The Swiss STAR trial – an evaluation of target groups for sexually transmitted infection screening in the sub-sample of men
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 determined the prevalence and incidence of human immunodeficiency virus (HIV), viral hepatitis and non-viral STIs in a multicentre prospective observational cohort of multi-partner men who have sex with men (MSM) and other men.
MATERIALS AND METHODS
Between January 2016 and June 2017, we offered free STI testing to all men 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) on pooled swabs (pharynx, urethra/vagina, anus), and antibody tests for HIV and Treponema pallidum at every visit, and for hepatitis B/C at baseline.
We screened 779 multi-partner MSM and 92 other men. Previously undiagnosed HIV was found in 0.5% vs 0.0%, respectively and T. pallidum antibodies in 15.3% vs 1.1%. STIs requiring antibiotic treatment comprised: active syphilis 1.7% vs 0.0%; N. gonorrhoeae 10.3% vs 0.0%; C. trachomatis 8.7% vs 1.1%. One in four MSM versus 1 in 100 other multi-partner men had any of these three STIs at baseline. 10.4% vs 1.3% had a history of hepatitis B, 31.9% vs 47.3% had no immunity (HBs-AB <10 IU/l). Ten MSM had HCV antibodies (1.4%), with 8 out of the 10 being MSM with HIV; HCV seroprevalence was 0.3% among HIV-negative MSM. In MSM, incidence of the three bacterial STIs was 25.5 per year over 333 person years of follow-up, HIV incidence was 0.3%. Non-condom-use (in the last 3 months) for anal/vaginal sex was not associated with STIs. Independent risk factors were sex with men (adjusted odds ratio [aOR] 16.4) and the number of sexual partners (aOR 2.3 for >20).
Among MSM, but not among other multi-partner men, STIs, mostly asymptomatic, are common. Given the high risk of onward transmission, low-cost or free routine screening of multi-partner MSM is 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].
- Wasserheit JN, Aral SO. The dynamic topology of sexually transmitted disease epidemics: implications for prevention strategies. J Infect Dis. 1996;174(Suppl 2):S201–13. doi:.https://doi.org/10.1093/infdis/174.Supplement_2.S201
- Warner L, Stone KM, Macaluso M, Buehler JW, Austin HD. Condom use and risk of gonorrhea and Chlamydia: a systematic review of design and measurement factors assessed in epidemiologic studies. Sex Transm Dis. 2006;33(1):36–51. doi:.https://doi.org/10.1097/01.olq.0000187908.42622.fd
- Marcus JL, Kohn RP, Barry PM, Philip SS, Bernstein KT. Chlamydia trachomatis and Neisseria gonorrhoeae transmission from the female oropharynx to the male urethra. Sex Transm Dis. 2011;38(5):372–3. doi:.https://doi.org/10.1097/OLQ.0b013e3182029008
- Rank RG, Yeruva L. Hidden in plain sight: chlamydial gastrointestinal infection and its relevance to persistence in human genital infection. Infect Immun. 2014;82(4):1362–71. doi:.https://doi.org/10.1128/IAI.01244-13
- Heijne JCM, van Liere GAFS, Hoebe CJPA, Bogaards JA, van Benthem BHB, Dukers-Muijrers NHTM. What explains anorectal chlamydia infection in women? Implications of a mathematical model for test and treatment strategies. Sex Transm Infect. 2017;93(4):270–5. doi:.https://doi.org/10.1136/sextrans-2016-052786
- 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 April 2020].
- Schmidt AJ, Falcato L, Zahno B, Burri A, Regenass S, Müllhaupt B, et al. Prevalence of hepatitis C in a Swiss sample of men who have sex with men: whom to screen for HCV infection? BMC Public Health. 2014;14(1):3. doi:.https://doi.org/10.1186/1471-2458-14-3
- Vernazza P, Rasi M, Ritzler M, Dost F, Stoffel M, Aebi-Popp K, et al. The Swiss STAR trial—An Evaluation of Target Groups for STI Screening in the Sub-sample of Women. Swiss Med Wkly. 2020;150:w20393.
- Schmidt AJ, Altpeter E. The Denominator problem: estimating the size of local populations of men-who-have-sex-with-men and rates of HIV and other STIs in Switzerland. Sex Transm Infect. 2019;95(4):285–91. doi:.https://doi.org/10.1136/sextrans-2017-053363
- Clerc O, Darling K, Calmy A, Dubois-Arber F, Cavassini M. Hepatitis C Virus Awareness Among Men Who Have Sex With Men in Southwest Switzerland. Sex Transm Dis. 2016;43(1):44–8. doi:.https://doi.org/10.1097/OLQ.0000000000000378
- Federal Office of Public Health FOPH, Swiss Federal Vaccination Commission. [Swiss vaccination plan 2014. Guidelines and recommendations]. Bern: Swiss Federal Office of Public Health, 2014. Article in German. Available from: https://kssg.guidelines.ch/api/filestore/2nBFP8jzYazi0cK6CAyJvw1tf1OpuUonjYKt8A/data/impfplan_2014_de_final-2.pdf [accessed 2020 April].
- Weber P, Gredig D, Lehner A, Nideröst S. European MSM Internet Survey (EMIS-2017). [National Report for Switzerland]. Olten: School of Social Work, University of Applied Sciences and Arts Northwestern Switzerland; 2019. Report in French and German. Available from: http://sigmaresearch.org.uk/local/item/emis-2017-national-reports.
- Spielmann N, Münstermann D, Hagedorn HJ, an der Heiden M, Houareau C, Gunsenheimer-Bartmeyer B, et al., German HIV-1 Seroconverter Study Group. Time trends of syphilis and HSV-2 co-infection among men who have sex with men in the German HIV-1 seroconverter cohort from 1996-2007. Sex Transm Infect. 2010;86(5):331–6. doi:.https://doi.org/10.1136/sti.2009.040857
- Gray RT, Hoare A, McCann PD, Bradley J, Down I, Donovan B, et al. Will changes in gay men’s sexual behavior reduce syphilis rates? Sex Transm Dis. 2011;38(12):1151–8. doi:.https://doi.org/10.1097/OLQ.0b013e318238b85d
- Clement ME, Hicks CB. Syphilis on the Rise: What Went Wrong? JAMA. 2016;315(21):2281–3. doi:.https://doi.org/10.1001/jama.2016.7073
- Shilaih M, Marzel A, Braun DL, Scherrer AU, Kovari H, Young J, et al.; and the Swiss HIV Cohort Study. Factors associated with syphilis incidence in the HIV-infected in the era of highly active antiretrovirals. Medicine (Baltimore). 2017;96(2):e5849. doi:.https://doi.org/10.1097/MD.0000000000005849
- Templeton DJ, Read P, Varma R, Bourne C. Australian sexually transmissible infection and HIV testing guidelines for asymptomatic men who have sex with men 2014: a review of the evidence. Sex Health. 2014;11(3):217–29. doi:.https://doi.org/10.1071/SH14003
- Low N, Unemo M, Skov Jensen J, Breuer J, Stephenson JM. Molecular diagnostics for gonorrhoea: implications for antimicrobial resistance and the threat of untreatable gonorrhoea. PLoS Med. 2014;11(2):e1001598. doi:.https://doi.org/10.1371/journal.pmed.1001598
- Braun DL, Marzel A, Steffens D, Schreiber PW, Grube C, Scherrer AU, et al.; Swiss HIV Cohort Study. High Rates of Subsequent Asymptomatic Sexually Transmitted Infections and Risky Sexual Behavior in Patients Initially Presenting With Primary Human Immunodeficiency Virus-1 Infection. Clin Infect Dis. 2018;66(5):735–42. doi:.https://doi.org/10.1093/cid/cix873
- Chow EP, Camilleri S, Ward C, Huffam S, Chen MY, Bradshaw CS, et al. Duration of gonorrhoea and chlamydia infection at the pharynx and rectum among men who have sex with men: a systematic review. Sex Health. 2016;13(3):199–204. doi:.https://doi.org/10.1071/SH15175
- 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
- Hocking JS, Temple-Smith M, Guy R, Donovan B, Braat S, Law M, et al.; ACCEPt Consortium. Population effectiveness of opportunistic chlamydia testing in primary care in Australia: a cluster-randomised controlled trial. Lancet. 2018;392(10156):1413–22. doi:.https://doi.org/10.1016/S0140-6736(18)31816-6
- Cornelisse VJ, Chow EP, Huffam S, Fairley CK, Bissessor M, De Petra V, et al. Increased Detection of Pharyngeal and Rectal Gonorrhea in Men Who Have Sex With Men After Transition From Culture To Nucleic Acid Amplification Testing. Sex Transm Dis. 2017;44(2):114–7. doi:.https://doi.org/10.1097/OLQ.0000000000000553
- Annan NT, Sullivan AK, Nori A, Naydenova P, Alexander S, McKenna A, et al. Rectal chlamydia--a reservoir of undiagnosed infection in men who have sex with men. Sex Transm Infect. 2009;85(3):176–9. doi:.https://doi.org/10.1136/sti.2008.031773
- Hoffman CM, Fritz L, Radebe O, Dubbink JH, McIntyre JA, Kock MM, et al. Rectal Trichomonas vaginalis infection in South African men who have sex with men. Int J STD AIDS. 2018;29(14):1444–7. doi:.https://doi.org/10.1177/0956462418788418
- Federal Office of Public Healh FOPH. Recommendations of the Swiss Federal Commission for Sexual Health (FCSH) on pre-exposure prophylaxis (PrEP) for HIV prevention. Bulletin. 2016;4. Available at: https://www.bag.admin.ch/dam/bag/en/dokumente/mt/p-und-p/richtlinien-empfehlungen/prep-empfehlungen-der-eksg-januar-2016.pdf. [accessed 2020 April 2020].
- The EMIS Network. EMIS-2017. The European Men-Who-Have-Sex-With-Men Internet Survey. Key findings from 50 countries. Stockholm: European Centre for Disease Prevention and Control; 2019. Available from: http://sigmaresearch.org.uk/reports/item/report2019a [accessed 2020 April].
- Giraudon I, Schmidt AJ, Mohammed H. Surveillance of sexualised drug use - the challenges and the opportunities. Int J Drug Policy. 2018;55:149–54. doi:.https://doi.org/10.1016/j.drugpo.2018.03.017
- Hampel B, Kusejko K, Kouyos RD, Böni J, Flepp M, Stöckle M, et al. Chemsex drugs on the rise: a longitudinal analysis of the Swiss HIV Cohort Study from 2007 to 2017. HIV Med. 2020;21(4):228–39. doi:.https://doi.org/10.1111/hiv.12821
- Federal Office of Public Health 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].
- Sultan B, White JA, Fish R, Carrick G, Brima N, Copas A, et al. The “3 in 1” Study: Pooling Self-Taken Pharyngeal, Urethral, and Rectal Samples into a Single Sample for Analysis for Detection of Neisseria gonorrhoeae and Chlamydia trachomatis in Men Who Have Sex with Men. J Clin Microbiol. 2016;54(3):650–6. doi:.https://doi.org/10.1128/JCM.02460-15
- Dudareva-Vizule S, Haar K, Sailer A, Wisplinghoff H, Wisplinghoff F, Marcus U ; PARIS study group. Prevalence of pharyngeal and rectal Chlamydia trachomatis and Neisseria gonorrhoeae infections among men who have sex with men in Germany. Sex Transm Infect. 2014;90(1):46–51. doi:.https://doi.org/10.1136/sextrans-2012-050929
- Fairley CK, Hocking JS, Zhang L, Chow EP. Frequent Transmission of Gonorrhea in Men Who Have Sex with Men. Emerg Infect Dis. 2017;23(1):102–4. doi:.https://doi.org/10.3201/eid2301.161205
- Jenness SM, Weiss KM, Goodreau SM, Gift T, Chesson H, Hoover KW, et al. Incidence of Gonorrhea and Chlamydia Following Human Immunodeficiency Virus Preexposure Prophylaxis Among Men Who Have Sex With Men: A Modeling Study. Clin Infect Dis. 2017;65(5):712–8. doi:.https://doi.org/10.1093/cid/cix439
- Potterat JJ, Muth SQ, Rothenberg RB, Zimmerman-Rogers H, Green DL, Taylor JE, et al. Sexual network structure as an indicator of epidemic phase. Sex Transm Infect. 2002;78(Suppl 1):i152–8. doi:.https://doi.org/10.1136/sti.78.suppl_1.i152
- Potterat JJ, Rothenberg RB, Woodhouse DE, Muth JB, Pratts CI, Fogle JS, 2nd. Gonorrhea as a social disease. Sex Transm Dis. 1985;12(1):25–32. doi:.https://doi.org/10.1097/00007435-198501000-00006
- Marcus JL, Bernstein KT, Kohn RP, Liska S, Philip SS. Infections missed by urethral-only screening for chlamydia or gonorrhea detection among men who have sex with men. Sex Transm Dis. 2011;38(10):922–4. doi:.https://doi.org/10.1097/OLQ.0b013e31822a2b2e
- Chan PA, Robinette A, Montgomery M, Almonte A, Cu-Uvin S, Lonks JR, et al. Extragenital Infections Caused by Chlamydia trachomatis and Neisseria gonorrhoeae: A Review of the Literature. Infect Dis Obstet Gynecol. 2016;2016:5758387. doi:.https://doi.org/10.1155/2016/5758387