0.03 to 0.61). CONCLUSION: Although HIV testing rates have increased, they are still lower than in other industrialised countries. Moreover, some men still undertake high-risk sex without knowing their own HIV status, which might pose a risk for ongoing HIV transmission. Therefore, more active testing promotion is needed.

HIV incidence and HIV testing behavior in men who have sex with men: using three incidence sources, The Netherlands, 1984-2005.

BACKGROUND: In The Netherlands, the western part, including Rotterdam and Amsterdam harbors the majority of the known HIV-infected population, of whom men who have sex with men (MSM) comprise the largest transmission category. Given a general rise in sexually transmitted infections (STI) and risky sexual behavior, we examine the HIV incidence among MSM in the Netherlands with data from three different sources. METHODS: To describe the HIV epidemic among MSM we use: a prospective cohort study in Rotterdam (ROHOCO: 1998-2003, n = 265) and another in Amsterdam (ACS: 1984-2005, n = 1498]) plus an anonymous HIV surveillance study (Amsterdam STI clinic: 1991-2004, n = 3733) in which HIV-positive MSM were tested with a less-sensitive HIV assay. We evaluated calendar trends in HIV incidence, also focusing on age effects. RESULTS: Since the start of the HIV epidemic in the early 1980s, incidence has declined strongly in the ACS. In recent years, an increase was noted among older MSM attending the Amsterdam STI clinic (P = 0.0334). In both cohort studies, HIV incidence was lower and recent time-trends were not statistically significant. Among recently infected men at the STI clinic, only 40% accepted named HIV testing at their STI consultation. CONCLUSIONS: Data suggest that among MSM in the Netherlands, the HIV incidence is between one and four infections per 100 person-years. The epidemic expands among older STI clinic attendees. Prevention should be developed specifically for older men, along with a more efficient HIV testing approach such as routine HIV testing of MSM when they are screened for STI.

No evidence for a sustained increase in sexually transmitted diseases among heterosexuals in Amsterdam, the Netherlands: a 12-year trend analysis at the sexually transmitted disease outpatient clinic, Amsterdam.

OBJECTIVES: Sexually transmitted diseases (STDs) are on the rise, mainly among men having sex with men (MSM). GOAL: The goal of this study was to evaluate whether STD increases as seen in MSM are also visible among heterosexuals. STUDY DESIGN: Attendees of the STD clinic in Amsterdam, The Netherlands, are routinely tested for chlamydia, gonorrhea, and syphilis. Additionally, all women are tested for trichomoniasis. STD time trends of heterosexual attendees between 1994 and 2005 were analyzed by logistic regression and generalized linear models with a negative binomial distribution. RESULTS: The number of consultations doubled since 1994. However, no long-term increase was seen in the number of syphilis and gonorrhea infections. Additionally, the trichomonas prevalence declined. However, the number of chlamydia infections increased over time. CONCLUSIONS: Although the number of attendees increased, no evidence for increasing STD incidence was found among heterosexuals. The increase in chlamydia infections can probably be explained by increased screening resulting from increased numbers of attendees.

Effectiveness of a risk-based visitor-prioritizing system at a sexually transmitted infection outpatient clinic.

OBJECTIVE: The objective of this study was to study the efficacy/effectiveness of a risk-based visitor-prioritizing system at a sexually transmitted infection (STI) clinic aimed to improve screening capacity by providing tailored service. STUDY DESIGN: In April 2004, a prioritizing system was implemented that classifies visitors as high or low risk depending on reported sexual behavior and previous STI events. The high- and low-risk groups are assigned to standard and short screening protocols, respectively. Both protocols include diagnostic testing for syphilis, urogenital gonorrhea, chlamydia, and optional for HIV. To assess the effectiveness of the system, differences in prevalence of STI diagnoses in the standard and short protocol were analyzed by chi test. RESULTS: In total, 14,391 visitors (64%) received standard screening and 8,056 visitors (36%) received short screening. The STI prevalence in both groups was 18.1% and 7.6%, respectively (P <0.001); prevalence of HIV was 1.8% and 0.3%, respectively (P <0.001). The sensitivity of the prioritizing system was 74%. Specificity was substantially lower (42%). CONCLUSIONS: This prioritizing system is effective in differentiating between visitors at high and low risk for STI, contributing to provision of tailored STI service, increasing efficiency, and client access to STI service.

Diagnostic and clinical implications of anorectal lymphogranuloma venereum in men who have sex with men: a retrospective case-control study.

BACKGROUND: Recently, outbreaks of anorectal lymphogranuloma venereum (LGV) have occurred among men who have sex with men (MSM). This study identifies risk factors and clinical predictors of LGV to determine the implications for clinical practice. METHODS: The Chlamydia trachomatis serovars for all MSM who had anorectal chlamydia diagnosed at a sexually transmitted infection clinic in Amsterdam, The Netherlands, in 2002 and 2003 were retrospectively typed; 87 persons were infected with C. trachomatis serovar L2b and received a diagnosis of LGV. MSM infected with C. trachomatis serovars A-K and who thus had non-LGV anorectal chlamydia (n = 377) and MSM who reported having receptive anorectal intercourse but who did not have anorectal chlamydia (n = 2677) served as 2 separate control groups. Risk factors and clinical predictors were analyzed by multivariate logistic regression. Receiver operating characteristic curves were used to determine clinical relevance. RESULTS: HIV seropositivity was the strongest risk factor for LGV (odds ratio for patients with LGV vs. those with non-LGV chlamydia, 5.7 [95% confidence interval, 2.6-12.8]; odds ratio for patients with LGV vs. control subjects without chlamydia, 9.3 [95% confidence interval, 4.4-20.0]). Proctoscopic findings and elevated white blood cell counts in anorectal smear specimens were the only clinically relevant predictors for LGV infection (area under the curve of the receiver operating characteristic curve, > 0.71). Use of these 2 parameters and HIV infection status provided the highest diagnostic accuracy (for MSM with anorectal chlamydia, the area under the curve was > 0.82; sensitivity and specificity were 89% and 50%, respectively). CONCLUSIONS: LGV testing is recommended for MSM with anorectal chlamydia. If routine LGV serovar typing is unavailable, we propose administration of syndromic LGV treatment for MSM with anorectal chlamydia and either proctitis detected by proctoscopic examination, > 10 white blood cells/high-power field detected on an anorectal smear specimen, or HIV seropositivity.

Slow epidemic of lymphogranuloma venereum L2b strain.

We traced the Chlamydia trachomatis L2b variant in Amsterdam and San Francisco. All recent lymphogranuloma venereum cases in Amsterdam were caused by the L2b variant. This variant was also present in the 1980s in San Francisco. Thus, the current "outbreak" is most likely a slowly evolving epidemic.

New lymphogranuloma venereum Chlamydia trachomatis variant, Amsterdam.

We retrospectively conducted a study of men who have sex with men who visited the Amsterdam, the Netherlands, sexually transmitted diseases clinic from January 2002 to December 2003 and had rectal Chlamydia trachomatis infections. We found that symptomatic (73%) as well as asymptomatic (43%) patients were infected with a new C. trachomatis LGV variant.

HIV incidence on the increase among homosexual men attending an Amsterdam sexually transmitted disease clinic: using a novel approach for detecting recent infections.

OBJECTIVE: Dramatic increases have occurred in sexually transmitted diseases (STD) and in sexual risk behaviour among homosexual men in Amsterdam and internationally. We investigated whether these trends indicate a resurgence of the HIV epidemic. METHODS: HIV incidence was determined among homosexual attendees of an STD clinic in Amsterdam, who had participated in semi-annual anonymous unlinked cross-sectional HIV prevalence studies from 1991 to 2001. Stored HIV-seropositive samples were tested with a less-sensitive HIV assay and, if non-reactive, were further tested for the presence of antiretroviral drugs, indicative of the use of highly active antiretroviral therapy. Seropositive men who tested non-reactive on the less-sensitive assay and had not used antiretroviral drugs were classified as recently infected (< 170 days). Annual HIV incidence and its changes were examined. RESULTS: Among 3090 homosexual participants (median age 34 years), 454 were HIV infected, of whom 37 were recently infectioned. From 1991 to 2001 the overall incidence was 3.0 infections/100 person-years. Incidence increased over time (P = 0.02) and, strikingly, the increase was evident in older (> or = 34 years) men (P < 0.01), but not in the young. Of men recently infected, 84% (n = 31) were unaware of their infection and 70.3% (n = 26) had a concurrent STD. These 26 men reportedly had sex with a total of 315 men in the preceding 6 months. CONCLUSION: HIV incidence is increasing among homosexual attendees of an STD clinic. It is imperative to trace recently infected individuals, because they are highly infectious, and can thus play a key role in the spread of HIV.