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EMIS 2017 Journal Articles 2017 Published Articles

PrEP Coverage in men who have sex with men in Germany across 95 regions

German-Austrian AIDS conference (DÖAK) 2025. Poster Nr. 194.

Authors: Axel J Schmidt, Daniel Schmidt, Dirk Sander, Silke Klumb

Abstract

Background. Pre-exposure prophylaxis (PrEP) is a highly effective biomedical intervention for HIV prevention. 
Its adaption among men-who-have-sex-with-men (MSM) is vital for achieving public health goals. 

This study assesses PrEP coverage across 95 postal code areas (PCAs) in Germany, identifying underserved regions and visualising supply-demand gaps using geographic data. 

Methods: We used geo data from the German Ministry of Health (gesund.bund.de) to locate physicians qualified to prescribe PrEP under statutory health insurance (supply). 

MSM populations (excluding HIV-diagnosed men) engaging in anal sex with multiple partners in the same regions (demand) were estimated (EMIS-2017 data). Standardisedsupply-demand ratios (SSDRs) were calculated, ranging from 0 to 1.

Postal code areas for Berlin (10,12,13), Hamburg (20,22), Munich (80,81), and Ruhr (44,45) were merged for the maps.

Findings: By Q3/2024, 455 physicians across Germany were prescribing PrEP. The highest MSM concentrations were in postal code areas 10xxx (Berlin; k=10.7), 20xxx (Hamburg; k=6.8), and 80xxx (Munich; k=4.0). Despite large prescriber numbers in these three cities (N=79, N=31, and N=32), SSDRs were moderate (0.39, 0.50, and 0.47). 

Conversely, the highest SSDRs were observed in areas with lower MSM concentrations, including PCAs 54xxx (Trier), 77xxx (Offenburg), 93xxx (Regensburg), and 39xxx (Magdeburg). Notably, 21 PCAs had no qualified prescribers, and 20 had only one.

Interpretation: PrEP supply is uneven across Germany, with better coverage in some regions with lower MSM concentrations but strong engagement from community organisations, while many major cities remain underserved. 

Addressing these disparities requires targeted efforts to increase the number of PrEP prescribers, particularly in urban hubs with significant MSM populations. Improved planning is crucial to ensure equitable access and reduce HIV transmission nationwide.

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EMIS 2017 Journal Articles 2017 Published Articles

Self-reported hepatitis A and B vaccination coverage among men who have sex with men (MSM), associated factors and vaccination recommendations in 43 countries of the WHO European Region: results from the European MSM Internet Survey, EMIS-2017

EuroSurveillance 2024. 29(45):pii=2400100; (doi: 10.2807/1560- 7917.ES.2024.29.45.2400100)

Authors: Michael Brandl, Axel J Schmidt, Ulrich Marcus, Erika Duffell, Ettore Severi, Antons Mozalevskis, Anda Kivite-Urtane, Matthias an der Heiden, Sandra Dudareva

Abstract

Background. Hepatitis A and B vaccinations are recommended for men who have sex with men (MSM), given their increased risk of infection. However, data on vaccination programmes are scarce.

Aim. To use information on vaccination recommendations and vaccine uptake among MSM in the WHO European Region to guide prevention.

Methods. From a large pan-European MSM Internet Survey (EMIS-2017), we analysed data on self-reported hepatitis A and B vaccination status by age, education, financial coping, settlement size, outness (disclosure of sexual behaviour), migration history and diagnosis with hepatitis C or HIV, using multivariable logistic regression. Additionally, we collected information on national hepatitis A and B vaccination recommendations.

Results. We present data of 113,884 MSM, median age 36 years (IQR: 27–47). Vaccination for hepatitis A and B was recommended and free for MSM in 7 and 18 of 43 countries, respectively. Of all respondents, 48% (n = 50,966) reported ever being vaccinated against hepatitis A, and 53% (n = 56,889) against hepatitis B. Odds for being vaccinated against hepatitis A increased with outness (‘out to (almost) all’ aOR: 1.78, 95% CI: 1.72–1.85 vs ‘out to none’) and were higher in countries where vaccination was recommended and free for MSM (aOR:2.22, 95% CI: 1.29–3.82 vs ‘no recommendation’). Results for hepatitis B were similar (outness: aOR:1.81, 95%CI:1.75–1.88 and MSM-specific vaccination recommendation: aOR: 2.44, 95% CI: 1.54–3.85).

Conclusion. Large proportions of MSM in Europe remain vulnerable to hepatitis A and B, despite available vaccination. Implementation of MSM-specific vaccination recommendations and greater efforts to improve the societal climate for MSM are needed to address gaps in vaccine coverage.

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EMIS 2017 Journal Articles 2017 Published Articles

Viral hepatitis knowledge and vaccination awareness among men who have sex with men (MSM) in 43 countries of the WHO European Region: results from the European MSM Internet Survey, EMIS-2017

EuroSurveillance 2024. 29(45):pii=2400099; (doi: 10.2807/1560-7917.ES.2024.29.45.2400099)

Authors: Sofia Burdi, Michael Brandl, Ulrich Marcus, Erika Duffell, Ettore Severi, Antons Mozalevskis, Kristi Rüütel, Achim Dörre, Axel J Schmidt*, Sandra Dudareva*

Abstract

Background. Recent hepatitis A virus outbreaks in Europe affecting men who have sex with men (MSM) and ongoing hepatitis B virus transmission among MSM underscore the ongoing need for viral hepatitis prevention in this population.

Aim. To describe viral hepatitis knowledge and associated factors among MSM in the WHO European Region to inform targeted prevention.

Methods. In the European MSM Internet Survey (EMIS-2017), basic knowledge was defined as correctly identifying at least 4 of 5 statements about viral hepatitis and vaccination. We described basic knowledge by country. In a multilevel logistic regression model, we estimated adjusted odds ratios (aOR) with 95% confidence intervals (CI) for having basic knowledge and explanatory variables: sociodemographic characteristics, history of hepatitis C and/or HIV diagnosis, sexual orientation disclosure at last sexually transmitted infections (STI) test and outness..

Results. Of 113,884 participants across 43 WHO European Region countries, 68% demonstrated basic knowledge, ranging from 50% in Israel to 80% in the Netherlands. Basic knowledge was significantly associated with older age (≥ 40 years vs < 25 years, aOR: 2.9, 95% CI: 2.7–3.0), a history of hepatitis C and/or HIV diagnosis (aOR:1.8, 95% CI: 1.7–1.9) and sexual orientation disclosure at last STI test (aOR: 1.3, 95% CI: 1.2– 1.3), among other factors.

Conclusion. We found a knowledge disparity regard- ing viral hepatitis and hepatitis vaccination aware- ness among MSM across Europe, highlighting a need to address these gaps. A non-judgemental, accept- ing climate that allows individuals attending medical services to safely disclose their sexual orientation is fundamental to enable healthcare professionals to target information and preventative measures more effectively.

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EMIS 2017 Journal Articles 2017 Published Articles

Sex work, syndemic conditions and condomless anal intercourse among MSM who engage in sex work in Latin America

Sexual Health 2024. 21, SH23112; (doi: 10.1071/SH23112)

Authors: Ibrahim Sönmez, Nicolas Lorente, Jocelyn Mesías-Gazmuri, Axel J. Schmidt, Kai J. Jonas, Valeria Stuardo Avila, Ulrich Marcus, Maria Amelia Veras, Jordi Casabona Barbarà, Cinta Folch

Abstract

Background. In Latin American countries and Suriname, sexual transmission is one of the most common modes of HIV transmission, and men who have sex with men (MSM) who engage in sex work constitute a key population.

Methods. In a sample of MSM (N = 53,166) from the Latin American Internet Survey (2018) across 18 countries, we examined how sex work engagement is associated with syndemic conditions (multidrug use, homophobic abuse, depression/anxiety, alcohol dependency (CAGE alcohol questionnaire) and internalised homonegativity) and condomless anal intercourse with non-steady male partners using separate logistic regressions. We then used a structural equation model to determine if and how syndemic conditions mediate the relationship between sex work engagement and non-steady male partners.

Results. We found that getting paid for sex was associated with less condom use for anal intercourse with non-steady male partners and particular syndemic conditions, such as multidrug use, homophobic abuse and alcohol dependency. In our structural equation model, the results showed that the direct relationship between sex work engagement and non-steady male partners was positive and significant, and syndemic conditions partially mediated this relationship.

Conclusion. Our results highlight the continuing need for including MSM who engage in sex work and those who experience syndemic conditions in the prevention strategies targeted to MSM in Latin America and Suriname, to prevent the transmission of HIV.

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EMIS 2017 Journal Articles 2010 Journal Articles 2017 Published Articles

HIV Testing and Treatment among HIV-Positive Men who have Sex with Men (MSM) Living in Russia: Data from Two Waves of the European MSM Internet Survey

AIDS and Behavior 2024; (doi: 10.1007/s10461-024-04476-y)

Authors: Rigmor C. Berg, Vegard Skogen, Axel J. Schmidt, Roman Nesterov & Andrey Beloglazov

Abstract

We examined changes in HIV testing and medical care among men who have sex with men (MSM) in Russia. Data come from the 2010 and 2017 waves of the European MSM Internet Survey. From 2010 to 2017 there was an increase in the proportion who had ever received an HIV test (+ 11.2%), had tested for HIV in the last year (+ 2.1%), had ever taken antiretroviral therapy (ART) (+ 31.9), were currently taking ART (+ 31.5%), and had an undetectable viral load (+ 19.4%). These results are encouraging, yet they also reveal that substantial proportions of MSM experience considerable unmet prevention and treatment needs.

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EMIS 2017 Journal Articles 2017 Published Articles

Still trouble with bleeding: Risk factors for HCV transmission in men who have sex with men and behavioural trajectories from 2019 to 2021

HIV Medicine 2024; (doi: 10.1111/hiv.13657)

Authors: Axel Jeremias Schmidt, Peter Weatherburn, Haoyi Wang, Thomas Lutz, Knud Schewe, Stefan Mauss, Ivanka Krznaric, Axel Baumgarten, Christoph Boesecke, Jürgen K. Rockstroh, Stefan Christensen, Patrick Ingiliz

Abstract

Objectives

To identify sexual/sex-associated risk factors for hepatitis C transmission among men who have sex with men (MSM) and visualise behavioural trajectories from 2019 to 2021.

Methods

We linked a behavioural survey to a hepatitis C cohort study (NoCo), established in 2019 across six German HIV/hepatitis C virus (HCV) treatment centres, and performed a case–control analysis. Cases were MSM with recent HCV infection, and controls were matched for HIV status (model 1) or proportions of sexual partners with HIV (model 2). We conducted conditional univariable and multivariable regression analyses.

Results

In all, 197 cases and 314 controls completed the baseline questionnaire and could be matched with clinical data. For regression models, we restricted cases to those with HCV diagnosed since 2018 (N = 100). Factors independently associated with case status included sex-associated rectal bleeding, shared fisting lubricant, anal douching, chemsex, intravenous and intracavernosal injections, with population-attributable fractions of 88% (model 1) and 85% (model 2). These factors remained stable over time among cases, while sexual partner numbers and group sex decreased during COVID-19 measures.

Conclusions

Sexual/sex-associated practices leading to blood exposure are key factors in HCV transmission in MSM. Public health interventions should emphasize the importance of blood safety in sexual encounters. Micro-elimination efforts were temporarily aided by reduced opportunities for sexual encounters during the COVID-19 pandemic.

Note: The questionnaire underlying this case-control study based many questions on EMIS-2010 and EMIS-2017.

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EMIS 2017 Journal Articles 2017

Determinants of HIV Testing Among Migrant Men Who Have Sex With Men from Sub‐Saharan Africa and Other Regions Residing in 10 European Countries

AIDS and Behavior 2024; (doi: 10.1007/s10461-023-04239-1)

Authors: Oladipupo Shobowale, Axel J. Schmidt, Paula Meireles, Daniela Rojas Castro, Sandrine Detandt, Sarah E. Stutterheim, Peter Weatherburn, Kai J. Jonas

Abstract

Migrant men who have sex with men (mMSM) from sub-Saharan Africa (SSA) and other regions outside Europe are highly vulnerable to HIV. However, research on the determinants of HIV testing among mMSM from SSA, and how these differ across the categories of mMSM living in Europe, is limited.

Using data from the European MSM Internet Survey (EMIS- 2017), we assessed HIV testing prevalence and recency in mMSM from SSA and other mMSM residing in ten European countries, as well as the determinants of HIV testing across different mMSM categories with logistic regression analyses.

Ever-testing for HIV was slightly higher in mMSM from SSA (83%) compared to other mMSM categories (75–80%), except for mMSM from Latin America and Caribbean region (84%). Overall, 20% of mMSM had never tested. In multivariable analysis, higher age (adjusted odds ratio [AOR] 1.05, 95% confidence interval [CI] 1.01–1.10), higher HIV knowledge (AOR 1.45, 95%-CI 1.11–1.90), and residence in smaller settlements (AOR 0.45, 95%-CI 0.21–0.96) were significantly associated with ever testing for HIV in mMSM from SSA. Comparing mMSM from SSA to mMSM from other regions, we found varying significant similarities (higher age, residence in smaller settlements and HIV knowledge) and differences (lower educational attainment, not identifying as gay, being a student, and limited disclosure of homosexual attraction) in the determinants of ever-testing for HIV.

Community-specific interventions addressing identified sociodemographic and behavioral determinants to increase HIV testing uptake in the different mMSM categories and better data for further research are warranted.

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EMIS 2010 Journal Articles 2010

What’s on the rise in Sexually Transmitted Infections?

Lancet Reg Health Eur. 2023. (doi: 10.1016/j.lanepe.2023.100742)

Authors: Axel Jeremias Schmidt, Ulrich Marcus

Invited Commentary.

Several factors related to Sexually Transmitted Infections (STIs) transmission and detection are on the rise. For example, there is increasing evidence that e.g., anal intercourse combined with drug use is becoming common among young heterosexuals, and the diversity of heterosexual practices has been on the rise for many years. Data from the European MSM Internet Survey (2010) illustrate how sexual repertoire diversity impacts STIs in MSM, independent of partner numbers (Fig. 1). Unfortunately, much research neglects these specific factors and persists in employing ambiguous terms like “high-risk behaviour” or “risk compensation”, which are poorly defined and often stigmatizing.

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EMIS 2017 Journal Articles 2017

Sexualized drug use among gay men and other men who have sex with men in Latin America: A description of the phenomenon based on the results of LAMIS-2018

PLoS One 2023;18(10):e0288171 (doi: 10.1371/journal.pone.0287683)

Authors: Cristian Lisboa, Valeria Stuardo, Cinta Folch

Abstract

Background

Sexualized drug use (SDU) to enhance and extend sexual relations may involve risks of substances abuse (intoxication, interactions and overdose) and higher exposure to HIV and other sexually transmitted infections. There are inconsistencies in the methodology and find- ings of previous research on SDU in Latin America (LA), and more studies are required. The purpose of this research was to characterize SDU in gay men and other men who have sex with men from 18 LA countries, and describe the aspects by comparing people who practice and do not practice SDU, at the general and country levels.

Material and methods

Cross-sectional study based on the data collected by LAMIS-2018. Dependent variable was SDU (last 12 months), and the independent variables were: drug use (in any context/in sex- ual context), sociodemographic, socioepidemiological, and psychosocial aspects. A descriptive analysis was carried out, comparing those who practiced and did not practice SDU.

Results

LAMIS-2018 included 64,655 participants, averaging 30 years of age. 13.6% declared hav- ing practiced SDU (6.6% with multiple partners). In the last sexual encounter the most com- monly used drugs were cannabis (9.3%), poppers (6%), and Viagra (5.4%), and in the last encounter with multiple partners, poppers (19.7%), cannabis (17%), and Viagra (13.2%). HIV diagnosis was reported by 27% of people practicing SDU, vs. 14.3% in the other group. Severe anxiety-depression symptoms were more common among people practicing SDU (9.2% vs. 7%), as were the episodes of homophobic intimidation (52.6% vs. 48.2%), insults (34.4% vs. 28.6%), and aggression (4.1% vs. 3.0%).

Conclusion

SDU was reported by a high percentage of people, with a predominance of the use of drugs related to sexual practice, and others for recreational use. Aspects described as the higher proportion of self-reported HIV diagnosis and severe symptoms of anxiety-depression among those who practiced SDU, show that is necessary to implement preventive strate- gies to reduce the harmful impacts that can sometimes result from this practice, including harm reduction policies, promote access to mental health services and support in situations of homophobia and stigma.

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EMIS 2017 Journal Articles 2017

Recreational and sexualised drug use among gay, bisexual, and other men who have sex with men (gbMSM) in Ireland–Findings from the European MSM internet survey (EMIS) 2017

PLoS One 2023;18(7):e0288171 (doi: 10.1371/journal.pone.0288171)

Authors: Fionn P. Daly , Kate O’Donnell, Martin P. Davoren, Chris Noone, Peter Weatherburn, Mick Quinlan, Bill Foley, Fiona Lyons, Derval Igoe, Peter Barrett

Abstract

Background

Gay, bisexual, and other men who have sex with men (gbMSM) report a higher prevalence of drug use in comparison to the general male population. However, in Ireland, there is a paucity of literature regarding the prevalence of drug use and its determinants among gbMSM.

Aims/Objectives

To quantify the prevalence of (i) recreational drug use (RDU) and (ii) sexualised drug use (SDU) among gbMSM in Ireland, and to identify the factors associated with these drug use practices.

Methods

The European MSM Internet Survey (EMIS) 2017 was an online, anonymous, internationally-promoted questionnaire. Two binary outcomes were included in our analyses: (1) RDU and (2) SDU in the previous year. Multivariable-adjusted logistic regression explored factors associated with these outcomes, and all independent covariates were adjusted for one another.

Results

Among gbMSM without HIV (n = 1,898), 40.9% and 13.1% engaged in RDU and SDU in the previous year, respectively. Among diagnosed-positive gbMSM (n = 141), the past-year respective prevalence estimates were 51.8% and 26.2%. Increased odds of RDU were observed among gbMSM who were younger (vs. 40+ years) (18–24 years; AOR 2.96, 95% CI 2.05–4.28, 25–39 years; AOR 1.66, 95% CI 1.27–2.16), lived in Dublin (vs. elsewhere) (AOR 1.47, 95% CI 1.17–1.83), and engaged in condomless anal intercourse (CAI) in the previous year (vs. none) (1–2 partners; AOR 1.79, 95% CI 1.34–2.38, 6+ partners; AOR 1.79, 95% CI 1.18–2.71). Greater odds of SDU were identified among those who lived in Dublin (vs. elsewhere) (AOR 1.50, 95% CI 1.07–2.10), and engaged in CAI (vs. none) (1–2 partners; AOR 3.16, 95% CI 2.05–4.88, 3–5 partners; AOR 2.50, 95% CI 1.47–4.26, and 6+ partners; AOR 3.79, 95% CI 2.23–6.43).

Conclusion

GbMSM report a high prevalence of drug use in Ireland. Targeted interventions, including harm reduction campaigns, may be needed to support healthier drug use choices among this community.

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