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In Europe, men who have sex with men (MSM) are one of the key populations most affected by sexually transmitted infections (STIs), including HIV. In many European countries, sex between men accounts for the bulk of new diagnoses of STIs and HIV. For example, 50% of new syphilis cases reported in 2012 in Europe were among MSM (and up to 80% in some countries) and 45% of new cases of HIV. Furthermore, in the last decade, there have been a number of outbreaks of STIs, such as Lymphogranuloma venereum, which have occurred simultaneously in a number of European cities, highlighting dense international sexual networks that exist among MSM.1
STIs are a major health concern because they can facilitate the transmission of HIV and in their own right, as many STIs have major sequelae. Gonorrhoeal infections are becoming increasingly difficult to treat and resistance is most apparent among MSM.2 The incidence of STIs among MSM is due, in part, to the high levels of sexual risk behaviour reported by MSM, which can be exacerbated by sero-adaptive sexual practices.3 Furthermore, concerns that new HIV prevention and treatment options, such the increasing emphasis on treatment as prevention for the HIV-positive individual and pre-exposure prophylaxis to prevent acquisition of infection in the negative individuals, may contribute to increasing levels of STIs in the future. Thus there is a need to ensure that strong prevention and control measures for STIs among MSM exist throughout Europe.
The International Union against STI has recently published European clinical guidelines for the management of STIs which recommend the screening of all patients for HIV, syphilis, gonorrhoea and chlamydia.4 Nonetheless, the European MSM Internet Survey highlights strong geographical differences between countries in Northern Europe (UK, Ireland, Scandinavian countries and the Netherlands) and in the rest of Europe regarding clinical practice as reported by MSM.5 The most common reported diagnostic procedure is a blood test, with 85% or more of surveyed MSM having reported having had a blood test at last visit. However, physical inspection of the anus or penis, or anal swabbing to detect an STI was reported by 50% or more of MSM surveyed in cities from northern Europe, whereas this was reported by only 6–10% of MSM in cities from central and southern Europe. Therefore, MSM were 10–50 times less likely to have received an anal swab in French and Spanish cities compared to London. The publication of these guidelines should be used to improve clinical practice so that the best treatment and care available is given, which will also have a major impact on the prevention and control of STIs, including HIV, among MSM.
This study also noted differences among MSM in Europe in their access to free or affordable STI testing that reflects the geographical gradient for screening practices reported by survey respondents. Thus MSM surveyed in Northern Europe were much more aware of free and accessible services than those MSM in southern and central Europe. These results may reflect the differences in the types of services where most STIs are diagnosed and treated, with primary care services being the main service for treatment of STIs in many countries.6 The call of the authors, and of others, to establish voluntary and anonymous testing services for HIV/STI that ‘are non-judgemental, gay-friendly and easily accessible to MSM’ should be supported. Nonetheless, barriers to such accessible services still exist in many of the countries where the survey was conducted and these include cultural attitudes, homophobia, stigma, policy and legislative structures, as well as insensitivity or lack of awareness among healthcare providers. The establishment of such clinics will assist in the dissemination of best practice to other local healthcare providers as well as contributing to the prevention and control of STIs and HIV.
European MSM Internet Survey is based on a very large convenience sample of more than 170 000 MSM from 38 European countries who responded simultaneously to the same questionnaire placed across 200 websites in 2010. However, as with many other studies conducted among MSM, questions arise about the representativeness of the sample, as there is no evident sampling frame of MSM, who are often underrepresented in general population-based surveys. Results from such community samples are not representative of all MSM and may be biased, although the direction and extent of this bias may vary.7 ,8 The most motivated men for whom prevention is important agreed to participate and those MSM were more likely to be gay-identified. Some findings suggest that community samples (internet or gay venues) are likely to overestimate levels of risk behaviour among all MSM.9 ,10 The advantage of such convenience samples is the ability to recruit many individuals, but only a tool such as the internet is able to collect such a large number of respondents during a limited period of time. Therefore, further research into how representative such samples are of the general population of MSM and how to improve further the recruitment of representative samples of MSM through gay websites is needed. For example, using similar methods to those used for time–location sampling, some researchers have developed an analogous method ‘internet venue-based sampling’.7 Internet surveys can provide large numbers of respondents in a short time, which can minimise some of the biases inherent in convenience samples and are thus an important tool to monitor, evaluate and improve sexual health in this population that is most affected by STIs and HIV.
Good sexual health is a right enshrined in WHO11 and the link between stigma and discrimination towards MSM and poor sexual health has been made by many researchers. There is a need throughout Europe for a strong STI prevention strategy for MSM, to be given an equal emphasis as an HIV prevention strategy. A cornerstone of any such strategy is the early diagnosis and treatment of infections, especially asymptomatic infections. It is clear from the results from the recent paper of Schmidt et al published in this issue of Sexually Transmitted Infections, that this is not the case in all major European cities. Ensuring the provision of easily accessible services for MSM offering a comprehensive sexual health screen is essential and the challenge is to establish and promote such clinical services in at least all the major European cities. This will require leadership, resources and advocacy by local and national stakeholders, including government, health professionals and non-governmental organisations. These same stakeholders in other countries and in international bodies also have a vital role to play by offering examples of best practice, building a strong evidence base and providing support and advice to countries and cities to enhance and develop clinical services for the prevention and control of STIs among MSM. The road ahead is difficult, but good quality internationally comparable data will sustain the efforts to overcome this challenge.
Contributors Written and approved by both authors.
Competing interests None.
Provenance and peer review Commissioned; internally peer reviewed.