Prevalence of HIV among MSM in Europe: comparison of self-reported diagnoses from a large scale internet survey and existing national estimates

Comparison of the burden of self-reported bacterial sexually transmitted infections among men having sex with men across 68 countries on four continents

BACKGROUND

Men who have sex with men (MSM) are in general more vulnerable to sexually transmitted infections (STIs) than the heterosexual men population. However, surveillance data on STI diagnoses lack comparability across countries due to differential identification of MSM, diagnostic standards and methods, and screening guidelines for asymptomatic infections.

METHODS

We compared self-reported overall diagnostic rates for syphilis, gonorrhea, and chlamydia infections, and diagnostic rates for infections that were classified to be symptomatic in the previous 12 months from two online surveys. They had a shared methodology, were conducted in 68 countries across four continents between October 2017 and May 2018 and had 202,013 participants.

RESULTS

Using multivariable multilevel regression analysis, we identified age, settlement size, number of sexual partners, condom use for anal intercourse, testing frequency, sampling rectal mucosa for extragenital testing, HIV diagnosis, and pre-exposure prophylaxis use as individual-level explanatory variables. The national proportions of respondents screened and diagnosed who notified some or all of their sexual partners were used as country-level explanatory variables. Combined, these factors helped to explain differences in self-reported diagnosis rates between countries. The following differences were not explained by the above factors: self-reported syphilis diagnoses were higher in Latin America compared with Europe, Canada, Israel, Lebanon, and the Philippines (aORs 2.30 - 3.71 for symptomatic syphilis compared to Central-West Europe); self-reported gonorrhea diagnoses were lower in Eastern Europe and in Latin America compared with all other regions (aORs 0.17-0.55 and 0.34 - 0.62 for symptomatic gonorrhea compared to Central-West Europe); and self-reported chlamydia diagnoses were lower in Central East and Southeast Europe, South and Central America, and the Philippines (aORs 0.25 - 0.39 for symptomatic chlamydia for Latin American subregions compared to Central West Europe).

CONCLUSIONS

Possible reasons for differences in self-reported STI diagnosis prevalence likely include different background prevalence for syphilis and syndromic management without proper diagnosis, and different diagnostic approaches for gonorrhea and chlamydia.

Social and behavioural determinants of syphilis: Modelling based on repeated cross-sectional surveys from 2010 and 2017 among 278,256 men who have sex with men in 31 European countries

Background

Syphilis case notifications among men-who-have-sex-with-men (MSM) have increased markedly over the past two decades in Europe. We tested several potential factors for this resurgence.

Methods

Self-reported data from two cross-sectional waves of the European MSM Internet Survey (EMIS-2010 and EMIS-2017, N = 278,256 participants living in 31 European countries) were used to fit multivariable hierarchical logistic regression models designed to evaluate potential social, behavioural, and interventional determinants of syphilis diagnosis. Additional multivariable hierarchical negative binomial models investigated determinants of the number of non-steady male condomless anal intercourse (CAI) partners. We tested the hypothesis that more CAI and syphilis-screening are associated with syphilis resurgence, both linked to use of pre-exposure prophylaxis (PrEP).

Findings

Between 2010 and 2017, incidence of syphilis diagnosis in the previous 12 months rose from 2.33% (95%CI: 2.26–2.40) of respondents reporting a syphilis diagnosis in 2010 compared with 4.54% (95%CI: 4.42–4.66) in 2017. Major factors contributing to syphilis diagnosis were living with diagnosed HIV (adjusted odds ratio (aOR) 2.67, 95%CI: 2.32–3.07), each additional non-steady male CAI partner (aOR 1.01, 95%CI: 1.01–1.01), recency of STI-screening (previous month vs no screening, aOR 25.76, 95%CI: 18.23–36.41), selling sex (aOR 1.45, 95%CI: 1.27–1.65), and PrEP use (aOR 3.02, 95%CI: 2.30–3.96). Living with diagnosed HIV (adjusted incidence rate ratio (aIRR) 3.91, 95%CI: 3.77–4.05), selling sex (aIRR 4.39, 95%CI: 4.19–4.59), and PrEP use (aIRR 5.82, 95%CI: 5.29–6.41) were associated with a higher number of non-steady male CAI partners. The association between PrEP use and increased chance of syphilis diagnosis was mediated by STI-screening recency and number of non-steady male CAI partners, both substantially higher in 2017 compared to 2010.

Interpretation

Syphilis cases are concentrated in three MSM population groups: HIV-diagnosed, PrEP users, and sex workers. Behavioural and interventional changes, particularly more non-steady male CAI partners and recency of STI-screening, are major contributing factors for increasing syphilis diagnoses among MSM in Europe.

Funding

European Centre for Disease Prevention and Control.

Ocular Syphilis: Our Experience in Selayang Hospital, Malaysia

Objectives: This study aims to describe the demographic features, clinical profile, Human Immunodeficiency Virus (HIV) status, and visual outcome after completing treatment in patients diagnosed with uveitic syphilis. 

Methods: A retrospective review was conducted of all cases diagnosed with ocular syphilis from January 2014 to December 2019 at the ophthalmology clinic of Selayang Hospital, Selangor, Malaysia. A total of 31 cases were reviewed, and the collected data included demographic features, history of high-risk behavior, ocular symptoms and signs, visual acuity at presentation and after completing treatment, treatment received, complications, and HIV status. Serology tests to confirm the diagnosis were also included, such as the rapid plasma reagin (RPR), venereal disease research laboratory test (VDRL) titer, and treponema pallidum hemagglutination (TPHA) tests, and some cases also included the VDRL cerebrospinal fluid (CSF) test. 

Results: A total of 31 patients with ocular syphilis were identified within the study period. Male patients comprised the majority with 27 cases. Nineteen patients were below the age of 50. The majority were ethnic Malay (21 patients). Seventeen patients were identified to have HIV co-infection. Twenty patients reported high-risk behaviors, and among them, six cases were HIV-infected homosexuals. The commonest symptom was blurring of vision (61%), followed by eye redness (16%), floaters (13%), and incidental findings (10%). There were 18 bilateral cases and 13 unilateral cases. The larger share presented as panuveitis (14 cases), followed by intermediate uveitis (nine cases), anterior uveitis (four cases), posterior uveitis (two cases), endophthalmitis (one case), and branch retinal vein occlusion (one case). RPR and TPHA tests were done for all patients. Only 12 patients consented to lumbar puncture for a CSF VDRL test, and one tested positive. All patients received intravenous (IV) administration of 3.0 to 4.0 million units of benzylpenicillin every four hours for 14 days. All cases reported a good outcome with an improvement in visual acuity of at least two Snellen lines after treatment. 

Conclusion: Early detection and treatment of ocular syphilis will usually preserve visual acuity and ocular function. This study highlights the need for a high degree of suspicion of HIV co-infection, as the majority of our patients were discovered to be HIV-seropositive. Thus, HIV screening is mandatory in all patients presenting with syphilitic uveitis.

Improving Underestimation of HIV Prevalence in Surveys Using Time-Location Sampling

We sought to find a method that improves HIV estimates obtained through time-location sampling (TLS) used to recruit most-at-risk populations (MARPs). The calibration on residuals (CARES) method attributes weights to TLS sampled individuals depending on the percentile to which their logistic regression residues belong. Using a real country database, provided by EMIS-2010, with 9591 men who have sex with men (MSM) and an HIV prevalence of 12.1%, we simulated three populations (termed "pseudo-populations") with different levels of HIV. From each pseudo-population, 1000 TLS samples were drawn, and the HIV prevalence estimated by the TLS method and by the CARES method were recorded and compared with the HIV prevalence of the 9591 men. Results showed that the CARES method improves estimates given by the TLS method by getting closer to the real HIV prevalence.

Temporal Trends in the Epidemiology of HIV in Turkey

OBJECTIVE

The aim of this study was to analyze the temporal trends of HIV epidemiology in Turkey from 2011 to 2016.

METHODS

Thirty-four teams from 28 centers at 17 different cities participated in this retrospective study. Participating centers were asked to complete a structured form containing questions about epidemiologic, demographic and clinical characteristics of patients presented with new HIV diagnosis between 2011 and 2016. Demographic data from all centers (complete or partial) were included in the analyses. For the cascade of care analysis, 15 centers that provided full data from 2011 to 2016 were included. Overall and annual distributions of the data were calculated as percentages and the Chi square test was used to determine temporal changes.

RESULTS

A total of 2,953 patients between 2011 and 2016 were included. Overall male to female ratio was 5:1 with a significant increase in the number of male cases from 2011 to 2016 (p<0.001). The highest prevalence was among those aged 25-34 years followed by the 35-44 age bracket. The most common reason for HIV testing was illness (35%). While the frequency of sex among men who have sex with men increased from 16% to 30.6% (p<0.001) over the study period, heterosexual intercourse (53%) was found to be the most common transmission route. Overall, 29% of the cases presented with a CD4 count of >500 cells/mm3 while 46.7% presented with a CD4 T cell count of <350 cells/mm3. Among newly diagnosed cases, 79% were retained in care, and all such cases initiated ART with 73% achieving viral suppression after six months of antiretroviral therapy.

CONCLUSION

The epidemiologic profile of HIV infected individuals is changing rapidly in Turkey with an increasing trend in the number of newly diagnosed people disclosing themselves as MSM. New diagnoses were mostly at a young age. The late diagnosis was found to be a challenging issue. Despite the unavailability of data for the first 90, Turkey is close to the last two steps of 90-90-90 targets.

Accurately Assessing Gay Men's Erectile Functioning: A Critique of the International Index of Erectile Function (IIEF) Use with Gay Men

The International Index of Erectile Functioning (IIEF) has been widely used to measure gay men's erectile functioning. However, the IIEF was initially developed using a sample of men whose sexual orientation was unspecified. Using scales not validated for specific populations can result in inaccurate assessments. The purpose of the current study was to evaluate the dimensionality, reliability, and validity of the IIEF with a large sample of gay men. One thousand and eighteen men self-identifying as "exclusively gay" completed an online survey consisting of demographics, the IIEF, the Hospital Anxiety and Depression Scale (HADS), the Perceived Stress Scale 4 (PSS4), and the Gay Male Sexual Difficulties (GMSD) erectile difficulties sub-scale. The replicability of the IIEF factor structure with a gay male sample was determined using exploratory and confirmatory factor analyses. Additionally, the HADS, PSS4, and GMSD were used to determine the validity of the IIEF. The current study was unable to replicate the IIEF factor structure. Four items required deletion and the factor solution differed from the original. Thus, reinterpretation of the latent variables was deemed necessary. Although the resultant 12-item IIEF evidenced model fit, validity, and reliability, it is not recommended for use with gay men. The revised IIEF is unable to accurately measure gay men's erectile functioning as the content of the items fail to capture their sexual behaviors (i.e., insertive and receptive anal sex).

Estimated Number of Men Who Have Sex With Men With Indications for HIV Pre-exposure Prophylaxis in a National Sexual Network Study

BACKGROUND

A 2015 CDC analysis estimated that 24.7% of sexually active men who have sex with men (MSM) had indications for HIV pre-exposure prophylaxis (PrEP) based on 2014 US Public Health Service (USPHS) clinical practice guidelines. Given that the USPHS revised these guidelines in 2017, updated estimates of the fraction of MSM indicated for PrEP overall and stratified by demographic factors and geography are needed to scale-up PrEP for MSM in the US.

METHODS

We conducted a national web-based study of 4904 MSM aged 15-65 who had ever had sex with another man between July 2017 and January 2019. We estimated the percentage of HIV-negative, sexually active MSM meeting USPHS indications for PrEP by demographic category.

RESULTS

Of 3511 sexually active, HIV-negative MSM, 34.0% (95% confidence interval: 32.4 to 35.6) met USPHS indications for PrEP, with percentages consistent across US census region and varying slightly by race/ethnicity (Black: 32.2%, White: 33.7%, Hispanic: 36.4%, Other: 33.6%). Among individuals meeting USPHS PrEP indications, 93.5% reported condomless anal intercourse in the prior 6 months. Among all survey respondents, PrEP eligibility was lowest among non-Hispanic black (18.4%) and younger respondents (15-17: 4.1%; 18-24: 18.1%).

CONCLUSIONS

Estimated percentages of MSM meeting indications for PrEP exceeded the previous CDC estimate across race/ethnicity, age, and census regions, with one-third of adult, sexually active, HIV-negative MSM exhibiting indications for PrEP. This study suggests, given current guidelines for PrEP indications, that a different fraction of eligible MSM could be receiving PrEP than previously estimated.

Links between transactional sex and HIV/STI-risk and substance use among a large sample of European men who have sex with men

BACKGROUND

In Europe, the highest proportion of HIV diagnoses are in gay men and other men who have sex with men (MSM). Globally, HIV prevalence is particularly high among males who report selling sex, but rates among men who buy sex from other men are less clear. This study analyzed the association of transactional sex (TS) and HIV diagnosis, sexually transmitted infection (STI) diagnoses, and various drug use; and examined the variations in TS by payment direction.

METHODS

We conducted a cross-sectional, non-randomized, observational study. This European MSM Internet Survey recruited MSM from 38 European countries. For descriptive purposes we stratified according to TS behavior (frequently selling sex, frequently buying sex, neither frequently selling nor buying sex in the previous 12 months), and we constructed separate multivariable logistic regression models to investigate whether engaging in TS accounted for some of the HIV- and STI diagnoses and drug use in this population.

RESULTS

Of almost 161,000 sexually active MSM, 12.2% engaged in TS. The multivariable logistic regression results showed that relative to not frequently engaging in TS, frequently selling sex was independently associated with a higher odds of reporting diagnosed HIV (ever, adjusted odds ratio [aOR] 1.60, confidence interval [CI] 95% 1.39 to 1.85), bacterial STIs (past 12 months, aOR 1.75 CI 95% 1.54 to 2.00), using heroin or crack cocaine or injecting drugs (aOR 3.17, CI 95% 2.70 to 3.73), and using benzodiazepines (aOR 2.13, CI 95% 1.88 to 2.41). Compared to men not engaging in frequent TS, frequently buying sex was associated with a higher odds of using benzodiazepines (aOR 2.13, CI 95% 1.88 to 2.41).

CONCLUSIONS

MSM who frequently sell sex suffer greater sexual- and substance use risks than other MSM, but both men who frequently sell and those who buy sex are more likely to use benzodiazepines. MSM who sell sex to other men constitute an important at-risk population who must be offered targeted health services.

HIV incidence among men who have sex with men at a community-based facility in Greece

OBJECTIVE

Men who have sex with men (MSM) are disproportionately affected by HIV in Greece. However, research on HIV incidence in this group is lacking. This study aimed at estimating HIV incidence among MSM in Athens, Greece.

METHODS

The analysis included routinely collected data between January 2013-June 2015 from adult MSM who visited a community-based facility (Ath Checkpoint) at least twice and were non-reactive to the rapid INSTI^TM HIV-1/HIV-2 assay at baseline. HIV conversion rates were calculated by dividing the number of clients who became reactive by the person-years of observation. All statistical analyses including Poisson regression models were conducted in STATA 14.

RESULTS

A total of 1,243 MSM contributed 1,102.50 person-years (py). The overall (per 100 py) conversion rate was 3.99 (95% CI: 2.97-5.36). In multivariable analyses, age less than 30 years was associated with an increased risk of HIV conversion (rate ratio: 2.01; 95% CI: 1.08-3.76).

CONCLUSIONS

This analysis shows high rates of HIV conversion among MSM who repeatedly visit a community-based testing site. Ath Checkpoint could contribute to HIV surveillance and identify a high-risk group that could benefit from essential health interventions.

Lack of HIV testing and dissatisfaction with HIV testing and counselling among men having sex with men in Hungary

Background

Using data from a large internet-based survey of European men having sex with men (MSM), we assessed factors associated with HIV testing and reasons for dissatisfaction with HIV testing and counselling among Hungarian MSM.

Methods

A total of 2052 Hungarian MSM provided evaluable data for the European MSM Internet Survey (EMIS) in 2010. χ2 tests and Poisson regression with a robust variance estimator were used to assess factors associated with HIV testing and dissatisfaction with HIV testing and counselling.

Results

A total of 42.1% of MSM reported never being testing for HIV. Over one-half of men (54.1%) who reported condomless anal intercourse (CAI) in the prior 12 months with a person of unknown or sero-discordant HIV status reported no lifetime HIV testing. The factor most strongly associated with dissatisfaction with HIV testing and counselling was test site with increased dissatisfaction with inpatient hospital settings vs. community-based organizations. Both lack of HIV testing and dissatisfaction with testing were independently associated with MSM who reported that no one, or only a few people, knew they were attracted to men.

Conclusions

Lack of HIV testing was strongly associated with CAI. MSM reported that community-based organizations better supported confidentiality and were more respectful during HIV testing.

[Data on the sexual health of providers and clients of sexual services for men who have sex with men in Germany]

Little is known about the sexual health of male providers and clients of transactional sex. The data of participants of the European MSM Internet Survey (EMIS-DE; N = 50,086) who live in Germany were analysed. The outcomes were testing for and diagnoses of HIV and other sexually transmitted infections (STIs), partner numbers, illicit drug use, and sexual happiness in two populations: (1) men who offered and (2) men who paid for transactional sex in the past 12 months.In the age group of under 30 years (n = 19,138), providers of sexual services (escorts) were compared with non-providers; in the age group of 30 years and above (n = 30,948), we compared men who paid for sexual services with those who did not. We applied univariable and multinomial, multivariable logistic regression analyses in both age groups.Of those under the age of 30, 8% (n = 1529) had been paid for sex in the last 12 months, of which 49% were only paid once or twice. Escorts had lower educational achievements, lived more commonly in large cities, were more often born abroad, self-defined less frequently as gay, and were more frequently single. They reported higher numbers of sex partners, more drug use, and more sexual happiness. Escorts were more frequently tested for HIV and STIs, and among the tested, more diagnoses of HIV and STIs were reported, but those with HIV were less likely to be treated.Among those over 30 years, 11% (n = 3334) had paid for sex, the majority (58%) only once or twice. Payers were older, lived more commonly in large cities, and were more likely to be single, bisexual, or living with a woman. Clients used more illicit drugs, sexual enhancement drugs, and sedatives, but reported less sexual happiness. They were less likely to be tested for HIV and STIs.

Using data from a behavioural survey of men who have sex with men (MSM) to estimate the number likely to present for HIV pre-exposure prophylaxis (PrEP) in Ireland, 2017

In Ireland, men who have sex with men (MSM) have increased HIV risk. Pre-exposure prophylaxis (PrEP), combined with safe sex practices, can reduce HIV acquisition. We estimated MSM numbers likely to present for PrEP by applying French PrEP criteria to Irish MSM behavioural survey data. We adjusted for survey bias, calculated proportions accessing testing services and those likely to take PrEP. We estimated 1-3% of MSM in Ireland were likely to present for PrEP.

Sex tourism among Chinese men who have sex with men: a cross-sectional observational study

BACKGROUND

Sex tourism among men who have sex with men (MSM) may exacerbate transmission of HIV and other sexually transmitted infections (STIs). Sex tourism is defined as purchasing sex with gifts or money outside of one's hometown. Our objective was to characterize the frequency, socio-demographic characteristics, and sexual risk behaviors among Chinese MSM sex tourists.

METHODS

An online, cross-sectional survey for high-risk MSM throughout China was conducted in November 2015 covering sociodemographic characteristics, sexual risk behaviors, and sex tourism. Univariate and multivariable logistic regressions were performed to identify correlates of sex tourism. The mean MSM HIV prevalence of sex tourism journey origins and destinations were compared.

RESULTS

Of 1189 MSM who completed the survey, 62 (5%) men identified as sex tourists; among these sex tourists, twenty (32%) traveled primarily to purchase sex and the remainder purchased sex while traveling for another purpose. There was minimal socio-demographic and behavioral difference between the two groups. In multivariable analyses, adjusting for age and income, sex tourism was correlated with high-risk sexual behaviors, higher income (aOR 4.44, 95%CI 1.77-11.18) and living with HIV (aOR 2.79, 95%CI 1.03-7.55). Sex tourism was more often from locations with lower to higher MSM HIV prevalence (mean = 4.47, SD = 2.01 versus mean = 6.86, SD = 5.24).

CONCLUSION

MSM sex tourists were more likely to have risky sexual behaviors and travel to locations with a higher HIV prevalence. MSM sex tourists may be part of core groups that are disproportionately responsible for MSM HIV transmission. Enhanced surveillance and interventions tailored to MSM sex tourists should be considered.

Systematic review of electronic surveillance of infectious diseases with emphasis on antimicrobial resistance surveillance in resource-limited settings

BACKGROUND

Electronic surveillance of infectious diseases involves rapidly collecting, collating, and analyzing vast amounts of data from interrelated multiple databases. Although many developed countries have invested in electronic surveillance for infectious diseases, the system still presents a challenge for resource-limited health care settings.

METHODS

We conducted a systematic review by performing a comprehensive literature search on MEDLINE (January 2000-December 2015) to identify studies relevant to electronic surveillance of infectious diseases. Study characteristics and results were extracted and systematically reviewed by 3 infectious disease physicians.

RESULTS

A total of 110 studies were included. Most surveillance systems were developed and implemented in high-income countries; less than one-quarter were conducted in low-or middle-income countries. Information technologies can be used to facilitate the process of obtaining laboratory, clinical, and pharmacologic data for the surveillance of infectious diseases, including antimicrobial resistance (AMR) infections. These novel systems require greater resources; however, we found that using electronic surveillance systems could result in shorter times to detect targeted infectious diseases and improvement of data collection.

CONCLUSIONS

This study highlights a lack of resources in areas where an effective, rapid surveillance system is most needed. The availability of information technology for the electronic surveillance of infectious diseases, including AMR infections, will facilitate the prevention and containment of such emerging infectious diseases.

Indicator condition based HIV testing: Missed opportunities for earlier diagnosis in men who have sex with men

INTRODUCTION

Contact with the healthcare system by a sample of seropositive men who have sex with men (MSM) prior to their HIV diagnosis are analysed, and missed opportunities (MO) for an earlier HIV diagnosis are identified.

METHODOLOGY

Between 2012-2013, an online survey was conducted among HIV-positive MSM, mainly recruited from gay websites. Those who were diagnosed with HIV between 2010-2013 were analysed. MO were defined as episodes prior to the HIV diagnosis in which the healthcare system was contacted due to an indicator condition of HIV infection and the test was not suggested. The proportion of missed opportunities were compared according to the type of indicator condition, the department consulted and the healthcare professional's knowledge that the patient was MSM.

RESULTS

Overall, 639 participants (66% of 966) reported 1,145 episodes with some indicator condition, the majority of these being identified in primary care (n=527; 46%). The highest percentage of MOs is also observed in primary care (63%). Although the indicator condition with the highest number of MOs was STIs (n=124), the highest percentage of MOs was observed in consultations due to diarrhoea with no known cause (69.8%). The percentage of MOs when the doctor knew that the patient was MSM was 40 vs. 70% when the doctor did not know.

CONCLUSION

The majority of HIV-positive MSM analysed in this study went to healthcare services for HIV-infection indicator conditions prior to their HIV diagnosis. Primary care was the most-frequently-visited department and is also where the most opportunities were missed to perform an HIV test, even when it was known that the patient was a MSM.

Cruising Venues as a Context for HIV Risky Behavior Among Men Who Have Sex With Men

We examined differences in sexual risk behaviors, HIV prevalence, and demographic characteristics between men who have sex with men (MSM) who visit different types of venues to meet sexual partners, and identified correlates of high-risk behaviors. A cross-sectional behavioral survey was conducted with a venue-based sample of 1011 MSM in Portugal. Overall, 36.3 % of MSM usually visit cruising venues to meet sexual partners (63.7 % only visit social gay venues). Cruising venues' visitors reported higher HIV prevalence (14.6 % [95 % CI 11-18 %] vs. 5.5 % [95 % CI 4-7 %]). Visiting cruising venues was more likely among those older, reporting high number of male sexual partners, group sex, and unprotected anal sex with a partner whose HIV status was unknown. Cruising venues play an important role in increasing risk of HIV transmission among MSM who frequent them. Venue-focused behavioral interventions that promote healthy sexual behaviors are needed.

Motivators and barriers for HIV testing among men who have sex with men in Sweden

AIMS AND OBJECTIVES

To explore motivators and barriers to HIV testing and to assess the factors associated with testing among men who have sex with men.

BACKGROUND

Previous research has considered fear, worries and structural barriers as hindrances to HIV testing among men who have sex with men. However, few studies have included assessments of actual HIV testing when exploring barriers or motivators for such testing.

DESIGN

The design of the study was a stratified cross-sectional online survey (n = 2373).

METHOD

Factor analysis was conducted to analyse the barriers and motivators for HIV testing. Logistic regression analysis was conducted to assess predictors for HIV testing.

RESULTS

Many men who have sex with men test for HIV regularly, and specific reasons for testing were having unprotected sex or starting/ending a relationship. A lack of awareness and a perception of being at low risk for exposure were common reasons for never being tested. Fear and anxiety as well as barriers related to the use of test services remain important hindrances for testing. Predictors associated with having been tested within the past 12 months were: younger age (15-25 years old compared with 47+); knowledge on where to take an HIV test on short notice as well as having talked with a counsellor, having received condoms for free, or having had unprotected anal intercourse with casual partners within the last 12 months.

CONCLUSION

Easily accessible test services offering testing and counselling on short notice should be available for all men who have sex with men. Outreach activities, distribution of free condoms and testing at venues where men who have sex with men meet are important prevention add-ons that can contribute to increased awareness about HIV and testing.

RELEVANCE TO CLINICAL PRACTICE

Test services must ensure confidentiality and health care professionals who meet men who have sex with men for testing need competency with regards to men who have sex with men sexual health needs.

Bayesian evidence synthesis to estimate HIV prevalence in men who have sex with men in Poland at the end of 2009

HIV spread in men who have sex with men (MSM) is an increasing problem in Poland. Despite the existence of a surveillance system, there is no direct evidence to allow estimation of HIV prevalence and the proportion undiagnosed in MSM. We extracted data on HIV and the MSM population in Poland, including case-based surveillance data, diagnostic testing prevalence data and behavioural data relating to self-reported prior diagnosis, stratified by age (⩽35, >35 years) and region (Mazowieckie including the capital city of Warsaw; other regions). They were integrated into one model based on a Bayesian evidence synthesis approach. The posterior distributions for HIV prevalence and the undiagnosed fraction were estimated by Markov Chain Monte Carlo methods. To improve the model fit we repeated the analysis, introducing bias parameters to account for potential lack of representativeness in data. By placing additional constraints on bias parameters we obtained precisely identified estimates. This family of models indicates a high undiagnosed fraction [68·3%, 95% credibility interval (CrI) 53·9-76·1] and overall low prevalence (2·3%, 95% CrI 1·4-4·1) of HIV in MSM. Additional data are necessary in order to produce more robust epidemiological estimates. More effort is urgently needed to ensure timely diagnosis of HIV in Poland.

Evaluation of a temporary vaccination recommendation in response to an outbreak of invasive meningococcal serogroup C disease in men who have sex with men in Berlin, 2013–2014

Meningococcal serogroup C (MenC) vaccination of men who have sex with men (MSM) was temporarily recommended to control an outbreak of invasive MenC disease among MSM in Berlin in 2012–2013. Vaccination was offered to HIV-infected MSM free of charge; others had to request reimbursement or pay out of pocket. We aimed to assess (i) awareness and acceptance of this recommendation through an online survey of MSM, (ii) implementation through a survey of primary care physicians and analysis of vaccine prescriptions, and (iii) impact through analysis of notified cases. Among online survey respondents, 60% were aware of the recommendation. Of these, 39% had obtained vaccination (70% of HIV-infected, 13% of HIV-negative/non-tested MSM). Awareness of recommendation and vaccination were positively associated with HIV infection, primary care physicians’ awareness of respondents’ sexual orientation, and exposure to multiple information sources. Most (26/30) physicians informed clients about the recommendation. Physicians considered concerns regarding reimbursement, vaccine safety and lack of perceived disease risk as primary barriers. After the recommendation, no further outbreak-related cases occurred. To reach and motivate target groups, communication of a new outbreak-related vaccination recommendation should address potential concerns through as many information channels as possible and direct reimbursement of costs should be enabled.

Factors associated with unprotected anal sex with multiple non-steady partners in the past 12 months: results from the European Men-Who-Have-Sex-With-Men Internet Survey (EMIS 2010)

BACKGROUND

Practising unprotected anal intercourse (UAI) with high numbers of partners is associated with increased risk for acquiring and transmitting HIV and other sexually transmitted infections. Our aim was to describe factors associated with UAI with multiple partners in a large sample of MSM from 38 European countries recruited for an online survey in 2010.

METHODS

Data are from the European Men-Who-Have-Sex-With-Men Internet Survey (EMIS). The analysis was restricted to men who reported any anal sex with a non-steady partner in the past 12 months, and who were either never diagnosed with HIV, or who had been diagnosed with HIV more than 12 months ago, reported a detectable viral load and did not exclusively serosort (n = 91,477). Multivariable logistic regression was used to compare men reporting UAI with four or more (4+) non-steady partners to two comparison groups: a) no UAI with non-steady partners, and b) UAI with 1-3 non-steady partners.

RESULTS

Overall, 9.6% of the study population reported UAI with 4+ partners in the past 12 months. In both models, factors consistently associated with this behaviour were: having been diagnosed with HIV, lower educational levels, use of nitrite inhalants, drugs associated with sex and parties, or erectile dysfunction drugs in the past 4 weeks, using sex-on-site venues in the past 4 weeks, buying or selling sex in the past 12 months, having experienced physical violence due to sexual attraction to men in the past 12 months, reporting sexual happiness, being out to all or almost all of one's acquaintances, and knowing that ART reduces HIV transmissibility.

CONCLUSIONS

Effective antiretroviral treatment drastically reduces HIV transmission for men diagnosed with HIV, irrespective of partner numbers. Apart from reducing partner numbers or increasing condom use no other recommendations are currently in place to reduce the risk of HIV acquisition and onward transmission for HIV-negative men practicing UAI with multiple partners. A range of factors were identified as associated with UAI with four or more partners which allow the strengthening and targeting of prevention strategies to reduce HIV transmission risks resulting from condomless anal intercourse with multiple partners.

Comparing databases: determinants of sexually transmitted infections, HIV diagnoses, and lack of HIV testing among men who have sex with men

Background

Early detection and treatment of STI/HIV are public health priorities. Our objective was to compare characteristics of men who have sex with men (MSM) in Dutch data available in 2010 from EMIS, an international internet survey, Schorer Monitor, a Dutch internet survey, and data from STI- clinic visits, since these might be subject to different and unknown biases.

Methods

Data from Dutch MSM Internet Surveys (EMIS_NLN = 3,787; Schorer Monitor, SMON N = 3,602), and 3,800 STI clinic visits (SOAP) were combined into one dataset. We included factors that were measured in all three databases. The socio-demographics included were age (at the time of the survey), zip code, and ethnicity. Behavioural variables included were the number of sexual partners, condom use with last sexual partner, drug use, being diagnosed with STI, being diagnosed with HIV, and HIV testing. Outcomes we investigated were being diagnosed with STI, HIV, and never been tested for HIV.

Results

Logistic regressions showed that determinants for being diagnosed with STI were having more sexual partners, drug use, and having had an HIV test (aORs 1.3 to 17.1) in EMIS and SMON. Determinants for being diagnosed with HIV in all three databases were older age, living in Amsterdam, and having more partners (aORs 1.8 to 4.4). In EMIS and SMON, drug use, non-condom use, and having STI were additional determinants (aORs 1.6 to 8.9). Finally, determinants associated with never been tested for HIV were being younger (only SOAP), living outside of Amsterdam, having fewer partners, no drug use, and no STI (aORs 0.2 to 0.8).

Conclusions

Risk factors from internet surveys were largely similar, but differed from STI clinics, possibly because it involves self-reports rather than diagnoses or because of differences in timing. The difference between the internet surveys and STI clinic data is much less pronounced for having never been tested, suggesting both are appropriate for this outcome. These findings shed light on conclusions drawn from different data sources, as well as the comparability of recruitment strategies, the robustness of risk factors, consequences of phrasing questions differently, and on (policy) implications based on different data sources.

High prevalence of multiple syndemic conditions associated with sexual risk behavior and HIV infection among a large sample of Spanish- and Portuguese-speaking men who have sex with men in Latin America

The HIV epidemic in Latin America is highly concentrated in men who have sex with men (MSM). In the United States, multiple co-occurring psychosocial conditions have been shown to act as intertwined epidemics to potentiate HIV transmission among MSM. To date, no study has examined the role of syndemics and condomless sex among MSM in Latin America. In 2012, an online survey was conducted among members of the largest social/sexual networking website for MSM in Latin America. Participants were asked about demographics, sexual behaviors, HIV/STI diagnoses, and psychosocial well-being, including depression, suicidal ideation, hazardous alcohol use, hard drug use during sex, history of childhood/adolescent sexual abuse, intimate partner violence, and sexual compulsivity. Multivariable logistic generalized estimation equations were used to assess the relationship of syndemic factors and (1) engagement in higher risk condomless anal sex and (2) self-report of prior HIV diagnosis. Among 24,274 survey respondents, 74.6 % of the sample had at least one syndemic factor. In an additive model, syndemics were associated with increased odds of higher risk condomless anal sex, ranging from adjusted odds ratio of 1.31 (95 % CI 1.20, 1.43) for one syndemic factor to 4.06 (95 % CI 3.25, 5.09) for 6/7 syndemic factors. Similarly, syndemics were associated with increased odds of HIV infection (p < .0001). This study provides initial evidence that intertwined syndemics increase HIV risk behavior and HIV infection among MSM in Latin America. In the Latin American context, comprehensive HIV prevention interventions for MSM should be developed and tested that simultaneously address co-occurring psychosocial conditions and HIV risk.

Factors Associated with Low Levels of HIV Testing among Men Who Have Sex with Men (MSM) in Brazil

The aim of this study was to assess risk factors associated with low levels of HIV testing among MSM recruited through respondent driven sampling (RDS) in Brazil. Of 3,617 participants, 48.4% had never tested previously for HIV. A logistic model indicated that younger age, lower socioeconomic class, education, poor HIV/AIDS knowledge, no history of cruising, and having been tested during the study were characteristics independently associated with low levels of previous HIV testing. The HIV testing rate among MSM in Brazil is still low in spite of the availability of a large number services providing universal and free access to HIV/AIDS diagnosis and treatment. To respond to low utilization, the authors propose a higher priority for testing for key populations such as MSM, expanded education, expanding testing sites and a welcoming and nonjudgmental environment in health services.

Hidden from health: structural stigma, sexual orientation concealment, and HIV across 38 countries in the European MSM Internet Survey

Objective

Substantial country-level variation exists in prejudiced attitudes towards male homosexuality and in the extent to which countries promote the unequal treatment of MSM through discriminatory laws. The impact and underlying mechanisms of country-level stigma on odds of diagnosed HIV, sexual opportunities, and experience of HIV-prevention services, needs and behaviours have rarely been examined, however.

Design

Data come from the European MSM Internet Survey (EMIS), which was administered between June and August 2010 across 38 European countries (N =174 209).

Methods

Country-level stigma was assessed using a combination of national laws and policies affecting sexual minorities and a measure of attitudes held by the citizens of each country. We also assessed concealment, HIV status, number of past 12-month male sex partners, and eight HIV-preventive services, knowledge, and behavioural outcomes.

Results

MSM living in countries with higher levels of stigma had reduced odds of diagnosed HIV and fewer partners but higher odds of sexual risk behaviour, unmet prevention needs, not using testing services, and not discussing their sexuality in testing services. Sexual orientation concealment mediated associations between country-level stigma and these outcomes.

Conclusion

Country-level stigma may have historically limited HIV transmission opportunities among MSM, but by restricting MSM’s public visibility, it also reduces MSM’s ability to access HIV-preventive services, knowledge and precautionary behaviours. These findings suggest that MSM in European countries with high levels of stigma are vulnerable to HIV infection. Although they have less opportunity to identify and contact other MSM, this might change with emerging technologies.

The Lisbon Cohort of men who have sex with men

PURPOSE

Newly diagnosed HIV infections among men who have sex with men (MSM) are rising in many European countries. Surveillance tools must be tailored to the current state of the epidemic, and include decentralised prospective monitoring of HIV incidence and behavioural changes in key populations. In this scenario, an open prospective cohort study was assembled--The Lisbon Cohort of MSM--aiming to dynamically monitor the frequency of disease and its predictors.

PARTICIPANTS

The Lisbon Cohort of MSM is an ongoing observational prospective study conducted at a community-based voluntary HIV counselling and testing centre in Lisbon, Portugal (CheckpointLX). Men testing negative for HIV, aged 18 or over and reporting having had sex with men are invited to follow-up visits every 6 months. At each evaluation, a face-to-face interview using a structured questionnaire is conducted, and HIV and syphilis rapid tests are performed by trained peer counsellors. From April 2011 to February 2014, 3106 MSM were eligible to the cohort of whom 923 (29.7%) did not participate. The remaining 2183 (70.3%) MSM were enrolled and 804 had at least one follow-up evaluation, for a total of 893 person-years of observation.

FUTURE PLANS

The study findings will be disseminated in peer-reviewed journals and presented at national and international conferences. The follow-up of this cohort of HIV-negative MSM will be a valuable tool for monitoring HIV incidence in a setting where limited prospective information existed. Moreover, it will allow for a deeper analytical approach to the study of population time trends and individual changes in risk factors that currently shape the HIV epidemic among MSM.

A systematic review of evidence to inform HIV prevention interventions among men who have sex with men in Europe

An estimated 42% of all newly diagnosed HIV cases in Europe in 2013 were transmitted during sex between men. This review was performed to identify and describe studies evaluating the efficacy and effectiveness of HIV prevention interventions among men who have sex with men (MSM), in relation to implementation data from European settings. A systematic search was performed individually for 24 interventions.Data were extracted from studies including efficacy or implementation data from European settings,appraised for efficacy, implementation and plausibility, and assigned a grade (1-4) according to the Highest Attainable Standard of Evidence (HASTE)framework. Four interventions (condom use, peer outreach,peer-led groups, and using universal coverage of antiretroviral treatment and treatment as prevention)were assigned the highest HASTE grade, 1. Another four interventions were assigned 2a for probable recommendation, including voluntary counseling and testing for HIV, using condom-compatible lubricant,using post-exposure prophylaxis, and individual counselling for MSM living with HIV. In addition, seven interventions were assigned a grade of 2b, for possible recommendation. Encouragingly, 15 interventions were graded to be strongly, probably or possibly recommended.In the relatively resource-rich European setting, there is an opportunity to provide global leadership with regard to the regional scale-up of comprehensive HIV prevention interventions for MSM.

Incident risk factors as predictors of HIV seroconversion in the Lisbon cohort of men who have sex with men: first results, 2011-2014

HIV incidence in men who have sex with men (MSM) is increasing in western countries, including Portugal. We aimed to estimate HIV incidence and to assess how individual short-term changes in exposures over time predict seroconversion. We evaluated participants of an open cohort of HIV-negative MSM enrolled after testing at a community-based voluntary HIV counselling and testing centre in Lisbon. At each evaluation a structured questionnaire was completed and HIV status was ascertained using rapid followed by confirmatory testing. Between April 2011 and February 2014, 804 MSM were followed for a total of 893 person-years. Predictors of HIV seroconversion were identified using Poisson generalised linear regression. The overall seroincidence was 2.80/100 person-years (95% confidence interval: 1.89-4.14). Men who seroconverted had a higher mean number of tests per year. Seroconversions were significantly associated with partner disclosure of HIV status during follow-up, newly-adopted unprotected anal intercourse (UAI) with a steady partner and being newly-diagnosed with syphilis during follow-up. Likewise, sexual intercourse with HIV-positive men, having an HIV-positive steady partner at least once during follow-up and persistent UAI with occasional partners were predictors of seroconversion. High HIV incidence in this cohort is likely driven by short-term contextual and behavioural changes during follow-up.

[Deficits in STI diagnosis for men who have sex with men (MSM) in German-speaking cities: results of the European MSM Internet Survey (EMIS)]

BACKGROUND

Sexually transmitted infections (STIs) such as anal/genital warts, syphilis, and genital/rectal gonorrheal/chlamydial infections compromise the health of men who have sex with men (MSM), and increase the per-contact risk of HIV infection. Early detection of asymptomatic STIs requires regular screening including physical examinations and collection of clinical specimens that allow for the detection of infections at sites common to men's same-sex practices.

METHODS

From June to August 2010, the European MSM Internet Survey (EMIS) recruited 174,209 MSM from 38 European countries to an anonymous online questionnaire in 25 languages. As sexual health care for MSM in most countries is organized locally, we chose cities for comparison. Multivariable regression models were used to compare accessibility of services and applied diagnostic procedures across 1 Dutch, 1 Swiss, 1 Austrian, 3 English, and 19 German cities (N = 29,962).

RESULTS

The proportion of respondents tested for STIs in the last 12 months in the absence of symptoms ranged from 13 % in Magdeburg to 48.0 % in Amsterdam. At a city level, low STI screening correlated with inaccessible services (R(2) = 0.72). At an individual level, anal/penile inspection and anal swabbing was most common in English cities and in Amsterdam. Compared to London, MSM in German-speaking cities had an adjusted odds ratio (AOR) of 0.06-0.20 for anal/penile inspection, and of 0.05-0.17 for anal swabbing (p < 0.001).

CONCLUSIONS

Anal/genital warts and rectal infections are likely to be profoundly underdiagnosed among MSM in all German-speaking cities. This has implications for the sexual health of MSM, for HIV prevention, and for comparing European surveillance data. There is an urgent need to implement or improve sexual health care tailored to MSM at risk for STIs.

Nonprobability Web surveys to measure sexual behaviors and attitudes in the general population: a comparison with a probability sample interview survey

Background

Nonprobability Web surveys using volunteer panels can provide a relatively cheap and quick alternative to traditional health and epidemiological surveys. However, concerns have been raised about their representativeness.

Objective

The aim was to compare results from different Web panels with a population-based probability sample survey (n=8969 aged 18-44 years) that used computer-assisted self-interview (CASI) for sensitive behaviors, the third British National Survey of Sexual Attitudes and Lifestyles (Natsal-3).

Methods

Natsal-3 questions were included on 4 nonprobability Web panel surveys (n=2000 to 2099), 2 using basic quotas based on age and sex, and 2 using modified quotas based on additional variables related to key estimates. Results for sociodemographic characteristics were compared with external benchmarks and for sexual behaviors and opinions with Natsal-3. Odds ratios (ORs) were used to express differences between the benchmark data and each survey for each variable of interest. A summary measure of survey performance was the average absolute OR across variables. Another summary measure was the number of key estimates for which the survey differed significantly (at the 5% level) from the benchmarks.

Results

For sociodemographic variables, the Web surveys were less representative of the general population than Natsal-3. For example, for men, the average absolute OR for Natsal-3 was 1.14, whereas for the Web surveys the average absolute ORs ranged from 1.86 to 2.30. For all Web surveys, approximately two-thirds of the key estimates of sexual behaviors were different from Natsal-3 and the average absolute ORs ranged from 1.32 to 1.98. Differences were appreciable even for questions asked by CASI in Natsal-3. No single Web survey performed consistently better than any other did. Modified quotas slightly improved results for men, but not for women.

Conclusions

Consistent with studies from other countries on less sensitive topics, volunteer Web panels provided appreciably biased estimates. The differences seen with Natsal-3 CASI questions, where mode effects may be similar, suggest a selection bias in the Web surveys. The use of more complex quotas may lead to some improvement, but many estimates are still likely to differ. Volunteer Web panels are not recommended if accurate prevalence estimates for the general population are a key objective.

Epidemiology of sexual health in the virtual environment: a multinational online survey of Spanish- and Portuguese-speaking men who use an internet sexual networking site

There is limited data on the sexual health of users of sexual networking websites for men who have sex with men (MSM) in Latin America. Members of a MSM-targeted social/sexual networking website in Latin America, Spain, and Portugal participated in an online sexual health survey. Among 36,063 respondents, nearly 90 % reported having anal or vaginal intercourse in the past 3 months. Among sexually active men, 53.2 % used condoms inconsistently. In the past year, 54 % of respondents reported undergoing sexually transmitted infections (STI) testing and 67 % reported testing yearly or more often for HIV. Self-reported HIV prevalence was 9.1 %. Differences were seen by geographic region. Unprotected intercourse with partners of different or unknown HIV status was associated with recent STI diagnosis (OR = 1.83, t = 13.15, d.f. = 21, p < .001) and HIV diagnosis (OR = 2.20, t = 14.00, d.f. = 21, p < .001). Online surveys are a promising tool for HIV/STI surveillance and prevention internationally to reach an important subset of MSM.

Sexual risk behaviour and donor deferral in Europe

One of the most controversial policies in blood transfusion worldwide is the permanent deferral from donating blood of men with sexual contacts to other men (MSM). This policy was implemented for safety reasons as sex between men is known to be a high risk factor for acquiring severe infectious diseases transmissible by blood transfusion. Sexual contacts among heterosexual persons may hold similar risks but a clear-cut discrimination between different individual risks is impossible. Nevertheless, the current blood donor deferral periods defined by European Union (EU) legislation depend on a distinction of different grades of risk with respect to sexual behaviour. Under the aegis of the Steering Committee on Blood Transfusion (CD-P-TS) of the Council of Europe (CoE), an international working group evaluated epidemiological and behavioural data, modelling studies on residual risk and spread of infections, and studies on adherence to donor selection criteria. The aim was to distinguish sexual behaviour of different risk categories. It was concluded, that existing data confirm that MSM and commercial sex workers (CSW) are groups at high risk. Any further grading lacks a scientific data base. Modelling studies indicate that adherence to deferral policies is of major relevance suggesting that good donor adherence may outweigh the small negative effects on blood safety postulated for changing from permanent to temporary deferral periods for high risk sexual behaviours. The fact that a considerable percentage of donors are MSM - despite the permanent deferral policy - demonstrates the need to increase donor understanding and adherence.

International mobility, sexual behaviour and HIV-related characteristics of men who have sex with men residing in Belgium

Background

European men who have sex with men (MSM) continue to be disproportionally affected by the human immunodeficiency virus (HIV). Several factors are contributing to the rates of new HIV infections among MSM. The aim of this study was to investigate the potential role of travel behaviour and sexual mobility in the spread of HIV and sexually transmitted infections (STI) among European MSM.

Methods

Belgian data from the first pan-European MSM internet survey EMIS was used (n=3860) to explore individual and contextual determinants of sexual behaviour among MSM, who resided in Belgium at the time of data collection and who reported having had sexual contact abroad in the last 12 months. Descriptive and bivariate analyses were performed. Odds ratios and 95% confidence intervals were calculated by means of logistic regression.

Results

MSM who practiced unprotected anal intercourse UAI during their last sexual encounter abroad were less likely to be living in a large city (OR:0.62, 95% CI:0.45-0,86, p<0.01) and more likely to be HIV positive (OR:6.20, 95% CI:4.23-9.06, p<0.001) ), to have tested HIV positive in the last 12 months (OR:3.07, 95% CI:1.07-8.80, p<0.05), to have been diagnosed with any STI in the last 12 months (OR:2.55; 95% CI:1.77-3.67, p<0.05), to have used party drugs (OR:2.22, 95% CI:1.59-3.09, p<0.001), poppers (OR:1.52, 95% CI:1.07-2.14, p<0.001) and erection enhancing substances (OR:2.23, 95% CI:1.61-3.09, p<0.001) compared to MSM who did not have UAI with their last sexual partner abroad. Men having had UAI in the last 12 months were more likely to have done so in a neighbouring country of Belgium (OR:1.66, 95% CI:1.21-2.29, p<0.001). Different sexual behavioural patterns related to condom use and drug use were identified according to HIV test status among travelling men.

Conclusions

The results of this study provide evidence for the role of international mobility and sexual behavior while travelling, in the spread of HIV and STI among MSM in Europe. Further, the findings underline the need for development of European cross-border HIV and STI interventions with coherent messages and prevention policies for MSM.

Estimating the size of the MSM populations for 38 European countries by calculating the survey-surveillance discrepancies (SSD) between self-reported new HIV diagnoses from the European MSM internet survey (EMIS) and surveillance-reported HIV diagnoses among MSM in 2009

Background

Comparison of rates of newly diagnosed HIV infections among MSM across countries is challenging for a variety of reasons, including the unknown size of MSM populations. In this paper we propose a method of triangulating surveillance data with data collected in a pan-European MSM Internet Survey (EMIS) to estimate the sizes of the national MSM populations and the rates at which HIV is being diagnosed amongst them by calculating survey-surveillance discrepancies (SSD) as a measure of selection biases of survey participants.

Methods

In 2010, the first EMIS collected self-reported data on HIV diagnoses among more than 180,000 MSM in 38 countries of Europe. These data were compared with data from national HIV surveillance systems to explore possible sampling and reporting biases in the two approaches. The Survey-Surveillance Discrepancy (SSD) represents the ratio of survey members diagnosed in 2009 (HIVsvy) to total survey members (Nsvy), divided by the ratio of surveillance reports of diagnoses in 2009 (HIVpop) to the estimated total MSM population (Npop). As differences in household internet access may be a key component of survey selection biases, we analysed the relationship between household internet access and SSD in countries conducting consecutive MSM internet surveys at different time points with increasing levels of internet access. The empirically defined SSD was used to calculate the respective MSM population sizes (Npop), using the formula Npop = HIVpop*Nsvy*SSD/HIVsvy.

Results

Survey-surveillance discrepancies for consecutive MSM internet surveys between 2003 and 2010 with different levels of household internet access were best described by a potential equation, with high SSD at low internet access, declining to a level around 2 with broad access. The lowest SSD was calculated for the Netherlands with 1.8, the highest for Moldova with 9.0. Taking the best available estimate for surveillance reports of HIV diagnoses among MSM in 2009 (HIVpop), the relative MSM population sizes were between 0.03% and 5.6% of the adult male population aged 15–64. The correlation between recently diagnosed (2009) HIV in EMIS participants and HIV diagnosed among MSM in 2009 as reported in the national surveillance systems was very high (R² = 0.88) when using the calculated MSM population size.

Conclusions

Npop and HIVpop were unreliably low for several countries. We discuss and identify possible measurement errors for countries with calculated MSM population sizes above 3% and below 1% of the adult male population. In most cases the number of new HIV diagnoses in MSM in the surveillance system appears too low. In some cases, measurement errors may be due to small EMIS sample sizes. It must be assumed that the SSD is modified by country-specific factors.

Comparison of community-based survey data with surveillance data suggests only minor sampling biases in the former that – except for a few countries - do not seriously distort inter-country comparability, despite large variations in participation rates across countries. Internet surveys are useful complements to national surveillance systems, highlighting deficiencies and allowing estimates of the range of newly diagnosed infections among MSM in countries where surveillance systems fail to accurately provide such data.

Age biases in a large HIV and sexual behaviour-related internet survey among MSM

BACKGROUND

Behavioural data from MSM are usually collected in non-representative convenience samples, increasingly on the internet. Epidemiological data from such samples might be useful for comparisons between countries, but are subject to unknown participation biases.

METHODS

Self-reported HIV diagnoses from participants of the European MSM Internet Survey (EMIS) living in the Czech Republic, Germany, The Netherlands, Portugal, Sweden and the United Kingdom were compared with surveillance data, for both the overall diagnosed prevalence and for new diagnoses made in 2009. Country level prevalence and new diagnoses rates per 100 MSM were calculated based on an assumed MSM population size of 3% of the adult male population. Survey-surveillance discrepancies (SSD) for survey participation, diagnosed HIV prevalence and new HIV diagnoses were determined as ratios of proportions. Results are calculated and presented by 5-year age groups for MSM aged 15-64.

RESULTS

Surveillance derived estimates of diagnosed HIV prevalence among MSM aged 15-64 ranged from 0.63% in the Czech Republic to 4.93% in The Netherlands. New HIV diagnoses rates ranged between 0.10 per 100 MSM in the Czech Republic and 0.48 per 100 in The Netherlands. Self-reported rates from EMIS were consistently higher, with prevalence ranging from 2.68% in the Czech Republic to 12.72% in The Netherlands, and new HIV diagnoses rates from 0.36 per 100 in Sweden to 1.44 per 100 in The Netherlands. Across age groups, the survey surveillance discrepancies (SSD) for new HIV diagnoses were between 1.93 in UK and 5.95 in the Czech Republic, and for diagnosed prevalence between 1.80 in Germany and 4.26 in the Czech Republic.Internet samples of MSM were skewed towards younger age groups when compared to an age distribution of the general adult male population. Survey-surveillance discrepancies (SSD) for EMIS participation were inverse u-shaped across the age range. The two HIV-related SSD were u- or j-shaped with higher values for the very young and for older MSM. The highest discrepancies between survey and surveillance data regarding HIV-prevalence were observed in the oldest age group in Sweden and the youngest age group in Portugal.

CONCLUSION

Internet samples are biased towards a lower median age because younger men are over-represented on MSM dating websites and therefore may be more likely to be recruited into surveys. Men diagnosed with HIV were over-represented in the internet survey, and increasingly so in the older age groups. A similar effect was observed in the age groups younger than 25 years. Self-reported peak prevalence and peak HIV diagnoses rates are often shifted to higher age groups in internet samples compared to surveillance data. Adjustment for age-effects on online accessibility should be considered when linking data from internet surveys with surveillance data.

The emerging and re-emerging human immunodeficiency virus epidemics in Europe

We provide a summary of the current status of the human immunodeficiency virus (HIV) epidemic, including data on the transmission of drug-resistant virus in the European Region of the WHO. The review was conducted by searching the reports of the European Centre for Disease Prevention and Control and the United Nations General Assembly Special Session country reports to identify the number of HIV cases reported in 2002-2011, the number of HIV tests performed, and the results of the most recent HIV surveys in at-risk groups. In the West, a 5-year linear trend analysis suggests an increase in the number of reported HIV cases in Belgium, Greece, and Iceland, and a decline in The Netherlands, Ireland, Portugal, Switzerland, and the UK. In the Centre, the number of reported cases increased in Bulgaria and Turkey, and in the East, the number of reported cases increased in Armenia, Georgia, and Ukraine. Estonia and Latvia reported a significant downward trend. HIV transmission in men who have sex with men (MSM) and heterosexual transmission accounted for, respectively, 40% and 38% of newly reported HIV cases in the West in 2011, whereas the epidemic in the Centre is predominantly concentrated in MSM. Although injection drug use remains the key driving force of the epidemic in the East, there is increasing evidence of sexual transmission from the core groups of injection drug users, and increasing spread within MSM. The pattern of transmitted drug resistance (TDR) is heterogeneous accross Europe; a significant number of clusters of TDR have been recently observed in several European countries.

The GAy MEn Sex StudieS: design of an online registration of sexual behaviour of men having sex with men and preliminary results (GAMESSS-study)

BACKGROUND

There has been limited investigation of the sexuality and sexual dysfunction in homosexuals by the sexual medicine community. The purpose of this article is to describe the methodology of the online GAy MEn Sex StudieS (GAMESSS) on the sexual behaviour and sexual dysfunctions of Belgian men who have sex with men (MSM).

AIM

To describe the methodology of an online study that investigate sexual behaviour and sexual function and dysfunction in a sample of Belgian MSM.

METHODS

An internet-based survey on sexual behaviour and sexual dysfunctions was administered to MSM between April and December 2008. The questionnaire was a compilation of the Kinsey Scale for Sexual Orientation, the Index of Premature Ejaculation (IPE), the Erection Quality Scale (EQS), the Female Sexual Function Index (FSFI), the Brief (Male) Sexual Function Inventory (BSFI) and the Gay Men Sexual Addiction Screening Test (G-SAST). The analytic sample comprised 1,830 Belgian men aged 18 years or older, who reported having sex with men.

CONCLUSION

The use of an online questionnaire is a convenient way to gather information from a hidden population such as MSM. The anonymity of the participants is guaranteed. The collected data can be easily analyzed. With this online study, we aim to detect variables in sexual behaviour (SB) and sexual dysfunction (SD) that can help to improve care for MSM. Belgian MSM have a very active and varied sex life. They are rather promiscuous and do not always practice safe sex. This behaviour poses a high risk of spreading sexually transmitted diseases. Additional research in this MSM population is needed.

Comparison of the performance of STI screening services for gay and bisexual men across 40 European cities: results from the European MSM Internet Survey

OBJECTIVES

Sexually transmitted infections (STIs) such as anal/genital warts, syphilis and genital/rectal gonorrhoeal/chlamydial infections compromise the health of men who have sex with men (MSM). Rectal bacterial STIs increase the per-contact risk of HIV infection. Early detection of asymptomatic STIs requires regular screening including collection of clinical specimens (or, for warts: physical examinations) that allow for the detection of infections at sites common to men's same sex practices.

METHODS

From June to August 2010, the European MSM Internet Survey recruited 174,209 men from 38 European countries to an anonymous online questionnaire in 25 languages. As sexual healthcare for MSM in most countries is organised locally, we chose cities for comparison. Multivariable regression models were used to compare accessibility of services and applied diagnostic procedures across 40 cities.

RESULTS

The proportion of respondents tested for STIs in the last 12 months in the absence of symptoms ranged from 8.9% in Istanbul to 48.0% in Amsterdam. At city level, low STI screening correlated with inaccessible services (R2=44.1%). At individual level, anal/penile inspection and anal swabbing was most common in U.K. cities, Amsterdam, Dublin and Stockholm. Compared to London, MSM in 30 cities had an adjusted OR (AOR) of (0.02 to 0.18) for anal swabbing; and (0.06 to 0.25) for anal/penile inspection (p<0.001).

CONCLUSIONS

Anal/genital warts and rectal infections are likely to be profoundly underdiagnosed among MSM in most European cities. This has implications for the sexual health of MSM, HIV prevention and comparing national surveillance data. There is an urgent need to improve sexual healthcare tailored to MSM at risk for STIs.

Community-Based Surveys for Determining the Prevalence of HIV, Chlamydia, and Gonorrhoea in Men Having Sex with Men in Hong Kong

Background. Community sampling of men having sex with men (MSM) for human immunodeficiency virus (HIV) and sexually transmitted infections prevalence studies poses challenges in view of problems in logistics and the hidden nature of MSM population. Methods. MSM in Hong Kong were recruited through social venues and the Internet. All participants were invited to complete a behavioural questionnaire and submit a urine specimen for HIV, Chlamydia, and gonorrhoea testing. Results. Totally, 994 MSM were recruited. No differences between venue and online-recruited respondents were identified regarding their demographics and infection status. The prevalence of HIV, Chlamydia, and gonorrhoea was 3.6% (95% CI: 2.6–5.0%), 4.7% (95% CI: 3.6–6.2%), and 0.2% (95% CI: 0.1–0.7%), respectively. Of all HIV cases, only 8.3% were aware of the infection; reflecting newly infected MSM were probably overrepresented. Some 58.3% had had HIV test within the past year, and 11.1% had CT/NG coinfection. HIV infection was associated with group sex [aOR: 2.67 (1.03–6.92)], receiving money for anal sex [aOR: 4.63 (1.12–19.18)], and unprotected anal sex with nonregular partners [aOR: 3.047 (1.16–8.01)]. Conclusion. Difference between venue- and online-recruited MSM was observed. A combination of sampling methods is complementary for epidemiology purpose. Overall, risk behaviours practised by undiagnosed HIV-positive MSM remains a cause for concern.