Association between knowledge, risk behaviours, and testing for sexually transmitted infections among men who have sex with men: findings from a large online survey in the United Kingdom

Factors associated with human papillomavirus, hepatitis A, hepatitis B and mpox vaccination uptake among gay, bisexual and other men who have sex with men in the UK- findings from the large community-based RiiSH-Mpox survey

BACKGROUND

Gay, bisexual, and other men who have sex with men (GBMSM) face a disproportionate burden of sexually transmitted infections and are eligible for targeted vaccinations for hepatitis A (HAV), hepatitis B (HBV), human papilloma virus (HPV) and mpox. This study examines the sociodemographic characteristics, sexual behaviours, and sexual healthcare service (SHS) use associated with vaccination uptake.

METHODS

We undertook analyses of RiiSH-Mpox - an online, community-based survey with GBMSM recruited via social media and dating apps. We calculated vaccination uptake (≥1 dose) among eligible GBMSM. Bivariate and multivariable logistic regression was performed to identify factors independently associated with vaccination uptake among eligible participants.

RESULTS

Reported uptake in eligible GBMSM was around two-thirds for each of the vaccinations considered: mpox 69% (95% confidence interval (CI): 66%-72%), HAV 68% (CI:65%-70%), HBV 72% (CI:69%-74%) and HPV 65% (CI:61%-68%). Vaccination course completion (receiving all recommended doses) ranged from 75% (HBV) to 89% (HAV) among eligible GBMSM. Individuals who represented missed opportunities for vaccination ranged from 22 to 30% of eligible SHS attendees. Younger participants, individuals identifying as bisexual, reporting lower educational qualifications, or being unemployed reported lower uptake across multiple GBMSM-selective vaccinations. Individuals who reported greater levels of sexual behaviour and recent SHS use were more likely to report vaccinations.

CONCLUSION

Eligible participants reported high uptake of vaccinations; however, uptake was lower amongst young GBMSM and self-identifying bisexual men. Awareness of groups with lower vaccination uptake will help inform practice, delivery strategies and health promotion, to improve the reach and impact of vaccinations amongst GBMSM.

A Qualitative Evaluation of the Acceptability of Shigellosis Prevention Recommendations Among Gay, Bisexual, and Other Men Who Have Sex With Men

BACKGROUND

Shigellosis is diarrheal disease caused by highly infectious Shigella bacteria. Shigella can spread in multiple ways, including sexual contact. Gay, bisexual, and other men who have sex with men are particularly at risk for shigellosis.

METHODS

To evaluate the acceptability of 3 Centers for Disease Control and Prevention-developed behavioral recommendations for the prevention of sexually transmitted shigellosis, virtual in-depth interviews were conducted among 26 gay or bisexual men in March to May 2021.

RESULTS

Participants had a median age of 25 years; 65% were non-Hispanic White, 12% were Hispanic White, 12% Asian, 4% Hispanic Black, and 8% multiracial/other. Respondents indicated willingness to engage in certain prevention behaviors (e.g., washing hands, genitals, and anus before and after sex), but were less willing to engage in behaviors that were viewed as outside social norms or difficult to practice (e.g., dental dams for oral-anal contact; latex gloves for fingering or fisting). Respondents thought recommendations may be more feasible if knowledge of shigellosis was greater; however, some perceived that the severity of shigellosis is low and did not warrant the effort of engaging in prevention behaviors.

CONCLUSIONS

Educational efforts to increase awareness of shigellosis and other enteric diseases spread through sexual contact are needed and public health practitioners should consider the acceptability of how realistic it is for individuals to engage in certain prevention behaviors. Rather than recommending behaviors that do not have buy-in, it may be more efficacious to focus recommendations on adopting behaviors reported as acceptable to the target audience.

Etiological, sociodemographic and clinical characteristics of sexually transmitted infections and M. genitalium resistance in Shenzhen: a multicenter cross-sectional study in China

Introduction

This study aims to determine the etiological, sociodemographic, and clinical characteristics of STIs, and the level of resistance in M. genitalium in Shenzhen, a representative first-tier city of southern China.

Methods

A multicenter cross-sectional study was conducted and 7886 sexually active participants attending STI-related departments were involved from 22 hospitals. Nine STI-related organisms including N. gonorrhoeae, C. trachomatis, T. vaginalis, M. genitalium, HSV-1, HSV-2, M. hominis, U. parvum, and U. urealyticum were screened.

Results

Being single or divorced was associated with increased detection of N. gonorrhoeae, C. trachomatis, M. genitalium, HSV-1, HSV-2 and M. hominis. Lower education level was associated with increased detection of C. trachomatis, HSV-2 and M. hominis. No insurance coverage was an independent risk factor for T. vaginalis, M. hominis and U. parvum positivity. Three resistance-determining regions related to macrolide and fluoroquinolone were sequenced in 154 M. genitalium positive samples, among which 90.3% harbored mutations related to macrolide or fluroquinolone resistance and 67.5% were multidrug-resistant M. genitalium. A2072G in 23S rRNA and Ser83Ile in parC were the most common mutations. M. hominis was associated with manifestations of bacterial vaginosis in female and epididymitis in male.

Conclusions

Single or divorced individuals, those with lower education level and individuals without insurance are higher-risk key populations for STIs. The prevalence of antimicrobial-resistant M. genitalium in Shenzhen is high. Detection of M. hominis increased significantly with lower education level and no health insurance coverage, and it is associated with bacterial vaginosis or epididymitis, indicating that M. hominis deserves further attention.

Risk factors and provider awareness of sexually transmitted enteric pathogens among men who have sex with men

Sexual transmission of enteric pathogens among men who have sex with men (MSM) is well documented, although whether providers are cognizant of this risk when MSM patients present with gastrointestinal symptoms has not been studied. Over 34 months at a major tertiary metropolitan medical system, this study retrospectively analyzed 436 BioFire FilmArray Gastrointestinal results from 361 patients documented as MSM. An extensive chart review was performed, including specific sexual behaviors, socioeconomic risk factors, and whether providers charted a sexual history when a patient presented for care. Overall BioFire positivity rate was 62% with no significant difference in positivity between persons living with HIV and those without. Patients charted as sexually active had a significantly increased odds ratio (OR) of a positive result compared to those who were not. Anilingus had the highest OR. Providers charted any type of sexual history in 40.6% of cases, and HIV/infectious disease providers were significantly more likely to do this compared to other subspecialties. Sexual transmission of enteric pathogens within MSM is ongoing, and patients are at risk regardless of living with HIV. Not all sexual behaviors have the same associated risk, highlighting opportunities to decrease transmission. Increased provider vigilance and better patient education on sexual transmission of enteric pathogens are needed to reduce the disease burden.

IMPORTANCE

Our work adds several key findings to the growing body of literature describing the epidemiology of enteric pathogens as sexually transmitted infections among men who have sex with men (MSM). We analyzed clinical test results, housing status, provider awareness, sexual behaviors, and symptoms for 361 patients. We found that any sexual activity was associated with an increased risk of diarrheal pathogen detection, whereas being unhoused was not a risk factor. These findings suggest separate transmission networks between unhoused persons, who are also at risk of infectious diarrhea, and MSM. Moreover, our study suggested low awareness among patient-facing clinicians that diarrheal pathogens can be sexually transmitted. Together, our findings indicate an important opportunity to disrupt transmission cycles by educating clinicians on how to assess and counsel MSM patients.

Knowledge of Sexually Transmitted Infections and HIV among People Living with HIV: Should We Be Concerned?

Poor knowledge of sexually transmitted infections (STIs) and HIV among people with HIV (PLHIV) could worsen life quality. We aimed to investigate their STI and HIV knowledge, disclosure and undetectable = untransmittable (U=U). We proposed an anonymous questionnaire regarding STI and HIV to PLHIV attending ten Italian outpatient infectious diseases clinics. Moreover, disclosure and U=U were investigated. The calculated sample size was 178 people. Considering a missing response of 10%, the final sample size was 196. We enrolled 200 PLHIV (73.5% males), with a median age of 52.5 (IQR 41-59) years. The mean score was 7.61 ± 1.22 with no difference by gender, education, and employment. Significant statistical difference was observed by sexual orientation; bisexuals and those who preferred not to answer had a lower score than heterosexuals and MSM (p = 0.0032). PLHIV showed poor knowledge about HIV transmission (25% appropriately answered). Nearly 30% responded that virologically suppressed PLHIV could transmit the infection. Finally, 137 (68.5%) and 158 (79.0%) disclosed to the general practitioner and family and friends, respectively. Nearly 52.0% knew the meaning of U=U, and 83.6% highlighted its positive rebound. In conclusion, important knowledge gaps are present among PLHIV regarding U=U, and its implications are little-known. Improving PLHIVs' awareness will undermine self-stigma and enhance life quality.

Sexual behaviour, STI and HIV testing and testing need among gay, bisexual and other men who have sex with men recruited for online surveys pre/post-COVID-19 restrictions in the UK

OBJECTIVES

We examined sexual behaviour, sexually transmitted infection (STI) and HIV testing and testing need, and identified associated factors, among gay, bisexual and other men who have sex with men (GBMSM) in the UK after COVID-19 restrictions ended, and compared these with 'pre-pandemic' estimates.

METHODS

We analysed survey data from GBMSM (N=1039) recruited via social media and Grindr in November-December 2021. We then compared Grindr-recruited 2021 participants (N=437) with those from an equivalent survey fielded in March-May 2017 (N=1902). Questions on sexual behaviour and service use had lookback periods of 3-4 months in both surveys. Unmet testing need was defined as reporting any new male and/or multiple condomless anal sex (CAS) partners without recent STI/HIV testing. Participants were UK residents, GBMSM, aged ≥16 years who reported sex with men in the last year. Multivariable logistic regression identified associated sociodemographic and health-related factors with unmet STI/HIV testing need in 2021, and then for 2017/2021 comparative analyses, adjusting for demographic differences.

RESULTS

In 2021, unmet STI and HIV testing need were greater among older GBMSM (aged ≥45 years vs 16-29 years; adjusted OR (aOR): 1.45 and aOR: 1.77, respectively), and lower for pre-exposure prophylaxis (PrEP) users (vs non-PrEP users; aOR: 0.32 and aOR: 0.23, respectively). Less unmet STI testing need was observed among HIV-positive participants (vs HIV-negative/unknown; aOR: 0.63), and trans and non-binary participants (vs cisgender male; aOR: 0.34). Between 2017 (reference) and 2021, reported sexual risk behaviours increased: ≥1 recent new male sex partner (72.1%-81.1%, aOR: 1.71) and ≥2 recent CAS partners (30.2%-48.5%, aOR: 2.22). Reporting recent STI testing was greater in 2021 (37.5%-42.6%, aOR: 1.34) but not recent HIV testing, and there was no significant change over time in unmet STI (39.2% vs 43.7%) and HIV (32.9% vs 39.0%) testing need.

DISCUSSION

Comparable community surveys suggest that UK resident GBMSM may have engaged in more sexual risk behaviours in late 2021 than pre-pandemic. While there was no evidence of reduced STI/HIV service access during this time, there remained considerable unmet STI/HIV testing need.

Difficulty accessing condoms because of the COVID-19 pandemic reported by gay, bisexual and other men who have sex with men in the UK: findings from a large, cross-sectional, online survey

BACKGROUND

COVID-19 restrictions severely reduced face-to-face sexual health services, an important access point for condoms. We examine whether gay, bisexual and other men who have sex with men (GBMSM) in the UK had difficulty accessing condoms during the first year of the pandemic, and if so, which groups were most affected.

METHODS

Questions about difficulty accessing condoms were asked as part of a short, online cross-sectional survey of GBMSM undertaken November/December 2021, recruited via social media and Grindr. Eligible participants were UK-resident GBMSM (cis/trans/gender-diverse person assigned male at birth [AMAB]), aged ≥16 years who were sexually active (reported sex with men in the last year). Multivariable logistic regression was used to examine if and how reporting this outcome varied by key sociodemographic, health and behavioural factors independent of the potential confounding effect of numbers of new male sex partners.

RESULTS

Of all participants (N = 1039), 7.4% (n = 77) reported difficulty accessing condoms due to the pandemic. This was higher among younger GBMSM (aged 16-29 years vs. ≥45; 12.8% vs. 4.9%; aOR: 2.78); trans/gender-diverse AMAB participants (vs. cis gender males; 24.4% vs. 6.6%; aOR = 4.86); bisexually-identifying participants (vs. gay-identifying; 11.1% vs. 6.5%; aOR = 1.78); and those without degree level education (vs. having a degree; 9.8% vs. 5.6%; aOR = 2.01).

CONCLUSIONS

A minority of sexually active GBMSM reported difficulty accessing condoms because of the pandemic, however, this was more common amongst those who already experience a disproportionate burden of poor sexual health. Interventions are needed to address these inequalities in accessing this important primary STI/HIV prevention measure.

Regular Testing of HIV and Sexually Transmitted Infections With Self-Collected Samples From Multiple Anatomic Sites to Monitor Sexual Health in Men Who Have Sex With Men: Longitudinal Study

Background

Regular HIV and sexually transmitted infection (STI) testing for men who have sex with men (MSM) is an important means of infection prevention, the adoption of which remains suboptimal in the community.

Objective

On the hypothesis that engagement plays an important role in sexual health monitoring, this study aimed to pilot-test internet-based HIV and STI testing with self-sampling to enhance engagement of MSM with regular testing.

Methods

This 1-year cohort study was conducted on HIV-negative MSM aged 18 years or older. A designated website was set up to enable participants to make appointments for baseline and follow-up visits at 3-monthly intervals. On-site blood sampling was performed for HIV and syphilis tests, along with self-collection of pharyngeal swabs, rectal swabs, and urine samples for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) testing. Full engagement, as defined by having made at least 3 visits over a 6-12 months’ follow-up period, was compared with partial engagement in the bivariable logistic regression model.

Results

Between August 2019 and October 2020, 204 MSM were recruited, after the exclusion of 2 baseline HIV-positive MSM. The majority (189/204, 92.7%) were Chinese, the median age was 31 (IQR 26-39) years, and 58.0% (116/200) had experience with pre-exposure prophylaxis (PrEP) at baseline. Full engagement (146/204, 71.6%) was associated with incident STI during the follow-ups (odds ratio [OR] 4.23, 95% CI 1.63-10.94), seeking a medical referral after STI detection (OR 10.25, 95% CI 3.25-29.79), and a synchronized schedule of HIV and STI testing with PrEP visits (OR 51.85, 95% CI 19.30-139.34). No incident HIV was detected in the follow-up period. At baseline, the overall STI (CT, NG, or syphilis) prevalence was 30%, with CT at 18%, NG at 13%, and syphilis at 5%. During follow-up, the incidences were 59.08/100 person-years (py) for any STI, 33.05/100 py for CT, 29.86/100 py for NG, and 10.4/100 py for syphilis. The detection rates of CT and NG in urine samples were lower than with pharyngeal swabs and rectal swabs. The scores for convenience, confidence of correct sampling, and accuracy of self-sampling were high (7 to 8 out of 10).

Conclusions

Both baseline prevalence and incidence of STI were high among MSM engaged in regular testing. A high degree of engagement in regular STI and HIV testing was positively associated with incident STI, history of health-seeking behaviors, and perceived convenience of self-sampling. Self-sampling could be introduced as a means of enhancing engagement in regular HIV and STI testing.

'Stay at home …': exploring the impact of the COVID-19 public health response on sexual behaviour and health service use among men who have sex with men: findings from a large online survey in the UK

OBJECTIVES

The first UK national lockdown began on 23 March 2020, in response to the COVID-19 pandemic, and led to reduced STI/HIV service provision in the UK. We investigated sexual behaviour, use and need for sexual healthcare during the pandemic.

METHODS

Participants (N=2018), including men (cis/transgender), transwomen and gender-diverse people reporting sex with another man (cis/transgender) or non-binary person assigned male at birth, completed an online cross-sectional survey (23 June 2020-14 July 2020), in response to adverts on social media and dating apps.Sexual behaviour, service use and unmet need for STI testing (any new male and/or multiple condomless anal sex (CAS) partners without STI testing) in the 3 months since lockdown began were examined and compared using multivariable analyses with an equivalent 3-month period in a 2017 survey (N=1918), conducted by the same research team.

RESULTS

Since lockdown began, 36.7% of participants reported one or more new partners, 17.3% reported CAS with multiple partners, 29.7% HIV testing (among 1815 of unknown/negative status), 24.9% STI testing and 15.4% using pre-exposure prophylaxis (PrEP).Since lockdown began, 25.3% of participants had unmet need for STI testing. This was more likely among Asian versus white participants (adjusted OR (aOR)=1.76, (1.14 to 2.72), p=0.01); for participants living in Scotland (aOR=2.02, (1.40 to 2.91), p<0.001) or Northern Ireland (aOR=1.93, (1.02-3.63), p=0.04) versus England; and for those living with HIV (aOR=1.83, (1.32 to 2.53), p<0.001).Compared to 2017, the equivalent 2020 subsample were less likely to report new male partners (46.8% vs 71.1%, p<0.001), multiple CAS partners (20.3% vs 30.8%, p<0.001) and have unmet need for STI testing (32.8% vs 42.5%, p<0.001) in the past 3 months.

CONCLUSIONS

We found potential for ongoing STI/HIV transmission among men who have sex with men during the initial UK lockdown, despite reduced sexual activity, and inequalities in service access. These findings will support public health planning to mitigate health risks during and after the COVID-19 response.

Achieving proportional representation in a reproductive health survey through social media: process and recommendations

BACKGROUND

The narrative surrounding women's reproductive health has shifted from a medical model to an emphasis on reproductive well-being over different life-stages. We developed and piloted a tracker survey for monitoring women's reproductive health and well-being in England, recruiting respondents online. This paper reports on the success of the online recruitment strategies in achieving a sample proportionally representative of the England general population.

METHODS

Recruitment was through Facebook and Instagram advertisements and dissemination through Twitter and a blog. At the end week one, the sample was reviewed and compared to the 2011 Census England population. From week two, recruitment targeted under-represented groups. Key data were compared with prevalence estimates from the Third National Survey of Sexual Attitudes and Lifestyles (Natsal-3).

RESULTS

Between 1 July-17 August 2021, 13,962 people initiated the online survey, with 11,578 completing it. Numbers were low initially, but peaked at 1700 survey initiations per day after increasing the daily advertisement budget on day seven. At the end of week one, minority ethnic groups and people without a degree or equivalent were under-represented. From week two, we altered the advertisement settings to show to people whose profile indicated they were a 'high school leaver' had 'up to some high school', worked in industries that do not typically require a degree or lived in local authorities with a high proportion of ethnic minority residents. This had a modest effect, with the final sample short of proportional representation in terms of ethnicity and education but close in terms of region and age. Compared to Natsal-3, we found consistency in the proportion of respondents reporting an abortion and a live birth in the last year, however, the proportion of our sample reporting ever having experienced infertility was significantly higher than in Natsal-3, as was the proportion of 'planned' pregnancies in the last year.

CONCLUSIONS

It is possible to recruit large numbers of respondents online, relatively quickly, to complete a reproductive health survey. This will be valuable to track reproductive health and well-being at a national level over time. More work is needed to understand reasons for non-response among under-represented groups.

Patterns of sexualised recreational drug use and its association with risk behaviours and sexual health outcomes in men who have sex with men in London, UK: a comparison of cross-sectional studies conducted in 2013 and 2016

Objective

London has one of the highest identified prevalence of chemsex (sexualised recreational drug use) among men who have sex with men (MSM) in Europe. We examine MSM’s patterns of chemsex and its association with HIV/STI risk behaviours, STI diagnoses, and sexual healthcare-seeking behaviours, including if HIV testing behaviour met UK national guidelines (3-monthly if engaging in chemsex).

Methods

Cross-sectional survey data from 2013 (n=905) and 2016 (n=739) were collected using anonymous, self-administered questionnaires from MSM recruited in commercial gay venues in London, UK. Descriptive and multivariable analyses, stratified by self-reported HIV status, were conducted. Adjusted prevalence ratios (aPR) with 95% confidence intervals (CI) were calculated.

Results

Comparing the 2013 and 2016 surveys; chemsex prevalence in the past year remained stable, in both HIV-negative/unknown-status MSM (20.9% in 2013 vs 18.7% in 2016, p=0.301) and HIV-positive MSM (41.6% in 2013 vs 41.7% in 2016, p=0.992). Combined 2013-2016 data showed that compared to other MSM, those reporting chemsex were more likely to report HIV/STI risk behaviours, including condomless anal intercourse with serodifferent HIV-status partners (HIV-negative/unknown-status men: aPR 2.36, 95% CI 1.68-3.30; HIV-positive men: aPR 4.19, 95% CI 1.85-9.50), and STI diagnoses in the past year (HIV-negative/unknown-status men: aPR 2.10, 95% CI 1.64-2.69; HIV-positive men: aPR 2.56, 95% CI 1.57-4.20). 68.6% of HIV-negative/unknown-status men reporting chemsex attended sexual health clinics and 47.6% had tested for HIV more than once in the past year.

Conclusions

Chemsex in London MSM remained stable but high, particularly among HIV-positive men. Irrespective of HIV status, chemsex was associated with engagement in HIV/STI risk behaviours. Frequency of HIV testing in the past year among HIV-negative/unknown-status men was below national recommendations. Promoting combination prevention strategies, including 3-monthly HIV/STI testing, access to PrEP/ART, and behavioural interventions among MSM reporting chemsex, remain vital to address sexual health inequalities in MSM.