Archives of Sexual Behavior. 2022. (doi: 10.1007/s10508-022-02468-4)
Authors: Axel J. Schmidt, Michael W. Ross, Rigmor C. Berg, Peyman Altan
Abstract: To examine the impact of migration and acculturation of Turkish men who have sex with men (MSM) to Germany, using data from the European MSM Internet Survey (EMIS-2010), on measures of acculturation including circumcision status, internalized homonegativity (IH), HIV/STI knowledge, sexual orientation, outness, HIV-testing, and sexual behaviors.
We compared four groups of MSM: MSM born and residing in Germany who had completed the questionnaire in German (n = 38,915), MSM born and residing in Germany, with a father or mother born in Turkey (n = 97), MSM residing in Germany who were born in Turkey or whose parents were born in Turkey (n = 262), and MSM who were born and residing in Turkey and who completed the questionnaire in Turkish (n = 1,717).
Data showed that there were significant dose–response curves between level of migration and several outcome variables. As exposure to Germany increased, MSM had lower IH, higher HIV/STI knowledge, increased outness, and were less likely to be circumcised. There were similar significant findings with regard to sexual HIV risk behavior (condomless anal intercourse with partners of unknown (or sero-discordant) HIV status).
Data were consistent with acculturation over generations in immigrant groups in MSM migrating from Turkey to Germany. Integration includes both cultural aspects (circumcision) and integration into a more homopositive gay environment (IH, outness, increased HIV/STI knowledge), and sexual HIV risk behavior. Migration and associated acculturation may constitute a risk change for HIV/STI and mental health issues associated with IH and outness.
Lancet Reg Health Eur. 2022 Aug 9;22:100483. doi: 10.1016/j.lanepe.2022.100483. eCollection 2022 Nov.
Authors: Ana Mendez-Lopez, David Stuckler, Ulrich Marcus, Ford Hickson, Teymur Noori, Robert N Whittaker, Klaus Jansen, Asuncion Diaz, Lukasz Henszel, Annie Velter, Jan C Semenza, Axel J Schmidt
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.
J Int AIDS Soc. 2022 Oct;25 Suppl 5(Suppl 5):e25992. doi: 10.1002/jia2.25992.
Authors: Max Nicolai Appenroth, Uwe Koppe, Ford Hickson, Susanne Schink, Alexander Hahne, Axel J Schmidt, Peter Weatherburn, Ulrich Marcus
Introduction: The population of men-who-have-sex-with-men (MSM) includes people who are on the masculine spectrum but were assigned female at birth (AFAB), that is trans MSM. This study aims to identify current circumstances regarding sexual happiness and safety among German trans MSM. To date, there is no health information about trans MSM in Germany, limiting the ability of MSM sexual health programmes to meet their needs.
Methods: Data were used from the European MSM Internet Survey (EMIS-2017), where people identifying as men and/or trans men were recruited through dating apps for MSM, community websites and social media to participate in an online survey. We analysed parameters on sexual happiness and satisfaction with sexual safety among Germany-based trans MSM and compared those to outcomes of MSM assigned male at birth (cis MSM) living in Germany using descriptive methods and logistic regression models adjusting for age.
Results: In total, 23,001 participants from Germany were included, of which 122 (0.5%) indicated to be AFAB (i.e. trans MSM). Trans MSM were markedly younger than cis participants (median age: 28.5 vs. 39 years). Trans MSM more often reported being unhappy with their current sex life (adjusted odds ratio [aOR] = 1.82, 95% CI 1.24-2.67), had higher odds of disagreeing with the statements “the sex I have is always as safe as I want” ([aOR] = 1.82, 95% CI 1.24-2.67) and “I find it easy to say no to sex that I don’t want” ([aOR] = 1.80, 95% CI 1.18-2.77). Trans MSM were more likely to not be living comfortably financially ([aOR] = 2.43, 95% CI 1.60-3.67) and to be living with severe anxiety and/or depression ([aOR] = 3.90, 95% CI 2.22-6.83). Trans MSM were less likely to have ever tested for HIV ([aOR] = 0.63, 95% CI 0.43-0.93).
Conclusions: Sexual happiness, control of sexual boundaries, satisfaction with sexual safety, financial security, mental wellbeing and HIV testing were all lower in German trans MSM compared with cis MSM. Tailored sexual health interventions, contextualized with regard to needs and vulnerabilities, could address this inequality.
For World AIDS Day 2021, we partnered with UNAIDS to add eleven new EMIS-2017 indicators (by country) to their key population atlas including experience of STIs, partner notification, and hepatitis A & B vaccination status.
We thank our network partners for their translations of the following Community Reports.
The 3rd EMIS-2017 Community Report, published 14 August 2021, covers the stress factors affecting mental and sexual health and well-being and was coordinated by Mick Quinlan (Gay Health Network, Dublin, Ireland). It has been translated into the seven most commonly spoken languages in Europe: German, Russian, French, Turkish, Italian, Polish, and Spanish, as well as into Arabic, Czech, and Portuguese. The 3rd community report was funded by Ireland’s Health Services (HSE).
The 2nd EMIS-2017 Community Report, published 27 November 2020, focuses on gay men living with HIV in Europe and was coordinated by Mick Quinlan (Gay Health Network, Dublin, Ireland). It has been translated into the seven most commonly spoken languages in Europe: German, Russian, French, Turkish, Italian, Polish, and Spanish, as well as into Arabic, Czech, and Portuguese. The 2nd community report was funded by Ireland’s Health Services (HSE).
The 1st EMIS-2017 Community Report targeted at EMIS respondents and MSM in general was published in 31 languages by the end of 2018. We thank our network partners for their contributions and translations, and particularly the German NGO Deutsche AIDS-Hilfe for leading the process, and the Swiss AIDS Federation for financial support.
The first Community Report describes safer sex knowledge (including knowledge on Pre-Exposure Prophylaxis (PrEP) and Undetectable=Untransmittable (U=U). The English version was first presented at AIDS2018 in Amsterdam. The Philippines opted out from the 1st Community Report, so it covers 49, not 50, countries.
The Brazilian NGO Associação Brasileira de Lésbicas, Gays, Bissexuais, Travestis, Transexuais e Intersexos (ABGLT), published a comparable Community Report for Brazil, based on data from the Latin American Internet Survey (LAMIS), with support from Maria Amelia de Sousa Mascena Veras (Faculdade de Ciências Médicas da Santa Casa de São Paulo) and Sigma Research.
Since data collection has closed, we have distributed 39 country of residence datasets to our EMIS-2017 partners who are working on a wide range of national reports, in a variety of formats. As these reports are published they will be added here. No datasets were requested from Luxemburg, Bosnia iH, Iceland, or Turkey. As of June 2021, 20 countries have provided at least one national report. Many countries were interrupted in their report writing by the COVID-19 pandemic. We still expect a report from the Netherlands, Poland, Portugal, and Slovakia. No feedback has been received from BG, HR, LV/LT, SI, PH, RS. No reports are expected from Finland, Hungary, Lebanon, North Macedonia, Romania, or the United Kingdom.
For World AIDS Days 2018–2021 we partnered with UNAIDS to present some key findings from the European and Latin American MSM Internet Surveys on the UNAIDSwebsite for key populations. Findings are shown as interactive maps that include various sexual health indicatiors for gay men, bisexual men and other MSM.
Recruitment and Outness
Crude Recruitment Rate: Number of men reached by EMIS-2017/LAMIS, per 10,000 men aged 15–65
Not open about sexual orientation (non-outness): “Out” to few or none of friends, family, work (%)
HIV diagnosis: ever diagnosed with HIV (%)
Recent HIV diagnosis: HIV diagnosis in the past 12 months (%), excluding men diagnosed with HIV more than 12 months ago
HIV testing: Tested for HIV in the last 12 months (%), excluding those diagnosed longer ago
Community-based HIV testing: Using community HIV- testing at last HIV test (%, denominator includes untested men)
Sexually Transmitted Infections: Testing, Diagnosis, and Partner Notifiaction
Comprehensive STI screen: HIV test, STI blood test, rectal swab, urethral (trans men if applicable: vaginal) swab or urine in the last 12 months (%), excluding men diagnosed with HIV more than 12 months ago
STI testing: any test for a sexually transmitted infection, in the previous 12 months (%)
Disclosure in health care: Disclosure of same-sex contacts towards health care provider during STI-testing in the last 12 months (%)
Syphilis: diagnosed in the previous 12 months (%)
Symptomatic syphilis: in the previous 12 months (%)
Gonorrhoea: diagnosed in the previous 12 months (%)
Symptomatic gonorrhoea: in the previous 12 months (%)
Chlamydia: diagnosed in the previous 12 months (%)
Symptomatic chlamydia: in the previous 12 months (%)
Partner notification among men with syphilis (%)
Partner notification among men with gonorrhoea (%)
Targeted information: Saw or heard information about HIV/STIs for MSM, last 12 months (%)
Received free condoms: Received free condom from NGOs, clinics, bars, or saunas, last 12 months (%)
Risk and precaution behaviour
Condomless anal sex: Condomless anal sex with non-steady male partners of unknown HIV status, last 12 months (%)
PrEP use: Currently taking HIV pre-exposure prophylaxis daily or on demand (%), excluding HIV-diagnosed men
Lack of PrEP knowledge: Not knowing that PrEP is a pill taken before as well as after sex to prevent HIV infection (%)
Lack of PEP knowledge: Not knowing that PEP stops HIV infection after exposure (%)
Lack of U=U knowledge: Not knowing U=U (that a person with undetectable viral load cannot pass on HIV, %)
HAV vaccination: history of at least one dose of hepatitis A vaccine (%), exluding those with a history of hepatitis A
HBV vaccination: history of at least one dose of hepatitis B vaccine (%), exluding those with a history of hepatitis B
Suggested citation for EMIS/LAMIS indicators on the UNAIDS website for key populations:
Disclaimer: Indicators published on the UNAIDS website for key populations based on data collected by the Latin America MSM Internet Survey (LAMIS) are not official/governmental data of the participating countries.
Available in 33 languages, the European MSM Internet Survey (EMIS-2017) recruited 137,358 qualifying participants from 46 countries across Europe and Lebanon, Israel, Canada and the Philippines. The Latin American MSM Internet Survey (LAMIS) recruited 64,655 participants from 18 countries.
EMIS-2017 was undertaken by researchers from Sigma Research at the London School for Hygiene and Tropical Medicine and the Robert Koch Institute. Data was collected between 18 October 2017 and 31 January 2018.
LAMIS, using the same questionnaire and finishing data collection on 12 May 2018, was the first multi-country survey for gay, bisexual, and other men who have sex with men (MSM) in Latin America. It was implemented by researchers from the RIGHT-PLUS*, a coalition of researchers from Latin America, Portugal, Spain and the Netherlands, with support from the EMIS team. EMIS and LAMIS required a great deal of international cooperation and relied on the support of national stakeholders to aid local recruitment. Through this cooperation comparable data are now available for the first time for more than 60 countries across 4 continents.
LAMIS contributions: CEEISCAT, Spain (Jordi Casabona Barbara, Percy Fernández Dávila): LAMIS network and local recruitment coordination, economic and legal aspects of hosting the database. CIISSS, Peru (Carlos F. Cáceres, E. Michael Reyes): LAMIS Report for Latin America. NUDHES, Brazil (Maria Amelia de Sousa Mascena Veras, Daniel Barros): study website and its graphic design. LSHTM, United Kingdom (Sigma Research: Axel J. Schmidt, Ford Hickson, David Reid, Peter Weatherburn): questionnaire design, support with survey software and monitoring of recruitment, graphic arts of banners for promotion, data cleaning and labelling, error handling, variable manual, templates for national and community reports, collaboration with UNAIDS. Robert Koch Institute, Germany (Ulrich Marcus): negotiations with web pages/apps for free promotion of LAMIS and coordination of central recruitment.
LAMIS acknowledgements: We thank all men who took part in LAMIS, as well as our app partners Grindr and PlanetRomeo who helped to recruit participants through free-of-charge instant messages, and our local partners who recruited participants via Facebook and other social media, and placed promotional banners on their websites. Thank you for being part of something huge!
The following list acknowledges all LAMIS partners by country.
AR: Federación Argentina de Lesbianas, Gays, Bisexuales y Trans (FALGBT). BO: Fundación Diversencia; MANODIVERSA. BR: Núcleo de Pesquisa em Direitos Humanos e Saúde LGBT+ (NUDHES) da Faculdade de Ciências Médicas da Santa Casa de São Paulo; ABGLT. CL: Escuela de Salud Pública – Universidad de Chile; Fundación Savia; APROFA. CO: Asociación Ágora; UNIMINUTO Seccional Bello. CR: Centro de Investigación y Promoción para América Central de Derechos Humanos (CIPAC). EC: Fundación Ecuatoriana Equidad. GT: Fundación Sida y Sociedad; Centro de Investigaciones de las Ciencias de la Salud, Facultad de Ciencias Médicas, Universidad de San Carlos de Guatemala. HN: Asociación Kukulcan. MX: Red GayLatino. NI: Centro para la Educación y Prevención del SIDA (CEPRESI). PA: Grupo Génesis Panamá+. PY: SOMOSGAY. PE: Center for Research on Sexuality, AIDS and Society at Universidad Peruana Cayetano Heredia. SR: Parea Surinam. SV: Asociación Entre Amigos. UY: Colectivo Ovejas Negras; +VIHdas. VE: Venezuela Igualitaria.
LAMISfunding: Questionnaire design, core survey execution and variable manual were provided by EMIS-2017 (funded by the EU Health Programme 2014–2020 for Europe), and adapted for LAMIS use. Additional financial support was provided by CEEISCAT, CIISSS, Instituto de Saúde Pública da Universidade do Porto, Maastricht University, NUDHES, and Robert Koch Institute.
*The Red Iberoamericana de Estudios en Hombres Gay, otros Hombres que tienen Sexo con Hombres y Personas Trans is composed of the following institutions: Núcleo de Pesquisa em Direitos Humanos e Saúde LGBT+ (NUDHES) da Faculdade de Ciências Médicas da Santa Casa de São Paulo (Brazil); Escuela de Salud Pública, Universidad de Chile (Chile); CIISSS at Universidad Peruana Cayetano Heredia (Peru); CICS – Facultad de Ciencias Médicas, Universidad de San Carlos de Guatemala (Guatemala); Instituto de Saúde Pública da Universidade do Porto (Portugal); the Centre d’Estudis Epidemiològics sobre les Infeccions de Transmissió Sexual i VIH/Sida de Catalunya (CEEISCAT, Spain).
The following questionnaires have been used in the projects reported elsewhere on this website. Individuals and organisations are welcome to use individual questions, or whole questionnaires, on the understanding that they credit Sigma Research in any written outputs from the project.
Int J Environ Res Public Health. 2022 Jul 20;19(14):8829. doi: 10.3390/ijerph19148829.
Authors: Haoyi Wang, Oladipupo Shobowale, Chantal den Daas, Eline Op de Coul, Bouko Bakker, Aryanti Radyowijati, Koenraad Vermey, Arjan van Bijnen, Wim Zuilhof, Kai J Jonas
PrEP uptake in the Netherlands is growing but remains at suboptimal levels. Hence, the analysis of hurdles is paramount. Given the initial focus of PrEP provision among men-who-have-sex-with-men (MSM) via a demonstration project that was launched in June 2015, AmPrEP in Amsterdam, and pharmacies in the main urban areas (so called “Randstad”, entailing Amsterdam, Utrecht, Leiden, The Hague and Rotterdam), investigating regional differences is necessary. This study seeks to unravel regional differences jointly with the psycho-social determinants of PrEP uptake. This cross-sectional study included 3232 HIV-negative MSM recruited via the Dutch subsample of the European-MSM-Internet-Survey in late 2017 (EMIS-2017), which aimed to inform interventions for MSM who are highly affected by infections with HIV and other sexually transmitted infections. Prevalence and the standardised prevalence ratio (SPR) of PrEP awareness, intention and uptake were measured on a regional level (Randstad vs. the rest of the country). Multi-level logistic modelling was conducted to identify the association of PrEP uptake with PrEP awareness and intention, socio-demographic, psycho-social determinants and random effects from regional differences. MSM from the Randstad used more PrEP (SPR = 1.4 vs. 0.7) compared to the rest of the country, but there were minor differences for awareness and intention. The regional distinction was estimated to explain 4.6% of the PrEP use variance. We observed a greater influence from PrEP intention (aOR = 4.5, 95% CI 2.0-10.1), while there was limited influence from the awareness of PrEP (aOR = 0.4, 95% CI 0.04-4.4). Lower education (aOR = 0.4, 95% CI 0.2-0.9) was negatively associated with PrEP uptake; however, no significant difference was found between middle (aOR = 1.2, 95% CI 0.7-2.0) and high education. We showed that regional differences-MSM in non-urban regions-and other psycho-social determinants account for lower PrEP uptake. Based on these findings, more fine-tuned PrEP access with a focus on non-urban regions can be implemented, and tailored campaigns increasing intention/use can be conducted among target populations.