Risky sexual behaviors reported by patients in a free sexual health center in Paris (2017-2020)

Background

In France, a national network of free sexual health centers offers prevention, diagnosis and treatment for STI and HIV. These centers help socially disadvantaged and high-risk populations to access STI/HIV testing but few detailed data are available on patients' sexual behaviors. This study aims to describe sexual behaviors among attendees of a Parisian free sexual health center for STI/HIV screening.

Methods

This observational study included 5130 patients who attended the center for STI/HIV testing from August 2017 through January 2020 and completed a self-administered electronic questionnaire. Data obtained from the consultation database and the questionnaire included STI results, sociodemographic characteristics and sexual behaviors. Criteria reported in the literature to define “high-risk sexual behavior (HRSB)” were used to describe sexual practices.

Results

Median age of patients was 26 years [Q1-Q3:23-32] and 8% had no health insurance. Slightly less than one third of patients were women who had sex with men, 37% were men who had sex exclusively with women and 18% were men who had sex with men; 22% had never had HIV testing before the consultation. Regarding sexual practices, 76% reported unprotected sexual intercourse, 3% transactional sex and 8% a history of sexual violence. Depending on the threshold used to define multiple partners (≥6 vs ≥ 2 partners during the previous year), the proportion of patients varied from 31% to 81%. Globally, the proportion of patients reporting at least one HRSB ranged from 87% to 95%. Eleven percent of patients had at least one STI (mostly chlamydia).

Conclusions

Our sexual health center fulfills its missions as most patients consulting for STI/HIV testing reported HRSB and almost one quarter had never previously had an HIV test. The next step will be to explore profiles including sexual behavior, sociodemographic characteristics and HIV knowledge to adapt our prevention strategy to patients' needs.

Key messages

Our sexual health center fulfills its missions as most patients consulting for STI/HIV testing reported HRSB and almost one quarter had never previously had an HIV test. The next step will be to explore profiles including sexual behavior, sociodemographic characteristics and HIV knowledge to adapt our prevention strategy to patients’ needs.

Effectiveness among MSM of an HIV PrEP program developed in a Parisian sexual health center

Background

HIV pre-exposure prophylaxis (PrEP) is highly effective but depends on patients' adherence and follow-up. To enhance follow-up quality and care engagement, the PrEP program developed in our Parisian sexual health center offers accompanying measures throughout the patients' course of care, relying notably on an identified and easily accessible referent. This trained paramedic counselor in sexual health provides support in organizing appointments, phone and email follow-up to answer daily questions, as well as one-on-one sessions of therapeutic support and counseling. This study aimed to assess the effectiveness of such a PrEP program among men who have sex with men (MSM).

Methods

This retrospective observational study included all MSM who initiated PrEP for the first time between 1 August 2018 and 30 June 2019 in the Fernand-Widal hospital sexual health center, Paris, France. Sociodemographic characteristics, sexual practices including very high risk situations (chemsex practice and/or sexually transmitted diseases at initiation and/or history of post-exposure prophylaxis [PEP]) and course of care during the first year were described. A novel metric developed by Hendrickson et al., the PrEP success ratio at 12 months, was used to assess effectiveness of PrEP.

Results

Among the 125 MSM included in this study, the median age was 33 and most had only male partners. At initiation, 58% were considered at very high risk of HIV infection, mainly due to a history of PEP. During the first year, patients attended a median of 3 visits (Q1-Q3, 2-4). At 12 months, 96% (95% CI, 92.6 to 99.4) of patients had a successful PrEP course, with no reported seroconversion.

Conclusions

This experiment highlights the possibility of achieving a high PrEP success ratio among MSM in a real-world setting. The accompanying measures set up in our sexual health center could explain the effectiveness of our PrEP program in comparison with previous studies.

Key messages

In a Parisian sexual health center that developed an HIV PrEP program with a trained paramedic counselor in sexual health, 96% of MSM achieved a successful PrEP course at 12 months. Accompanying measures for PrEP users could play a key role in achieving high PrEP success among MSM.

What do patients consulting in a free STI center know about HIV transmission and prevention?

Background

Despite therapeutic progress, HIV remains a public health issue with about 6400 new HIV contaminations each year in France. HIV prevention relies on health education, early screening, treatment as prevention, post and pre-exposure prophylaxis. Patients’ visits to free sexually transmitted infections (STIs) screening centers (CeGIDD) are opportunities to spread prevention messages. This study aimed to assess level of HIV knowledge in a Parisian CeGIDD to improve prevention messages.

Methods

The study included patients older than 18 who came for STIs testing between August 2017 and August 2018 and who understand written French language. Data were collected by a self-administered electronic questionnaire filled in before medical consultation. It included sociodemographic data and knowledge regarding HIV transmission and prevention.

Results

The study included 2002 patients. The median age was 27 years and 66% were men. More than 96% of patients know that HIV transmission is possible through unprotected sexual intercourse and through needle exchange. However, some misconceptions persist: 20% of patients believe that HIV transmission is possible from using public toilets and 22% by mosquito bite. Prevention measures perceived as “absolutely or rather efficient” by patients were: using condom (97%), requesting a screening test from his partners (91%), getting screening tests regularly (90%), choosing his partners correctly (62%), having sex with few different partners (50%). Half of patients heard of post-exposure prophylaxis (51%).

Conclusions

Main modes of HIV transmission are well known (unprotected intercourse and needle exchange). However, false beliefs regarding prevention may lead to risk behavior (doing screening test regularly doesn’t protect against HIV) and need to be explored. Moreover, assessment of variation in level of HIV knowledge according to patient’s profile may help to target prevention message according to specific populations.

Key messages

Main modes of HIV transmission are well known. False beliefs regarding modes of prevention need to be explored to target HIV prevention messages.

How to reach migrant transgender women in Paris? An example of collaborative sexual health action

Issue

In France, screening for HIV and sexually transmitted infections (STIs) is provided by free HIV and STIs screening centers called CeGIDD. Despite a complete combined prevention offer, the number of new HIV diagnosis has been stable for years. Transgender women have one of the highest HIV prevalence.

Description of the problem

Transgender women are a hard to reach population with multifactorial barriers in their access to healthcare including fear of stigma, leading to late HIV diagnosis and untreated STIs. The CeGIDD of a university hospital in Paris aimed to reach this public working with two associations, creating a free, complete sexual health action outside the hospital in a safe environment.

Results

The CeGIDD identified a Parisian association, PASTT, which accompanies transgender women, mainly migrants, in accessing healthcare and social rights. Its active file is around 1500 persons a year, mostly resorting to prostitution. Another association, AREMEDIA, pioneer in outreach interventions, was involved. The partnership allowed access to the public and to gather the funds for the intervention. It included counseling, screening, Pre Exposure Prophylaxis (PrEP), and took place once a week in PASTT facilities. Any participant could be referred to other physicians if they needed it, even if they lacked health insurance coverage. From September 2017 to November 2018, 212 persons attended the consultation and 26 received PrEP.

Lessons

Working together with several associative partners presents many challenges, from the definition of the objectives to operational coordination. Overcoming these difficulties lead us to reach a new public with a high risk for STIs and HIV.

Key messages

Community based sexual health actions dedicated to transgender women are a successful way to reach this public. The safe environment provided by the association is a great opportunity to familiarize them with the medical staff and to empower them regarding healthcare.

Abstract P1-14-08: Prediction of pathological response (pCR) to neoadjuvant dose dense and intense cyclophosphamide and anthracycline in a prospective series of triple negative locally advanced breast cancers (TNLABC)

Background: Stage II-III TNBC retains a poor outcome despite high chemosensitivity. Patients (pts) with pCR after neoadjuvant chemotherapy have a good prognosis whereas non-responding pts have a 25-40% risk of distant relapse at 5 years. pCR is thus a major goal in TNBC. We previously reported that TNLABC benefit the most of dose dense dose intense cyclophosphamide (C)-epirubicin (E) (S.Giacchetti; BJC, 2014)

Aim: To confirm these results prospectively and analyze the predictive factors of response to high dose chemotherapy in TNBC.

Patients and methods: From january 2009 to april 2015 non inflammatory TNLABC received high dose C (1200 mg/m2 d1 qw 2) with E (75 mg/m2/ d1 qw2) for 6 cycles. The pts had a breast biopsy with frozen tissue. We performed molecular studies: qRT-PCR for AR, FOXA1, PI3K and FASAY technic for p53 mutation.The percentage of stromal Tumor-infiltrating lymphocytes (TILs) was also evaluated by two independent pathologists and assessed as a continuous variable. A18F-FDG PET/CT was performed initially and after 2 courses of chemotherapy and the metabolic answer assessed as a variation of the tumor uptake (ΔSUVmax). We report here the pathological complete response (pCR) (absence of infiltrative carcinomas in the breast and in the lymph nodes) and the factors associated with pCR.

Results: The characteristics of the 74 pts are listed in table 1. The median age is 48 years old, 48 pts (65.8%) are premenopausal and 79% did not have any family history of breast cancers. TIL was divided in 3 groups < 10 % (26 pts, 40 %); 10-50 % (30 pts, 46 %) > 50% (9 pts, 14 %). Pathological response was assessed in 66 pts, one pt progressed during chemotherapy and 6 pts did not undergo surgery yet. 28 pts were in pCR (42.4 %). With a median follow up of 25 months, 13 pts (17.8 %) progressed and 8 (11%) died.

Table 1: Patients characteristics and pCR according to tumor features and metabolic responseCharacteristicsNumber of pts (%)N of pts evaluated for pCRpCR (%)OR [IC 95%]p-valueTumor size T2363519 (54)10.04T337319 (29)0.34 [0.12 ; 0.96]Nodal status N0363315 (46)10.62N1/N2/N3 24/11/33313 (39)0.78 [0.29 ; 2.07]Histological grade: 2660 (0) 0.04*3676028 (47)TILs <10 %26 (40)2510 (40)10.02610-50 %30 (46)267 (27)0.55 [0.17 ; 1.80]≥ 509 (14)9 7 (78)5.25 [0.90 ; 30.62]P53 Mutated54 (89)5121 (41)10.43WT7 (12)53 (60)2.14 [0.33; 13.96]AR Negative43 (83)4318 (42)10.46Positive 9 (17)95 (56)1.74 [0.41 ; 7.38]FOXA1 Negative40 (77)4015 (38)10.08Positive 12 (23)128 (60) 3.33 [0.86 ; 12.99]Molecular Apocrine8 (17)85 (63)10.19TN38 (83)3814 (37)0.35 [0.07 ; 1.69]PI3K Non mutated44 (88)4419 (43)10.75Mutated6 (12)63 (50)1.31 [0.24 ; 7.26]SUVmax at 2 courses0.0001< 70 %27 (53)221 (5)1≥ 70 %24 (47)2318 (78)79.2 [8.48 ; 739.82]* Measured with a Fisher Test

Tumor size, tumor grade, percentage of TILs, the change in 18F-fluorodeoxyglucose tumor uptake (ΔSUVmax) were significantly associated with pCR at univariate analysis. Only one factor remained significant at multivariate analysis, the ΔSUVmax, OR: 0.04 [0.007- 0.27], p = 0.0008.

Conclusion: In this prospective phase III trial we confirm the efficacy of a dose dense EC in TNBC. The metabolic response evaluated with 18 F-FDG PET/CT is a strong and reliable predictor of pCR and could allow an early change of treatment for the non responders. A clinical trial is planned to test this strategy.

Citation Format: Giacchetti S, De Roquancourt A, Groheux D, Piron P, Lehmann-che J, Cuvier C, Resche-rigon M, Albiter M, Roche B, Frank S, Hamy A-S, Teixeira L, Marty M, Lalloum M, Espié M. Prediction of pathological response (pCR) to neoadjuvant dose dense and intense cyclophosphamide and anthracycline in a prospective series of triple negative locally advanced breast cancers (TNLABC). [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-14-08.