Vol. 150 No. 5153 (2020)
The Swiss STAR trial – an evaluation of target groups for sexually transmitted infection screening in the sub-sample of women
In Switzerland, universal health insurance does not cover any routine testing for sexually transmitted infections (STIs), not even in individuals at high risk, and extra-genital swabbing is not standard of care. We compared STI prevalence in a multicentre prospective observational cohort of multi-partner women with/without sex work and evaluated associated risk factors.
MATERIALS AND METHODS
Between January 2016 and June 2017, we offered free STI testing to women with multiple sexual partners (three or more in the previous 12 months), with follow-up examinations every 6 months. We used multiplex polymerase chain-reaction testing (for Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, Mycoplasma genitalium) for pooled swabs (pharynx, urethra/vagina, anus), and antibody tests for human immunodeficiency virus (HIV) and Treponema pallidum at every visit, and for hepatitis B and C at baseline.
We screened 490 female sex workers (FSWs), including 17 trans women, and 92 other multi-partner women. More than half reported a steady partner. Previously undiagnosed HIV was found in 0.2% vs 0.0%, respectively, and T. pallidum antibodies in 5.9% vs 0.0%. STIs requiring antibiotic treatment comprised: active syphilis 1.2% vs 0.0%; N. gonorrhoeae 4.9% vs 0.0%; C. trachomatis 6.3% vs 5.4%, T. vaginalis 10.4% vs 0.0%; M. genitalium 6.7% vs 6.5%. One in four FSWs vs one in nine other women had one or more of these STIs at baseline. 15.8% vs 3.8% had a history of hepatitis B, 45.5% vs 22.8% had no immunity (HBs-AB <10 IU/l). Two FSWs had hepatitis C virus antibodies (0.4%) without concurrent HIV infection. Non-condom-use (last three months) for anal/vaginal sex was not associated with STIs. Independent risk factors were group sex (adjusted odds ratio [aOR] 2.1, 95% confidence interval [CI] 1.1–4.0), age less than 25 (aOR 3.7, 95% CI 1.6–8.9), and being active in sex work for less than 1 year (aOR 2.7, 95% CI 1.3–5.3).
HIV and HCV do not appear to pose a major public health problem among FSWs in Switzerland, whereas vaccination against HBV should be promoted. FSWs showed high rates of STIs requiring treatment to reduce transmission to clients and/or steady partners. FSWs should be offered low-cost or free STI screening as a public health priority.
- Federal Office of Public Health FOPH. National Programme on HIV and other STIs (NPHS) 2011–2017. Bern: Swiss Federal Office of Public Health; 2010. Available from: https://www.bag.admin.ch/bag/en/home/strategie-und-politik/nationale-gesundheitsstrategien/nationales-programm-hiv-und-andere-sexuell-uebertragbare-infektionen/strategie.html [accessed 2020 April].
- Boily MC, Mâsse B. Mathematical models of disease transmission: a precious tool for the study of sexually transmitted diseases. Can J Public Health. 1997;88(4):255–65. doi:.https://doi.org/10.1007/BF03404793
- Notter J, Frey Tirri B, Bally F, Aebi Popp K, Yaron M, Nadal D, et al. [Sexually transmitted infection with Chlamydia trachomatis]. Swiss Med Forum. 2017;17(34):705–11. Article in German and French. doi:..https://doi.org/10.4414/smf.2017.03020
- Organisation for Economic Co-operation and Development. Purchasing power parities (PPP). Paris: OECD; 2018. Available from: https://data.oecd.org/conversion/purchasing-power-parities-ppp.htm [accessed 2020 April].
- Schmidt AJ, Rasi M, Esson C, Christinet V, Ritzler M, Lung T, et al. The Swiss STAR trial – an evaluation of target groups for sexually transmitted infection screening in the sub-sample of men. Swiss Med Wkly. 2020;150:w20392.
- Bremer V, Haar K, Gassowski M, Hamouda O, Nielsen S. STI tests and proportion of positive tests in female sex workers attending local public health departments in Germany in 2010/11. BMC Public Health. 2016;16(1):1175. doi:.https://doi.org/10.1186/s12889-016-3847-6
- Holmes KK, Sparling PF, Walter E. Stamm, Piot P, Wasserheit JN, Corey L, et al. Clinical Manifestations of Syphilis (Chapter 37). Sexually Transmitted Diseases. 4th edition ed. New York: The McGraw-Hill Companies; 2008. p. 661ff.
- Schroeter AL, Turner RH, Lucas JB, Brown WJ. Therapy for incubating syphilis. Effectiveness of gonorrhea treatment. JAMA. 1971;218(5):711–3. doi:.https://doi.org/10.1001/jama.1971.03190180033006
- Stoltey JE, Cohen SE. Syphilis transmission: a review of the current evidence. Sex Health. 2015;12(2):103–9. doi:.https://doi.org/10.1071/SH14174
- Gray RT, Hoare A, Prestage GP, Donovan B, Kaldor JM, Wilson DP. Frequent testing of highly sexually active gay men is required to control syphilis. Sex Transm Dis. 2010;37(5):298–305. doi:.https://doi.org/10.1097/OLQ.0b013e3181ca3c0a
- Biberstein L, Killias M. [Erotic operations as a gateway for human trafficking? A study on the extent and structure of the sex work market in Switzerland - investigation commissioned by the Federal Office of Police]. Lenzburg: Killias Research & Consulting AG; 2015. In German; available from: https://www.alexandria.unisg.ch/252621 [accessed 2020 April].
- Federal Office of Public Healh FOPH. [HIV, syphilis, gonorrhoea, and chlamydia in Switzerland: 2018 epidemiological overview]. Bulletin. 2019;41:10-20. Article in French and German; available from: https://www.bag.admin.ch/dam/bag/fr/dokumente/cc/Kampagnen/Bulletin/2019/BU_41_19.pdf [accessed 2020 April].
- Ong JJ, Fethers K, Howden BP, Fairley CK, Chow EPF, Williamson DA, et al. Asymptomatic and symptomatic urethral gonorrhoea in men who have sex with men attending a sexual health service. Clin Microbiol Infect. 2017;23(8):555–9. doi:.https://doi.org/10.1016/j.cmi.2017.02.020
- Walker CK, Sweet RL. Gonorrhea infection in women: prevalence, effects, screening, and management. Int J Womens Health. 2011;3:197–206. doi:.https://doi.org/10.2147/IJWH.S13427
- Lociciro S, Ernst M-L, Simonson T, Bize R. Les comportements face au VIH et autres IST des travailleuses et travailleurs du sexe en Suisse. Enquête SWAN 2016. Lausanne: Institut universitaire de médecine sociale et preventive (IUMSP); 2017. P 1–114.
- Chow EP, Fairley CK. The role of saliva in gonorrhoea and chlamydia transmission to extragenital sites among men who have sex with men: new insights into transmission. J Int AIDS Soc. 2019;22(S6, Suppl 6):e25354. doi:.https://doi.org/10.1002/jia2.25354
- Chemaitelly H, Weiss HA, Smolak A, Majed E, Abu-Raddad LJ. Epidemiology of Treponema pallidum, Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, and herpes simplex virus type 2 among female sex workers in the Middle East and North Africa: systematic review and meta-analytics. J Glob Health. 2019;9(2):020408. doi:.https://doi.org/10.7189/jogh.09.020408
- Jansen K, Bremer V, Steffen G, et al. Abstracts of the German STI Congress and Leopoldina Symposium 2016, 06.-09.07.2016, Berlin. J Dtsch Dermatol Ges. 2016;14(Suppl 3):2–55. doi:https://doi.org/10.1111/ddg.13106
- Viikki M, Pukkala E, Nieminen P, Hakama M. Gynaecological infections as risk determinants of subsequent cervical neoplasia. Acta Oncol. 2000;39(1):71–5. doi:.https://doi.org/10.1080/028418600431003
- Chandra NL, Broad C, Folkard K, Town K, Harding-Esch EM, Woodhall SC, et al. Detection of Chlamydia trachomatis in rectal specimens in women and its association with anal intercourse: a systematic review and meta-analysis. Sex Transm Infect. 2018;94(5):320–6. doi:.https://doi.org/10.1136/sextrans-2017-053161
- Hoenderboom BM, van Benthem BHB, van Bergen JEAM, Dukers-Muijrers NHTM, Götz HM, Hoebe CJPA, et al. Relation between Chlamydia trachomatis infection and pelvic inflammatory disease, ectopic pregnancy and tubal factor infertility in a Dutch cohort of women previously tested for chlamydia in a chlamydia screening trial. Sex Transm Infect. 2019;95(4):300–6. doi:.https://doi.org/10.1136/sextrans-2018-053778
- Brunham RC, Pourbohloul B, Mak S, White R, Rekart ML. The unexpected impact of a Chlamydia trachomatis infection control program on susceptibility to reinfection. J Infect Dis. 2005;192(10):1836–44. doi:.https://doi.org/10.1086/497341
- Batteiger BE, Xu F, Johnson RE, Rekart ML. Protective immunity to Chlamydia trachomatis genital infection: evidence from human studies. J Infect Dis. 2010;201(Suppl 2):S178–89. doi:.https://doi.org/10.1086/652400
- Brunham RC, Kimani J, Bwayo J, Maitha G, Maclean I, Yang C, et al. The epidemiology of Chlamydia trachomatis within a sexually transmitted diseases core group. J Infect Dis. 1996;173(4):950–6. doi:.https://doi.org/10.1093/infdis/173.4.950
- Gama A, Martins MRO, Mendão L, Barros H, Dias S. HIV Infection, risk factors and health services use among male-to-female transgender sex workers: a cross-sectional study in Portugal. AIDS Care. 2018;30(1):1–8. doi:.https://doi.org/10.1080/09540121.2017.1332736
- Verscheijden MMA, Woestenberg PJ, Götz HM, van Veen MG, Koedijk FDH, van Benthem BHB. Sexually transmitted infections among female sex workers tested at STI clinics in the Netherlands, 2006-2013. Emerg Themes Epidemiol. 2015;12(1):12. doi:.https://doi.org/10.1186/s12982-015-0034-7
- Reeves A, Steele S, Stuckler D, McKee M, Amato-Gauci A, Semenza JC. National sex work policy and HIV prevalence among sex workers: an ecological regression analysis of 27 European countries. Lancet HIV. 2017;4(3):e134–40. doi:.https://doi.org/10.1016/S2352-3018(16)30217-X
- Tokar A, Sazonova I, Mishra S, Smyrnov P, Saliuk T, Lazarus JV, et al. HIV testing behaviour and HIV prevalence among female sex workers in Ukraine: findings from an Integrated Bio-Behavioural Survey, 2013-2014. Sex Transm Infect. 2019;95(3):193–200. doi:.https://doi.org/10.1136/sextrans-2018-053684
- von Wyl V, Kouyos RD, Yerly S, Böni J, Shah C, Bürgisser P, et al.; Swiss HIV Cohort Study. The role of migration and domestic transmission in the spread of HIV-1 non-B subtypes in Switzerland. J Infect Dis. 2011;204(7):1095–103. doi:.https://doi.org/10.1093/infdis/jir491
- Terrault NA, Dodge JL, Murphy EL, Tavis JE, Kiss A, Levin TR, et al. Sexual transmission of hepatitis C virus among monogamous heterosexual couples: the HCV partners study. Hepatology. 2013;57(3):881–9. doi:.https://doi.org/10.1002/hep.26164
- Richard JL, Schaetti C, Basler S, Mäusezahl M. The epidemiology of hepatitis C in Switzerland: trends in notifications, 1988-2015. Swiss Med Wkly. 2018;148:w14619. doi:.https://doi.org/10.4414/smw.2018.14619
- Federal Office of Public Healh FOPH, Swiss Federal Vaccination Commission. [Swiss vaccination plan 2014. Guidelines and recommendations]. Bern: Swiss Federal Office of Public Healh, 2014. Article in German; available from: https://kssg.guidelines.ch/api/filestore/2nBFP8jzYazi0cK6CAyJvw1tf1OpuUonjYKt8A/data/impfplan_2014_de_final-2.pdf [accessed 2020 April].
- Federal Office of Public Healh FOPH. [HPV: complementary vaccination recommendation for boys and men aged 11 to 26 years]. Bulletin. 2015;10:141–9. Article in French and German; available from: www.bag.admin.ch/dam/bag/fr/dokumente/cc/Kampagnen/Bulletin/2015/BU_10_15_f.pdf; [accessed 2020 April].
- Chow EP, Howden BP, Walker S, Lee D, Bradshaw CS, Chen MY, et al. Antiseptic mouthwash against pharyngeal Neisseria gonorrhoeae: a randomised controlled trial and an in vitro study. Sex Transm Infect. 2017;93(2):88–93. doi:.https://doi.org/10.1136/sextrans-2016-052753
- Wetzel D, Delicado N, Wehrli M, et al. [Establishment of a VCT HIV / STI consultation for people practicing prostitution in Geneva. Activity report of the pilot phase March 2017–March 2019]. Geneva: Aspasie, GsG, PSM (HUG); 2019. Report in French.