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EMIS 2017 Journal Articles 2017

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

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

Abstract

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.

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EMIS 2017 Journal Articles 2017

Sexual happiness and satisfaction with sexual safety among German trans men who have sex with men: results from EMIS-2017

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

Abstract

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.

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EMIS 2017 Journal Articles 2017

Determinants of PrEP Uptake, Intention and Awareness in the Netherlands: A Socio-Spatial Analysis

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

Abstract

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.

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EMIS 2017 Journal Articles 2017

Chemsex users in Czechia: EMIS survey

Cent Eur J Public Health. 2022 Jun;30(2):86-92. doi: 10.21101/cejph.a6923.

Authors: Xenie Uholyeva, Michal Pitoňák

Abstract

Objectives: Chemsex is a phenomenon highly relevant to public health concerns. Our primary aim is to describe the Czech chemsex scene regarding substances used, sexual behaviour, mental health, sexual life satisfaction, internalization of homonegative attitudes, and prevalent chemsex patterns.

Methods: The data from the European Men Who Have Sex With Men Internet Survey (EMIS) 2017 were used. The mental health of chemsex users was assessed by the Patient Health Questionnaire 4 (PHQ4), internalized homonegativity was measured using the Short Internalized Homonegativity Scale. A sample of 87 men who have sex with men (MSM) chemsex users and a comparison group of 261 MSM were selected from the total sample of 1,688 respondents. Mann-Whitney and χ2 tests were used to compare groups.

Results: Active chemsex users made up 5% of the sample (87 of 1,688), with an average age of 37 years. Chemsex users were more likely to engage in condomless sex with non-steady partners (χ2 = 46.8, p < 0.001), and had dramatically more STIs, such as HIV (χ2 = 52.9, p < 0.001), HCV (χ2 = 25.9, p < 0.001), and syphilis (χ2 = 41.5, p < 0.001). Chemsex users frequently injected drugs (n = 19, 20%). More than half (n = 48; 55%) of chemsex users had sober sex in the last 4 weeks. Chemsex culture was associated with riskier substance use, both in terms of mode and frequency. The mental health of chemsex users in our sample did not differ significantly from the comparison group (χ2 = 0.2, p < 0.7). Chemsex users did not conceal their sexual identity more often than the comparison group, on the contrary, 69% (n = 59) of them were out to most significant others, compared to 53% (n = 134) in the comparison group (χ2 = 8.8, p < 0.05). In addition, we did not find differences in the degree of internalized homonegativity (χ2 = 0.9, p < 0.4). Chemsex users were clearly and significantly more satisfied with their sex life than the comparison group (Mann-Whitney U test, p < 0.001).

Conclusions: In our sample, chemsex use was not associated with a negative impact on health or wellbeing. Our results suggest that chemsex is not a homogeneous phenomenon. Many different patterns and subcultures exist, some of them are riskier, some safer than others.

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EMIS 2017 Journal Articles 2017

What is the empirical basis for converting banded ordinal data on numbers of sex partners among MSM into a continuous scale level variable? A secondary analysis of 13 surveys across 17 countries

BMC Med Res Methodol 22, 59 (2022). https://doi.org/10.1186/s12874-021-01483-8

Authors: Ana Mendez‑Lopez, Ford Hickson, Klaus Jansen, Nathan Lachowsky, Fiona Burns, Cinta Folch, Annie Velter, Peter Weatherburn, Ulrich Marcus , Ursula von Rüden, Massimo Mirandola, Lorenzo Gios, Jamie Frankis, David J. Brennan and Axel J. Schmidt

Abstract

Background: To provide empirically based guidance for substituting partner number categories in large MSM surveys with mean numbers of sexual and condomless anal intercourse (CAI) partners in a secondary analysis of survey data.

Methods: We collated data on numbers of sexual and CAI partners reported in a continuous scale (write-in number) in thirteen MSM surveys on sexual health and behaviour across 17 countries. Pooled descriptive statistics for the number of sexual and CAI partners during the last twelve (N = 55,180) and 6 months (N = 31,759) were calculated for two sets of categories commonly used in reporting numbers of sexual partners in sexual behaviour surveys.

Results: The pooled mean number of partners in the previous 12 months for the total sample was 15.8 partners (SD = 36.6), while the median number of partners was 5 (IQR = 2–15). Means for number of partners in the previous 12 months for the first set of categories were: 16.4 for 11–20 partners (SD = 3.3); 27.8 for 21–30 (SD = 2.8); 38.6 for 31–40 (SD = 2.4); 49.6 for 41–50 (SD = 1.5); and 128.2 for ‘more than 50’ (SD = 98.1). Alternative upper cut-offs: 43.4 for ‘more than 10’ (SD = 57.7); 65.3 for ‘more than 20’ (SD = 70.3). Self-reported partner numbers for both time frames consistently exceeded 200 or 300. While there was substantial variation of overall means across surveys, the means for all chosen categories were very similar. Partner numbers above nine mainly clustered at multiples of tens, regardless of the selected time frame. The overall means for CAI partners were lower than those for sexual partners; however, such difference was completely absent from all categories beyond ten sexual and CAI partners.

Conclusions: Clustering of reported partner numbers confirm common MSM sexual behaviour surveys’ questionnaire piloting feedback indicating that responses to numbers of sexual partners beyond 10 are best guesses rather than precise counts, but large partner numbers above typical upper cut-offs are common.

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EMIS 2017 Journal Articles 2017

Would eligible gay, bisexual and other men who have sex with men use PrEP? Awareness, knowledge, eligibility and intention to use PrEP among EMIS-2017 participants in Spain

Prev Med 2022 Mar;156:106962. doi: 10.1016/j.ypmed.2022.106962. Epub 2022 Jan 21

Authors: Carlos Iniesta, Cinta Folch, Sebastian Meyer, María Vázquez, Jordi Casabona, Asunción Díaz

Abstract

Pre-exposure prophylaxis (PrEP) is an efficacious strategy for reducing the incidence of HIV infection. It has been available in Spain since 2019. We aim to report on awareness, knowledge of, intention to use, and eligibility for PrEP and related factors among participants in the European Men-Who-Have-Sex-With-Men Internet Survey (EMIS-2017) in Spain. We used Spanish data from EMIS-2017, a cross-sectional study performed among gay, bisexual, and other men who have sex with mean (GBMSM) from 50 countries. We found that 65.3% of the 10,634 participants were aware of PrEP, some 30.1% of those HIV-negative and ≥ 18 years were eligible and 52.7% of those eligible intended to use it. Regarding knowledge about PrEP, only 15.4% of the participants knew 3 statement with true information about that PrEP meant. Older age, being born in Western Europe (WE) and greater outness were associated with greater awareness. Older age, being born in Latin America or Caribbean or WE, sex work, and living in a large city were associated with greater eligibility. A greater degree of outness was associated with reduced intention to use. Our study point to possible barriers in the implementation of PrEP in Spain and similar countries.

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EMIS 2017 Journal Articles 2017

Factors associated with low levels of HIV testing among young men who have sex with men (MSM) participating in EMIS-2017 in Spain

Sex Transm Infect 2022 Feb 4; sextrans-2021-055193. doi: 10.1136/sextrans-2021-055193.

Authors: Nuria Gallego, Asuncion Diaz, Cinta Folch, Sebastian Meyer, Maria Vazquez, Jordi Casabona, Victoria Hernando 

Abstract

Purpose: The European Men who have sex with men Internet Survey looked over the characteristics and needs of men who have sex with men (MSM) across Europe. Our objective was to estimate the prevalence of HIV testing and its associated factors among MSM younger than 25 years old participating in the EMIS-2017 in Spain.

Methods: Multivariable regression model was used to compare those who had been tested for HIV within the last 12 months and those that had not.

Results: Of 2313 participants, 1070 (46.3%) had been tested for HIV in the past 12 months. Increased age (age 19-21 years, aOR=3.38 (95% CI 2.57 to 4.44); age 22-24 years, aOR=5.26 (4.06 to 6.92) compared with age 16-18 years); being migrant (Latin America: aOR=1.34 (0.98 to 1.84); Europe, North America and Mediterranean countries (aOR=1.56 (0.98 to 2.51) compared with those from Spain); living more openly with one’s sexuality (out to some people (aOR=1.53 (1.19 to 1.96)); out to all or almost all people (aOR=2.24 (1.75 to 2.87) compared with those out to none or a few people); having had one condomless steady partners in the las year ((aOR=1.59 (1.26 to 2.02)); having had condomless non-steady partners in the last year (one: aOR=1.76 (1.35 to 2.29)); two or more partners: aOR=2.37 (1.84 to 3.04)); and having practised sex work in the past year (aOR=1.52 (1.07 to 2.13)) were associated with increased odds of HIV testing. Living in a smaller city was associated with less likelihood of HIV testing (<1 00 000 inhabitants: aOR=0.51 (95% CI 0.41 to 0.64); 100 000-500 000: aOR=0.68 (95% CI 0.54 to 0.86) compared with more than 500 000).

Conclusion: Young MSM showed low HIV testing rate. Future programming specifically targeting this population, especially those middle adolescents, living in a medium-small city and having less ‘outness’, can help increase HIV testing and prevent access barriers.

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EMIS 2017 Journal Articles 2017

Influence of Internalised Homonegativity on sexual risk behaviour of men who have sex with men in Spain

Sexuality & Culture, published online first 27 November 2021 (doi: 10.1007/s12119-021-09925-7).

Authors: İbrahim Sönmez, Cinta Folch, Nicolas Lorente, Rigmor C. Berg, Natalie Thurlby & Axel J. Schmidt

Abstract

In a sample of men who have sex with men (MSM) (N = 3436) in Spain who bear intrinsic HIV risk, we investigated how internalised homonegativity (IH) is associated with the number of non-steady male partners with condomless intercourse (as a proxy of sexual risk behaviour). Using structural equation modelling (SEM), we examined the relationship between IH and sexual risk behaviour, and mediating effects of HIV/PrEP knowledge and substance use during sex on this relationship. We found no direct association between IH and sexual risk behaviour, nor did IH influence substance use during sex. In line with our hypothesis, association between IH and sexual risk behaviour was significant when mediated by HIV/PrEP knowledge. We found that as IH increased, sexual risk behaviour decreased, because higher IH was associated with lower HIV/PrEP knowledge while higher HIV/PrEP knowledge was associated with increased non-condom use with non-steady partners. Substance use during sex was significantly associated with sexual risk behaviour. Our results emphasize the continuing importance of prevention strategies focused on behavioural changes and community level interventions, especially targeting substance use.

© 2021 Springer Nature Switzerland AG

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EMIS 2017 Journal Articles 2017

Awareness of, willingness to take PrEP and its actual use among Belgian MSM at high risk of HIV infection: secondary analysis of the Belgian European MSM internet survey

AIDS and Behavior, published online first 24 November 2021 (doi: 10.1007/s10461-021-03526-z).

Authors: Veerle Buffel, Thijs Reyniers, Caroline Masquillier, Estrelle Thunissen, Christiana Nöstlinger, Marie Laga, Edwin Wouters, Wim Vanden Berghe, Jessika Deblonde, Bea Vuylsteke

Abstract

We examined PrEP awareness, willingness to take it and early PrEP use among men who have sex with men (MSM) at increased risk of HIV acquisition in Belgium. This analysis of the Belgian EMIS online data of 2017–2018 adopts a cascade approach, with the following steps quantified as conditional probabilities: being eligible for, aware of, willing to take PrEP, and PrEP use. One out of three MSM was eligible to use PrEP according to the operationalized Belgian reimbursement criteria. PrEP awareness was lower among socioeconomically vulnerable MSM, MSM living outside large cities, MSM who were less open about their sexuality and those who did not identify as gay or homosexual. A lack of PrEP knowledge, a higher self-efficacy regarding safe sex, having a steady partner and reporting more symptoms of depression were related to unwillingness to use PrEP. Among those willing to take PrEP, less than one third were actually using PrEP. Not using PrEP was associated with living in small cities and experiencing financial problems.

Keywords: Awareness of and willingness to use PrEP; Cascade approach; Eligibility criteria; Men who have sex with men (MSM); Pre-exposure prophylaxis (PrEP) use.

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EMIS 2017 Journal Articles 2017

Changes in the prevalence of self-reported sexually transmitted bacterial infections from 2010 and 2017 in two large European samples of men having sex with men – is it time to re-evaluate STI-screening as a control strategy?

PLoS ONE, 2021; 16(3): e0248582 (doi: 10.1371/journal.pone.0248582).

Authors: Ulrich Marcus, Massimo Mirandola, Susanne B Schink, Lorenzo Gios, Axel J Schmidt

Abstract

Background/Objectives: Many European countries reported increased numbers of syphilis, gonorrhoea and chlamydia diagnoses among men who have sex with men (MSM) in recent years. Behaviour changes and increased testing are thought to drive these increases.

Methods: In 2010 and 2017, two large online surveys for MSM in Europe (EMIS-2010, EMIS-2017) collected self-reported data on STI diagnoses in the previous 12 months, diagnostic procedures, STI symptoms when testing, number of sexual partners, and sexual behaviours such as condom use during the last intercourse with a non-steady partner in 46 European countries. Multivariate regression models were used to analyse factors associated with diagnoses of syphilis, gonorrhoea/chlamydia, and respective diagnoses classified as symptomatic and asymptomatic. If applicable, they included country-level screening rates.

Results: Questions on STI diagnoses and sexual behaviours were answered by 156,018 (2010) and 125,837 (2017) participants. Between 2010 and 2017, overall diagnoses with gonorrhoea/chlamydia and syphilis increased by 76% and 83% across countries. Increases were more pronounced for asymptomatic compared to symptomatic infections. The proportion of respondents screened and the frequency of screening grew considerably. Condomless anal intercourse with the last non-steady partner rose by 62%; self-reported partner numbers grew. Increased syphilis diagnoses were largely explained by behavioural changes (including more frequent screening). Gonorrhoea/chlamydia increases were mainly explained by more screening and a change in testing performance. A country variable representing the proportion of men screened for asymptomatic infection was positively associated with reporting symptomatic gonorrhoea/chlamydia, but not syphilis.

Discussion/Conclusion: The positive association of country-level screening rates with the proportion of symptomatic infections with gonorrhoea/chlamydia may indicate a paradoxical effect of screening on incidence of symptomatic infections. Treatment of asymptomatic men might render them more susceptible to new infections, while spontaneous clearance may result in reduced susceptibility. Before expanding screening programmes, evidence of the effects of screening and treatment is warranted.

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