Increase in the overall level of protected anal sex in men who have sex with men in France: results from the repeated cross-sectional survey Rapport au Sexe, France, 2017-2019

Factors associated with bacterial sexually transmitted infection screening uptake and diagnosis among men who have sex with men in France

BACKGROUND

The prevalence of syphilis, Chlamydia trachomatis (CT), and Neisseria gonorrhoeae (NG) in men who have sex with men (MSM) is very high. As these bacterial sexually transmitted infections (bSTIs) are frequently asymptomatic, they are often undiagnosed and therefore untreated. We aimed to characterize the profile of MSM who reported bSTI screening and diagnosis in the previous 12 months, and to identify the factors associated with a diagnosis of a bSTI among MSM in France.

METHODS

We used data from Enquête Rapport au Sexe (ERAS), a large French national anonymous cross-sectional online survey among MSM conducted from 26 February to 11 April 2021. After comparing MSM screened and diagnosed in the previous year with those who were not, a binary logistic regression model was used to compare MSM diagnosed with at least one bSTI with those who were not.

RESULTS

Of the 13 300 survey respondents, 6 263 (47.1%) MSM reported screening for at least one bSTI in the previous 12 months. Of these, 1 060 (16.9%) were diagnosed for at least one bSTI during their most recent screening. Specifically, 446 (7.1%) MSM were diagnosed with NG, 427 (6.8%) with CT, and 402 (6.4%) for syphilis. The following self-reported factors were associated with a greater likelihood of bSTI diagnosis: younger age, a lower educational level, frequenting MSM meeting places, not currently using pre-exposure prophylaxis (PrEP) but willing to take preventive treatment against bSTIs (reference group: not using PrEP and not willing to take preventive treatment against bSTIs), low health literacy, more than one sexual male partner, practicing chemsex, and condomless anal intercourse with casual male partners (the latter three factors concerning the previous six months).

CONCLUSIONS

A large proportion of MSM were diagnosed for at least one bSTI. This result provides an insight into bSTI screening uptake and diagnosis among MSM in France, and could inform future decisions about how to plan effective bSTI screening and diagnosis programs for this population.

HIV pre-exposure prophylaxis (PrEP) knowledge among general practitioners in 2020: A French survey

INTRODUCTION

Since 2017, pre-exposure prophylaxis (PrEP) has been one of the tools in combination HIV prevention strategies. The objective of our questionnaire was to analyze the knowledge and the position of general practitioners in Hauts-de-France on PrEP.

METHOD

This quantitative, observational, cross-sectional study was conducted in 2020 using an anonymous questionnaire sent by post to a sample of 3007 GPs.

RESULTS

Four hundred and forty-four questionnaires (14.8 %) were included. The GPs were predominantly male (n = 253, 57 %) with a median age of 47 years. The median interest shown by respondents was 7/10. One hundred and sixty participating GPs (36%) were aware of the principles of PrEP, one hundred and sixty were only aware of the title (36%) and 124 (28%) showed no awareness at all. Out of the 160 GPs who knew about PrEP, 72 % considered it effective, 30 % knew about it from a patient and 34 % declared having at least one patient using PrEP. GPs who knew about PrEP were more likely to: have graduated less than 10 years before, having seen in consultation men who have sex with men (MSMs) and, lastly; using screening practices for sexually transmitted infections that were better aligned with the recommendations than those who reported not knowing about PrEP.

CONCLUSION

Although PrEP remains insufficiently known to GPs, many expressed eagerness to be involved. The training of health professionals and the highlighting of GPs' role in prevention could help to optimize the fight against HIV.

Pre-exposure prophylaxis in France: How many MSM are eligible and how much will it cost?

BACKGROUND

Pre-exposure prophylaxis (PrEP) was definitively authorized in France in 2017 after a two-year probationary period. The fact that the estimated number of MSM eligible for PrEP is still unknown is a barrier to this prevention tool's roll-out at the national level. This study aimed to estimate the number of MSM eligible for PrEP in France, and to evaluate the direct cost of its roll-out.

METHODS

We used data from several sources including the Enquête Rapport au Sexe 2019-ERAS 2019 survey, the 2019 French population census from National Institute of Statistics and Economic Studies (INSEE), and the National Public Health Agency's (Santé Publique France) 2016 health barometer survey. We also used data from previous studies which estimated the proportion of MSM who were sexually active in the 12 months prior to the studies, and HIV prevalence in MSM in France. Furthermore, we used data on PrEP drug costs from the French public drug database and data on medical examinations costs from the IPERGAY study.

RESULTS

For 2019, the number of HIV seronegative MSM in France who were sexually active in the previous 12 months was estimated at 398,015. Of these, 142,379 (95%CI: 139,893-145,241) and 104,645 (95%IC: 102311-106979) were eligible for PrEP, based on the Menza score and on official French criteria, respectively. The overall estimated cost of PrEP roll-out in eligible MSM varied between € 317,685,216 and € 545,903,216 for official French criteria, which was higher than the estimated €432,240,851 and €742,753,074 according to the Menza score.

CONCLUSIONS

Our estimations will enable policy makers to make evidence-based decisions about PrEP roll-out to MSM in France. To accelerate the process, it is important to decentralize PrEP delivery, authorize general practitioners to write prescriptions, and promote this prevention tool through information campaigns.

What is the empirical basis for converting banded ordinal data on numbers of sex partners among MSM into a continuous scale level variable? A secondary analysis of 13 surveys across 17 countries

BACKGROUND

To provide empirically based guidance for substituting partner number categories in large MSM surveys with mean numbers of sexual and condomless anal intercourse (CAI) partners in a secondary analysis of survey data.

METHODS

We collated data on numbers of sexual and CAI partners reported in a continuous scale (write-in number) in thirteen MSM surveys on sexual health and behaviour across 17 countries. Pooled descriptive statistics for the number of sexual and CAI partners during the last twelve (N = 55,180) and 6 months (N = 31,759) were calculated for two sets of categories commonly used in reporting numbers of sexual partners in sexual behaviour surveys.

RESULTS

The pooled mean number of partners in the previous 12 months for the total sample was 15.8 partners (SD = 36.6), while the median number of partners was 5 (IQR = 2-15). Means for number of partners in the previous 12 months for the first set of categories were: 16.4 for 11-20 partners (SD = 3.3); 27.8 for 21-30 (SD = 2.8); 38.6 for 31-40 (SD = 2.4); 49.6 for 41-50 (SD = 1.5); and 128.2 for 'more than 50' (SD = 98.1). Alternative upper cut-offs: 43.4 for 'more than 10' (SD = 57.7); 65.3 for 'more than 20' (SD = 70.3). Self-reported partner numbers for both time frames consistently exceeded 200 or 300. While there was substantial variation of overall means across surveys, the means for all chosen categories were very similar. Partner numbers above nine mainly clustered at multiples of tens, regardless of the selected time frame. The overall means for CAI partners were lower than those for sexual partners; however, such difference was completely absent from all categories beyond ten sexual and CAI partners.

CONCLUSIONS

Clustering of reported partner numbers confirm common MSM sexual behaviour surveys' questionnaire piloting feedback indicating that responses to numbers of sexual partners beyond 10 are best guesses rather than precise counts, but large partner numbers above typical upper cut-offs are common.

Impact of the early 2020 COVID-19 crisis and lockdown on PrEP use among men who have sex with men (MSM) in France

OBJECTIVE

To describe changes in pre-exposure prophylaxis (PrEP) use during and following the COVID-19 lockdown in France (March-May 2020) and identify the factors associated with PrEP discontinuation among men who have sex with men (MSM) after the lockdown.

METHODS

Data from the, an anonymous, cross-sectional internet survey among MSM in July 2020, were analysed. Among respondents who were using PrEP prior to the lockdown, a binary logistic regression model was used to compare participants who were still taking PrEP (current PrEP users) with those who were not taking PrEP at the time of the survey (former PrEP users).

RESULTS

Among 8345 respondents, 946 were PrEP users before the lockdown, of whom 58.8% (n=556) reported stopping PrEP during the lockdown and 15.4% (n=146) were not using PrEP at the time of the survey. Among the 556 who stopped PrEP during lockdown, 86.5% (n=481) reported no sexual activity; 76.8% (n=427) restarted PrEP after lockdown. Former PrEP users were more likely to be younger, not living with a stable male sexual partner, report moderate anxiety, report increased psychoactive drug use during the lockdown, and report not having tested for HIV or STI since the end of the lockdown because they did not know where to go, preferred to wait or for another reason. Reporting fewer male sexual partners in the last 6 months was also significantly associated with being a former PrEP user.

CONCLUSIONS

MSM adapted PrEP use to their sexual activity during and after the French lockdown. After the lockdown, discontinued PrEP occurred more often among MSM who had fewer sexual partners and had mental health vulnerabilities. These factors could also be predictive of PrEP discontinuation in a more general context. PrEP users should be informed on how to safely stop/start PrEP and on the use of other prevention tools to reduce potential risk exposure during PrEP discontinuation.

Low vaccination coverage for human papillomavirus disease among young men who have sex with men, France, 2019

Background

In France, human papillomavirus (HPV) vaccination has been recommended in 2016 for men who have sex with men (MSM) up to age 26 years.

Aim

We aimed to estimate HPV vaccine coverage in 18–28 year-old MSM and identify uptake determinants.

Methods

We collected data on socio-demographic characteristics, sexual behaviour, sexually transmitted diseases (STI) screening and vaccination uptake using a voluntary cross-sectional online survey conducted in 2019 targeting MSM. We calculated coverage of at least one dose of HPV vaccine and prevalence ratios (PR) of determinants with 95% confidence intervals (CI) using Poisson regression.

Results

Of 9,469 respondents (age range: 18–28 years), 15% (95% CI: 14–16) reported being vaccinated for HPV. Coverage was significantly higher among MSM < 24 years (PR: 1.25; 95% CI: 1.13–1.39), with education level below university degree (PR: 1.12; 95% CI: 1.08–1.32), living in rural areas (PR: 1.21; 95% CI: 1.08–1.36), attending sex parties (PR: 1.12; 95% CI: 1.03–1.33), using HIV-related biomedical prevention methods (PR: 1.31; 95% CI: 1.12–1.54), with STI diagnosis (PR: 1.22; 95% CI: 1.08–1.38) and with hepatitis A or B vaccination (PR: 4.56; 95% CI: 3.63–5.81 vs PR: 3.35; 95% CI: 2.53–4.44).

Conclusions

The HPV vaccination uptake among MSM in France was not satisfactory. It was higher among MSM benefitting from other vaccinations and biomedical preventive methods against HIV, suggesting a synergistic effect of the national preventive sexual health recommendations for MSM. Further efforts to improve HPV vaccination coverage targeting MSM are warranted.

Risk of Fecal Incontinence Following Receptive Anal Intercourse: Survey of 21,762 Men Who Have Sex With Men

BACKGROUND

The prevalence of receptive anal intercourse (RAI) is increasing. A few studies, with heterogeneous designs, have investigated the associated risk of fecal incontinence (FI).

AIM

The primary objective of this study was to determine FI prevalence in a population of men who have sex with men (MSM) engaging in RAI. The secondary objective was to identify risk factors for severe FI.

METHODS OUTCOMES

An online survey of 24,308 MSM was performed in 2019. Demographic and socioeconomic data were collected, together with information about RAI sexual practices, and FI defined by: "During the last month, have you experienced any involuntary leakage of stools?"

RESULTS CLINICAL IMPLICATIONS

In total, 1,734 (8%) of the 21,762 participants reported FI. Mean age was 35.3 years. The prevalence of FI was correlated with RAI frequency: 12.7% (if RAI ≥ 1 /wk) versus 5.7% (if no RAI). In multivariate analysis, the factors associated with FI were age (OR: 1.01), low socioeconomic status (OR 1.32 to 1.40), HIV-seropositivity (OR: 1.78), high RAI frequency (OR: 1.64), chemsex (OR: 1.67) and fist-fucking (OR: 1.61).

STRENGTHS AND LIMITATIONS

Main strengths of our study are population size and assessment of detailed modalities of sexual practices. Main limitations are the use of a convenience non-random sample and the assessment of FI only during the past month.

CONCLUSION

This study of a large MSM population, highlights risk factors for FI among RAI practices: RAI ≥ 1 /wk, chemsex, fist-fucking, low socioeconomic status. Garros A, Bourrely M, Sagaon-Teyssier L, et al. Risk of Fecal Incontinence Following Receptive Anal Intercourse: Survey of 21,762 Men Who Have Sex With Men. J Sex Med 2021;18:1880-1890.

Online self-sampling kits to screen multipartner MSM for HIV and other STIs: participant characteristics and factors associated with kit use in the first 3 months of the MemoDepistages programme, France, 2018

OBJECTIVES

In 2017, to reduce the proportion of men who have sex with men (MSM) in the undiagnosed HIV population in France (38%), HIV screening is advised each 3 months and STI screening is advised each year in multipartner MSM. Despite the range of testing solutions, over 40% of MSM were not tested for HIV and over 50% for STIs in the past year. Based on international experiments that offer screening solutions via online advertising, the French National Health Agency launched a programme (MemoDepistages) to provide a free self-sampling kit (SSK) for HIV and STIs. This article analyses the sociodemographic and behavioural characteristics of MSM in terms of kit acceptance and sample return.

METHODS

Participants were registered for the programme online after ordering an SSK. The study included men aged over 18 years, living in one of the four selected French regions, and willing to disclose their postal and email address; they had health insurance, acknowledged more than one male partner in the past year, indicated a seronegative or unknown HIV status and were not taking medically prescribed pre-exposure prophylaxis drugs. Samples were collected by users and posted directly to the laboratory. Characteristics associated with kit acceptance and sample return were analysed using logistic regression.

RESULTS

Overall, 7158 eligible MSM were offered to participate in the programme, with 3428 ordering the kit (47.9%) and 1948 returning their sample, leading to a return rate of 56.8% and an overall participation rate of 27.2%. Acceptance and return rates were strongly associated with sociodemographic characteristics, mainly education level but not with behavioural characteristics. Non-college graduates had lower acceptance (44.2%) and return rates (47.7%).

CONCLUSION

The programme rapidly recruited a large number of MSM. It removed geographical inequalities related to screening access.

Combination HIV Prevention Strategies Among Montreal Gay, Bisexual, and Other Men Who Have Sex with Men in the PrEP Era: A Latent Class Analysis

Pre-exposure prophylaxis (PrEP) became publicly available in Quebec for gay, bisexual and other men who have sex with men (GBM) in 2013. We used baseline data from Engage, a cohort of GBM recruited by respondent-driven sampling, to examine patterns of combination HIV prevention use among Montreal GBM since PrEP became available. Latent class analysis, stratified by HIV status, was used to categorize GBM by self-reported use of biomedical and behavioural prevention strategies. Correlates of resulting classes were identified using multinomial logistic regression. Among HIV-negative/unknown GBM (n = 968), we identified four classes: low use of prevention (32%), condoms (40%), seroadaptive behaviour (21%), and biomedical (including PrEP; 7%). Those using prevention (condoms, seroadaptive behaviour, and biomedical) had a higher number of anal sex partners and were more likely to report a recent sexually transmitted infection diagnosis. GBM using biomedical prevention also had a higher level of formal education. Among GBM living with HIV (n = 200), we identified three classes: mainly antiretroviral treatment (ART) with viral suppression (53%), ART with viral suppression and condoms (19%), and ART with viral suppression and seroadaptive behaviour (18%). Again, the number of anal sex partners was higher among those using condoms and seroadaptive behaviours. Our findings show antiretroviral-based prevention, either alone or in combination with other strategies, is clearly a component of the HIV prevention landscape for GBM in Montreal. Nevertheless, PrEP uptake remains low, and there is a need to promote its availability more widely.