Arjan Hogewoning

MSM starting preexposure prophylaxis are at risk of hepatitis C virus infection

OBJECTIVES AND DESIGN Hepatitis C virus (HCV) has been recognised as an emerging sexually transmitted infection (STI) among HIV-positive men who have sex with men (MSM). However, HIV-negative MSM at high risk for HIV might also be at increased risk for HCV. We studied the HCV prevalence in HIV-negative MSM who start pre-exposure prophylaxis (PrEP) in Amsterdam. Phylogenetic analysis was used to compare HCV strains obtained from HIV-negative and HIV-positive MSM. METHODS At enrolment in the Amsterdam PrEP (AMPrEP) demonstration project, HIV-negative MSM were tested for the presence of HCV antibodies and HCV RNA. If positive for HCV RNA, an HCV NS5B gene fragment (709 bp) was sequenced and compared with HCV isolates from HIV-positive MSM (n = 223) and risk groups other than MSM (n = 153), using phylogenetic analysis. RESULTS Of 375 HIV-negative MSM enrolled in AMPrEP, 18 (4.8%, 95%CI 2.9%-7.5%) of participants were anti-HCV and/or HCV RNA positive at enrolment; 15/18 (83%) had detectable HCV RNA. HCV genotyping showed genotype 1a (73%), 4d (20%) and 2b (7%). All HCV-positive MSM starting PrEP were part of MSM-specific HCV clusters containing MSM with and without HIV. CONCLUSION HCV prevalence among HIV-negative MSM who started PrEP was higher than previously reported. All HIV-negative HCV-positive MSM were infected with HCV strains already circulating among HIV-positive MSM. The increasing overlap between sexual networks of HIV-positive and HIV-negative MSM might result in an expanding HCV-epidemic irrespective of HIV-status. Hence, routine HCV testing should be offered to MSM at high risk for HIV, especially for those enrolling in PrEP programs.Objectives and design: Hepatitis C virus (HCV) has been recognized as an emerging sexually transmitted infection (STI) among HIV-positive MSM. However, HIV-negative MSM at high risk for HIV might also be at increased risk for HCV. We studied the HCV prevalence in HIV-negative MSM who start preexposure prophylaxis (PrEP) in Amsterdam. Phylogenetic analysis was used to compare HCV strains obtained from HIV-negative and HIV-positive MSM. Methods: At enrolment in the Amsterdam PrEP demonstration project, HIV-negative MSM were tested for the presence of HCV antibodies and HCV RNA. If positive for HCV RNA, an HCV NS5B gene fragment (709 bp) was sequenced and compared with HCV isolates from HIV-positive MSM (n = 223) and risk groups other than MSM (n = 153), using phylogenetic analysis. Results: Of 375 HIV-negative MSM enrolled in Amsterdam PrEP, 18 (4.8%, 95% confidence interval 2.9–7.5%) of participants were anti-HCV and/or HCV RNA positive at enrolment; 15 of 18 (83%) had detectable HCV RNA. HCV genotyping showed genotype 1a (73%), 4d (20%), and 2b (7%). All HCV-positive MSM starting PrEP were part of MSM-specific HCV clusters containing MSM with and without HIV. Conclusion: HCV prevalence among HIV-negative MSM who started PrEP was higher than previously reported. All HIV-negative HCV-positive MSM were infected with HCV strains already circulating among HIV-positive MSM. The increasing overlap between sexual networks of HIV-positive and HIV-negative MSM might result in an expanding HCV-epidemic irrespective of HIV-status. Hence, routine HCV testing should be offered to MSM at high risk for HIV, especially for those enrolling in PrEP programs.

Frequency and determinants of consistent STI/HIV testing among men who have sex with men testing at STI outpatient clinics in the Netherlands: a longitudinal study

Objectives Men who have sex with men (MSM) are at highest risk for STIs and HIV infections in the Netherlands. However, official guidelines on STI testing among MSM are lacking. They are advised to test for STIs at least every six months, but their testing behaviour is not well known. This study aimed to get insight into the proportion and determinants of consistent 6-monthly STI testing among MSM testing at STI outpatient clinics in the Netherlands. Methods This study included longitudinal surveillance data of STI consultations among MSM from all 26 STI outpatient clinics in the Netherlands between 1 June 2014 and 31 December 2015. Multinomial logistic regression analysis was used to identify determinants of consistent 6-monthly testing compared with single testing and inconsistent testing. Determinants of time between consultations among men with multiple consultations were analysed using a Cox Prentice-Williams-Peterson gap-time model. Results A total of 34 605 STI consultations of 18 634 MSM were included. 8966 (48.1%) men had more than one consultation, and 3516 (18.9%) men tested consistently 6-monthly. Indicators of high sexual risk behaviour, including having a history of STI, being HIV positive and having more than 10 sex partners, were positively associated with both being a consistent tester and returning to the STI clinic sooner. Men who were notified by a partner or who reported STI symptoms were also more likely to return to the STI clinic sooner, but were less likely to be consistent testers, identifying a group of event-driven testers. Conclusions The proportion of consistent 6-monthly testers among MSM visiting Dutch STI outpatient clinics was low. Testing behaviour was associated with sexual risk behaviour, but exact motives to test consistently remain unclear. Evidence-based testing guidelines are needed to achieve optimal reductions in STI transmission in the future.

Development and validation of the HCV-MOSAIC risk score to assist testing for acute hepatitis C virus (HCV) infection in HIV-infected men who have sex with men (MSM)

Current guidelines recommend hepatitis C virus (HCV) testing for HIV-infected men who have sex with men (MSM) with ongoing risk behaviour, without specifying the type of risk behaviour. We developed and validated the HCV-MOSAIC risk score to assist HCV testing in HIV-infected MSM. The risk score consisted of six self-reported risk factors identified using multivariable logistic regression using data from the Dutch MOSAIC study (n = 213, 2009–2013). Area under the ROC curve (AUC), sensitivity, specificity, post-test-probability-of-disease and diagnostic gain were calculated. The risk score was validated in case–control studies from Belgium (n = 142, 2010–2013) and the United Kingdom (n = 190, 2003–2005) and in cross-sectional surveys at a Dutch sexually transmitted infections clinic (n = 284, 2007–2009). The AUC was 0.82; sensitivity 78.0% and specificity 78.6%. In the validation studies sensitivity ranged from 73.1% to 100% and specificity from 56.2% to 65.6%. The post-test-probability-of-disease ranged from 5.9% to 20.0% given acute HCV prevalence of 1.7% to 6.4%, yielding a diagnostic gain of 4.2% to 13.6%. The HCV-MOSAIC risk score can successfully identify HIV-infected MSM at risk for acute HCV infection. It could be a promising tool to improve HCV testing strategies in various settings.

Design of the FemCure study: prospective multicentre study on the transmission of genital and extra-genital Chlamydia trachomatis infections in women receiving routine care

BackgroundIn women, anorectal infections with Chlamydia trachomatis (CT) are about as common as genital CT, yet the anorectal site remains largely untested in routine care. Anorectal CT frequently co-occurs with genital CT and may thus often be treated co-incidentally. Nevertheless, post-treatment detection of CT at both anatomic sites has been demonstrated. It is unknown whether anorectal CT may play a role in post-treatment transmission. This study, called FemCure, in women who receive routine treatment (either azithromycin or doxycycline) aims to understand the post-treatment transmission of anorectal CT infections, i.e., from their male sexual partner(s) and from and to the genital region of the same woman. The secondary objective is to evaluate other reasons for CT detection by nucleic acid amplification techniques (NAAT) such as treatment failure, in order to inform guidelines to optimize CT control.MethodsA multicentre prospective cohort study (FemCure) is set up in which genital and/or anorectal CT positive women (n = 400) will be recruited at three large Dutch STI clinics located in South Limburg, Amsterdam and Rotterdam. The women self-collect anorectal and vaginal swabs before treatment, and at the end of weeks 1, 2, 4, 6, 8, 10, and 12. Samples are tested for presence of CT-DNA (by NAAT), load (by quantitative polymerase chain reaction -PCR), viability (by culture and viability PCR) and CT type (by multilocus sequence typing). Sexual exposure is assessed by online self-administered questionnaires and by testing samples for Y chromosomal DNA. Using logistic regression models, the impact of two key factors (i.e., sexual exposure and alternate anatomic site of infection) on detection of anorectal and genital CT will be assessed.DiscussionThe FemCure study will provide insight in the role of anorectal chlamydia infection in maintaining the CT burden in the context of treatment, and it will provide practical recommendations to reduce avoidable transmission. Implications will improve care strategies that take account of anorectal CT.Trial registrationClinicalTrials.gov Identifier: NCT02694497.

Determinants of Human Papillomavirus Vaccination Intention Among Female Sex Workers in Amsterdam, the Netherlands

Introduction Female sex workers (FSWs) are at risk for human papillomavirus (HPV)–induced diseases but are currently not targeted by the HPV vaccination program in the Netherlands. We explored determinants of their intention to get vaccinated against HPV in case vaccination would be offered to them. Methods In 2016, FSWs 18 years and older having a sexually transmitted infection consultation with the Prostitution & Health Center (P&G292) in Amsterdam, either at the clinic or at their working location, were invited to complete a questionnaire assessing sociopsychological determinants of HPV vaccination intention (scale ranging from −3 to +3). Determinants of HPV vaccination intention were assessed with univariable and multivariable linear regression. In addition, we explored the effect of out-of-pocket payment on intention. Results Between May and September 2016, 294 FSWs participated. The median age was 29 years (interquartile range, 25–37 years). Human papillomavirus vaccination intention was high (mean, 2.0; 95% confidence interval [CI], 1.8–2.2). In multivariable analysis, attitude (&bgr; = 0.6; 95% CI, 0.5–0.7), descriptive norm (&bgr; = 0.2; 95% CI, 0.1–0.3), self-efficacy (&bgr; = 0.2; 95% CI, 0.1–0.3), beliefs (&bgr; = 0.1; 95% CI, 0.0–0.2), and subjective norm (&bgr; = 0.1; 95% CI, 0.0–0.2) seemed to be the strongest predictors of HPV vaccination intention (R 2 = 0.54). Human papillomavirus vaccination intention decreased significantly to a mean of 0.2 when vaccination would require out-of-pocket payment of &OV0556;350. Conclusions The HPV vaccination intention among FSWs seems relatively high and is most strongly constituted in attitudinal, normative, and self-efficacy beliefs. Out-of-pocket payment will probably have a negative impact on their HPV vaccination acceptability.

Men who have sex with men more often chose daily than event-driven use of pre-exposure prophylaxis: baseline analysis of a demonstration study in Amsterdam

The Amsterdam PrEP project is a prospective, open‐label demonstration study at a large sexually transmitted infection (STI) clinic. We examined the uptake of PrEP; the baseline characteristics of men who have sex with men (MSM) and transgender persons initiating PrEP; their choices of daily versus event‐driven PrEP and the determinants of these choices.

HPV vaccination intention among male clients of a large STI outpatient clinic in Amsterdam, the Netherlands

We explored HPV vaccination intention and its determinants among male clients of the sexually transmitted infections (STI) clinic in Amsterdam. In 2015, male clients aged ≥18 years were invited to complete a web-based questionnaire regarding HPV vaccination intention and socio-psychological determinants. Determinants (scale −3 to +3) were assessed with linear regression, stratified for men who have sex with men (MSM) (including men who have sex with men and women) and men who only have sex with women (MSW). Additionally, we explored the effect of out-of-pocket payment on intention. Of 1490 participants (median age 33 years [IQR:25–44]), 1,053(71%) were MSM. HPV vaccination intention was high (mean 1.68, 95%CI:1.55–1.81 among MSW; mean 2.35, 95%CI:2.29–2.42 among MSM). In multivariable analyses, socio-psychological determinants had similar effects on intention in both groups (R2=0.70 among MSW; R2=0.68 among MSM), except for subjective norms, self-efficacy, and HPV knowledge (significantly stronger associations among MSW). HPV vaccination intention decreased significantly when vaccination would require out-of-pocket payment; intention was negative at the current list price (€350). HPV vaccination intention among male clients of the Amsterdam STI-clinic is high and variance in intention was mostly be explained by socio-psychological factors. Out-of-pocket payment had a strong negative effect on HPV vaccination intention.

Increasing awareness and prompting HIV testing: Contributions of Amsterdam HIV Testing Week 2016:

We evaluated Amsterdam HIV Testing Week (HTW) 2016 regarding its primary goals of raising awareness and prompting HIV testing. Participating services offered free, anonymous HIV testing, with a focus on reaching men who have sex with men (MSM) and people with a non-western migration background. Sociodemographic characteristics, HIV testing history, intention to test regularly, beliefs about personal risk and severity of HIV, and perceived social norms regarding HIV testing and people living with HIV were assessed among all who tested. A community quick scan assessed awareness of Amsterdam HTW 2016 and attitudes and intentions regarding HIV testing. Of 806 people tested, 59.6% (405/679) belonged to key populations. None tested HIV-positive and 37.6% intended to test regularly in the future. The community quick scan found moderate awareness of Amsterdam HTW 2016. Awareness was highest among recent testers and HIV-positive MSM and not associated with HIV testing attitudes and intentions. People tested during Amsterdam HTW 2016 were from key populations and/or were not (adequately) reached via traditional testing approaches. The contribution of the Amsterdam HTW approach to raising awareness and prompting HIV testing in key populations may benefit from focusing on HIV-negative individuals who have not been tested recently.

The Acceptability of Pre-Exposure Prophylaxis: Beliefs of Health-Care Professionals Working in Sexually Transmitted Infections Clinics and HIV Treatment Centers.

Background Pre-exposure prophylaxis (PrEP) is highly effective for preventing HIV infections, but is not yet implemented in the Netherlands. As the attitudes of health-care professionals toward PrEP can influence future PrEP implementation, we studied PrEP knowledge and beliefs and their association with PrEP acceptability among professionals in clinics for sexually transmitted infection (STI professionals) and HIV treatment centers (HIV specialists). In addition, we examined preferred regimens, attitudes toward providing PrEP to key populations and to reimbursement of PrEP costs. Methods An online questionnaire was distributed among 24 public health STI clinics and 27 HIV treatment centers nationwide in the Netherlands between January and August 2015. The acceptability of PrEP was measured on a 7-point Likert scale ranging from 1 = low to 7 = high acceptability. Univariable and multivariable linear regression analyses were used to explore associations between demographic characteristics, PrEP knowledge, beliefs about PrEP, and PrEP acceptability. Results In total, 209 people (143 STI professionals and 66 HIV specialists) completed the questionnaire. The mean acceptability of PrEP implementation was 4.28 (SD 1.68) among STI professionals and 4.42 (SD 1.67) among HIV specialists. The mean score on self-perceived knowledge related to PrEP efficacy was 3.90 (SD 1.57) among STI professionals and 5.68 (SD 1.08) among HIV specialists (p-value of <0.001). Beliefs associated with lower PrEP acceptability among both groups were the fear that PrEP use will lead to a decrease in condom use and an increase in STI, the high costs of PrEP and ethical issues regarding prescribing antiretroviral medication to healthy individuals. No preference for a daily or an event-driven regimen was detected. Most participants deemed the following groups to be eligible for PrEP: men who have sex with men (MSM) who regularly get post-exposure prophylaxis, MSM who never used condoms with casual partners and MSM with an HIV-positive partner with a detectable viral load. Over half of the participants indicated that PrEP users should partly (54.1%) or fully (35.4%) pay the costs of PrEP. Conclusion In 2015, PrEP acceptability was only moderate among Dutch STI professionals and HIV specialists, which is far from an optimal setting. Addressing barriers to PrEP acceptability in educational programs for various types of health-care professionals is needed to successfully implement PrEP in the Netherlands.

P4.98 Spiro, a patient-managed mobile application to improve syphilis treatment follow-up among men who have sex with men

Introduction Syphilis incidence is rising in developed countries worldwide, and men who have sex with men (MSM) are disproportionally affected. Follow-up after treatment of syphilis is important as late complications (e.g. neurosyphilis), therapy failure and re-infections can occur, especially in HIV co-infected patients. Failure to complete follow-up occurs frequently. Moreover, medical history at follow-up is often incomplete, as follow-up occurs often at various health care providers. Self-management of the relevant medical data might improve patient engagement, and ensure the availability of medical data required during follow-up visits. Methods We developed a patient-managed mobile phone application – Spiro – that can be used by patients treated for syphilis, to record relevant data for follow-up like medical history, physical findings, treponomal (e.g. TTPA) and non-treponomal (e.g. VDRL) serum antibody results, conclusions and treatment. Spiro automatically summarises the data relevant for syphilis follow-up including a graphical depiction of the non-treponomal serum antibody titer over time. Follow-up data are stored locally on the mobile device. Optionally, encrypted online storage is available. Lay information on risk factors for, and symptoms, diagnosis and treatment of syphilis infections is available via the app. Results After launching Spiro on World AIDS day 2016, we intend to measure its acceptability and usability among patients who use the app and their care providers. In addition, we plan to evaluate retention to follow-up, the availability of required data for syphilis treatment follow-up, health-literacy and self-reported level of disease control among MSM newly diagnosed with syphilis in a multi-centre RCT, comparing standard care plus the use of Spiro by patients to standard care alone. Conclusion If feasible and effective, Spiro, a newly developed medical mobile phone application, can improve the engagement in, and retention to syphilis treatment follow-up among MSM.