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Centre for Genomic Pathogen Surveillance and the Euro-GASP study group: Sonja Pleininger, Alexander Indra, Irith De Baetselier, Wim Vanden Berghe, Blaženka Hunjak, Tatjana Nemeth Blažić, Panayiota Maikanti-Charalambous, Despo Pieridou, Hana Zákoucká, Helena Žemličková, Steen Hoffmann, Susan Cowan, Lasse Jessen Schwartz, Rita Peetso, Jevgenia Epstein, Jelena Viktorova, Ndeindo Ndeikoundam, Beatrice Bercot, Cécile Bébéar, Florence Lot, Susanne Buder, Klaus Jansen, Vivi Miriagou, Georgios Rigakos, Vasilios Raftopoulos, Eszter Balla, Mária Dudás, Lena Rós Ásmundsdóttir, Guðrún Sigmundsdóttir, Guðrún Svanborg Hauksdóttir, Thorolfur Gudnason, Aoife Colgan, Brendan Crowley, Sinéad Saab, Paola Stefanelli, Anna Carannante, Patrizia Parodi, Gatis Pakarna, Raina Nikiforova, Antra Bormane, Elina Dimina, Monique Perrin, Tamir Abdelrahman, Joël Mossong, Jean-Claude Schmit, Friedrich Mühlschlegel, Christopher Barbara, Francesca Mifsud, Alje Van Dam, Birgit Van Benthem, Maartje Visser, Ineke Linde, Hilde Kløvstad, Dominique Caugant, Beata Młynarczyk-Bonikowska, Jacinta Azevedo, Maria-José Borrego, Marina Lurdes Ramos Nascimento, Peter Pavlik, Irena Klavs, Andreja Murnik, Samo Jeverica, Tanja Kustec, Julio Vázquez Moreno, Asuncion Diaz, Raquel Abad, Inga Velicko, Magnus Unemo, Helen Fifer, Jill Shepherd, Lynsey Patterson Background: Genomic surveillance using quality-assured whole-genome sequencing (WGS) together with epidemiological and antimicrobial resistance (AMR) data is essential to characterise the circulating Neisseria gonorrhoeae lineages and their association to patient groups (defined by demographic and epidemiological factors). In 2013, the European gonococcal population was characterised genomically for the first time. We describe the European gonococcal population in 2018 and identify emerging or vanishing lineages associated with AMR and epidemiological characteristics of patients, to elucidate recent changes in AMR and gonorrhoea epidemiology in Europe. Methods: We did WGS on 2375 gonococcal isolates from 2018 (mainly Sept 1-Nov 30) in 26 EU and EEA countries. Molecular typing and AMR determinants were extracted from quality-checked genomic data. Association analyses identified links between genomic lineages, AMR, and epidemiological data. Findings: Azithromycin-resistant N gonorrhoeae (8·0% [191/2375] in 2018) is rising in Europe due to the introduction or emergence and subsequent expansion of a novel N gonorrhoeae multi-antigen sequence typing (NG-MAST) genogroup, G12302 (132 [5·6%] of 2375; N gonorrhoeae sequence typing for antimicrobial resistance [NG-STAR] clonal complex [CC]168/63), carrying a mosaic mtrR promoter and mtrD sequence and found in 24 countries in 2018. CC63 was associated with pharyngeal infections in men who have sex with men. Susceptibility to ceftriaxone and cefixime is increasing, as the resistance-associated lineage, NG-MAST G1407 (51 [2·1%] of 2375), is progressively vanishing since 2009-10. Interpretation: Enhanced gonococcal AMR surveillance is imperative worldwide. WGS, linked to epidemiological and AMR data, is essential to elucidate the dynamics in gonorrhoea epidemiology and gonococcal populations as well as to predict AMR. When feasible, WGS should supplement the national and international AMR surveillance programmes to elucidate AMR changes over time. In the EU and EEA, increasing low-level azithromycin resistance could threaten the recommended ceftriaxone-azithromycin dual therapy, and an evidence-based clinical azithromycin resistance breakpoint is needed. Nevertheless, increasing ceftriaxone susceptibility, declining cefixime resistance, and absence of known resistance mutations for new treatments (zoliflodacin, gepotidacin) are promising. This study was supported by the European Centre for Disease Prevention and Control, the Centre for Genomic Pathogen Surveillance, the Li Ka Shing Foundation (Big Data Institute, University of Oxford), the Wellcome Genome Campus, the Foundation for Medical Research at Örebro University Hospital, and grants from Wellcome (098051 and 099202). LSB was funded by Conselleria de Sanitat Universal i Salut Pública, Generalitat Valenciana (Plan GenT CDEI-06/20-B), Valencia, Spain, and Ministry of Science, Innovation and Universities (PID2020–120113RA-I00), Spain, at the time of analysing and writing this manuscript. info:eu-repo/semantics/publishedVersion

We report a ceftriaxone-resistant, multidrug-resistant urogenital gonorrhoea case in a heterosexual woman in France, June 2022. The woman was successfully treated with azithromycin 2 g. She had unprotected sex with her regular partner, who developed urethritis following travel to Vietnam and Switzerland. Whole genome sequencing of the gonococcal isolate (F92) identified MLST ST1901, NG-STAR CC-199, and the novel mosaic penA-237.001, which caused ceftriaxone resistance. penA-237.001 is 98.7% identical to penA-60.001, reported in various ceftriaxone-resistant strains, including the internationally spreading FC428 clone.

Background Clinical trials have demonstrated that oral pre-exposure prophylaxis (PrEP) has high efficacy in preventing HIV transmission. In many countries, HIV testing is recommended prior to PrEP initiation, 1 month after and quarterly thereafter. We assessed the uptake of HIV testing and estimated the incidence of HIV infections after oral PrEP initiation, by using the French national health database (SNDS). Methods A historic cohort study included every adult person who started oral PrEP between 1 January 2016 and 30 June 2018 in France. HIV infection was tracked in the follow-up, from first PrEP dispensation up to 31 December 2018. Factors associated with adherence to HIV testing in PrEP follow-up were analysed using a generalized linear mixed model. Results PrEP users (9893) were followed for a median duration of 551 days (IQR 350–769). The first HIV test, 1 month after PrEP initiation, was performed by 64% of users. For subsequent tests, this rate exceeded 81% and remained stable over time. HIV testing was lower among PrEP users without prescription refill (OR 0.15; 99% CI 0.12–0.20), but higher if the last prescription was made by a hospital practitioner (OR 2.03; 99% CI 1.69–2.45). Twenty-nine HIV infections were identified, leading to an incidence of 0.19 cases per 100 person-years (99% CI 0.12–0.30). Conclusions We confirmed good adherence to HIV testing and efficacy of PrEP in users, which should help in decreasing HIV incidence in France. This study also revealed that SNDS could be a powerful automated tool for the epidemiological monitoring of PrEP users.

Background Diagnoses of bacterial sexually transmitted infections (STIs) have increased in France since the 2000s. The main strategy to control STI transmission is recommending/facilitating access to condom use, testing, and antibiotic treatments. Aim This study analyses the evolution of STI testing in the private sector in France from 2006 to 2020. Methods National health insurance reimbursement data were used to determine numbers and rates of individuals aged ≥ 15 years tested for diagnoses of chlamydia, gonorrhoea and syphilis in the private sector in France and to describe their evolution from 2006 to 2020. Results Upward tendencies in testing were observed from 2006 to 2019 for all three STIs. The highest testing rates were identified in people aged 25‒29-years old. The observed testing-increase from 2017 to 2019 was twice as high in young people ( Conclusion Improvements found in STI testing rates may have resulted from better awareness, especially among young people and health professionals, of the importance of testing, following prevention campaigns. Nevertheless, testing levels remain insufficient considering increasing diagnoses. In 2020, the COVID-19 pandemic had a considerable impact on STI testing. Partner notification and offering diverse testing opportunities including self-sampling are essential to control STI epidemics particularly in exposed populations.

Background Hepatitis C virus (HCV) elimination by 2030, as targeted by the World Health Organization (WHO), requires that 90% of people with chronic infection be diagnosed and 80% treated. We estimated the cascade of care (CoC) for chronic HCV infection in mainland France in 2011 and 2016, before and after the introduction of direct-acting antivirals (DAAs). Methods The numbers of people (1) with chronic HCV infection, (2) aware of their infection, (3) receiving care for HCV and (4) on antiviral treatment, were estimated for 2011 and 2016. Estimates for 1) and 2) were based on modelling studies for 2011 and on a virological sub-study nested in a national cross-sectional survey among the general population for 2016. Estimates for 3) and 4) were made using the National Health Data System. Results Between 2011 and 2016, the number of people with chronic HCV infection decreased by 31%, from 192,700 (95% Credibility interval: 150,900-246,100) to 133,500 (95% Confidence interval: 56,900-312,600). The proportion of people aware of their infection rose from 57.7 to 80.6%. The number of people receiving care for HCV increased by 22.5% (representing 25.7% of those infected in 2016), while the number of people on treatment increased by 24.6% (representing 12.1% of those infected in 2016). Conclusions This study suggests that DAAs substantially impact CoC. However, access to care and treatment for infected people remained insufficient in 2016. Updating CoC estimates will help to assess the impact of new measures implemented since 2016 as part of the goal to eliminate HCV.

Background and objectives In France, blood donation deferral for men who have sex with men (MSM) was reduced from permanent to 12 months in July 2016. Assessing noncompliance (rate and reasons) with this criterion is important to maintain a high level of viral safety in blood products. Materials and methods An anonymous online survey (Complidon) of a sample of blood donors was conducted in 2017. Data were post-stratified to be representative of all those who donated blood between July 2016 and December 2017. A multivariable analysis was performed to assess factors associated with noncompliance. Results Among male donors, 0·73% [95% CI: 0·63-0·83] reported having sex with men in the 12 months preceding their donation. Factors associated with noncompliance were as follows: young age, a low educational level, concerns about privacy, and better knowledge of donor selection criteria and the window period than compliant men. More than half of noncompliant MSM donors (57·6% [95% CI: 50·6-64·3]) felt that sexual orientation should not be a criterion for donation, 47·2% [95% CI: 40·4-54·0] did not disclose their male-to-male sexual relations in order to avoid being excluded from donating, 40·5% [95% CI: 34·0-47·4] reported using condoms and 21·8% [95% CI: 16·7-27·9] had the same male partner for at least 12 months. Conclusion Complidon showed that compliance with blood donation criteria in MSM was high, but not optimal, especially among younger men. HIV residual risk did not increase after the implementation of 12-month deferral. Data from Complidon helped French policymakers to assess the additional HIV risk posed by increased access to blood donation for MSM.

Located in southwestern Indian Ocean, Mayotte is a French territory, with a very specific demographic, social and health context. To date, epidemiological data on infections by hepatitis B (HBV), C (HCV), and delta (HDV) viruses in Mayotte have been sparse. We aimed to estimate, in the 15-69-year-old general population living in Mayotte, the prevalence of infections by hepatitis B (HBV), C (HCV), and delta (HDV) viruses and the distribution of HBV status: current infection with positive HBs antigen (Ag); resolved infection with positive HBc antibodies and negative HBsAg; immunisation by vaccination with only positive HBs antibodies; and no infection/no immunisation with negative markers. We also described the characteristics of infected people and assessed the determinants of lifetime HBV infection.The Unono Wa Maore survey, implemented in a random sample of the general population in 2018-2019, consisted of an at-home collection of epidemiological data and venous blood samples. Detection of hepatitis B, C, and delta serological and molecular markers was performed.Among 5207 eligible people, 4643 responded to the questionnaire (89.2%), with 2917 being tested for HBV and HCV (62.8%). Estimated HBV status was as follows: current infection 3.0% (95% confidence interval [CI]: 2.3-3.9%) (n = 76); resolved infection 27.8% (95% CI: 25.8-29.9); immunisation by vaccination 27.7% (95% CI: 25.9-29.7); and no infection/no immunisation 41.5% (95% CI: 39.3-43.7). One participant was positive for HDV antibodies (Ab) (0.65%) with a negative HDV-RNA viral load. The risk of lifetime HBV infection was higher in men (adjusted prevalence ratio (aPR): 1.55, 95% CI: 1.29-1.89); in people aged 30-49 years (aPR: 3.83, 95% CI: 1.49-9.81) or 50-69 years (aPR: 4.52, 95% CI: 1.77-11.53) compared to those under 20; in individuals who reported no condom use during their first sexual intercourse (aPR: 1.46, 95% CI: 1.01-2.14); and in those living in Dembeni-Mamoudzou (aPR: 1.40, 95% CI: 1.09-1.80) compared to the West-Centre of Mayotte. Finally, six individuals were positive for HCV antibodies (0.21%), including three positive for HCV RNA.Mayotte is an area of intermediate endemicity for HBV and low endemicity for HCV and HDV. With a prevalence of HBsAg 10 times higher than in mainland France, a high proportion of people susceptible to HBV infection, and a demographic, health, and social context that may favour its transmission, hepatitis B is a major public health concern in Mayotte.

Background Blood donor selection, consisting of a pre-donation questionnaire and interview, excludes potential donors who may be at risk of transfusion-transmissible infections. Assessing the reasons for noncompliance with blood donor selection criteria is important to maintain a high level of viral safety of blood products. Study design and methods An anonymous French online survey of a sample of blood donors (Complidon) was conducted from September to December 2017. Data were poststratified to be representative of all donors who donated blood between July 2016 and December 2017. Results Of 420,190 solicited donors, 108,386 completed the survey (26%). Overall, noncompliance was estimated at 5.6%. The least respected criteria regarded sex with more than one partner during the previous 4 months for donors (1.9%) and for donors' partners (1%), travel-related criteria (1.2%) and sex between men during the previous 12 months (0.73% of men). Reasons for noncompliance differed according to criteria. Donors who were non-compliant to sexuality-based criteria mainly said they did not want to be excluded or that the questions were too personal. Conversely, donors who were exclusively non-compliant to criteria other than sexuality-based criteria more often mentioned their non-compliance during the pre-donation interview but were nevertheless authorized to donate blood. Conclusion Despite noncompliance to blood donor criteria being relatively low in France, it still represents a threat to blood safety. Accordingly, improved communication is important to ensure that donors fully understand each selection criterion and to emphasize to health professionals the importance of listening carefully without judging during pre-donation interviews.

Since the emergence of the human immunodeficiency virus at the beginning of the 1980s, the epidemic has spread extensively in all regions of the world. In France, there is still a significant number of new contaminations each year, mainly among men having sexual relations with men and heterosexuals born in Sub-Saharan Africa. The prevention efforts targeting the most exposed populations must be continued.

BACKGROUND Viral and bacterial sexually transmitted infections (STI) are public health concerns worldwide but surveillance systems are not comprehensive enough to design and monitor accurately STI control strategies in most countries. In 2016, 320 STI clinics (CeGIDD in French) with expanded sexual health missions were implemented in France, primarily targeting most exposed populations, although access is free of charge for anybody. OBJECTIVE This article describes the mandatory surveillance system (SurCeGIDD) based on CeGIDDs’ individual data aiming to better guide STI prevention. METHODS A decree ensured the use of software to manage consultations in CeGIDDs and to transfer surveillance data. A webservice was implemented to secure data transfer from CeGIDDs’ softwares to a centralized database. CeGIDDs can also transfer data in CSV format via a secured data-sharing platform. Then, data are automatically checked before integration. Socio-demographic variables, sexual exposure, blood exposure, symptoms, STI tests, STI diagnoses and sexual health services delivery were collected for the previous year (n-1). Preliminary and descriptive analyses of 2017-2018 data, respectively transmitted in 2018 and 2019, were performed using numbers and proportions for qualitative variables. RESULTS In 2017, 54 (out of 320 , i.e. 17%) of CeGIDD transmitted their data. In 2018, this number of participants increased to 143 (45%) CeGIDDs. Corresponding volume of records increased from 2,414 in 2017 to 382,890 in 2018. In 2018, majority of attendances were hospital based (69%, n= 263,480). Considering the growing volume of information, an advisory committee was set up to guide the construction of algorithms enabling accurate data management and analyses. CONCLUSIONS The automated surveillance SurCeGID is functional despites challenges hampering its expansion. The effectiveness of surveillances using routinely collected records, demonstrated through the monitoring of Covid-19 pandemic, might help to better guide and evaluate STI prevention and services delivery.

Background Viral and bacterial sexually transmitted infections (STIs) are public health concerns worldwide, but surveillance systems are not comprehensive enough to design and monitor accurately STI control strategies in most countries. In 2016, 320 STI clinics (CeGIDDs in French) were implemented in France, primarily targeting most exposed populations, although access is free of charge for anybody. Objective This article describes the mandatory surveillance system (SurCeGIDD) based on CeGIDD’s individual data aiming to better guide STI prevention. Methods A decree ensured the use of software to manage consultations in CeGIDDs and to transfer surveillance data. A web service was implemented to secure data transfer from CeGIDDs’ software to a centralized database. CeGIDDs can also transfer data in CSV format via a secured data-sharing platform. Then, data are automatically checked before integration. Data on sociodemographic variables, sexual exposure, blood exposure, symptoms, STI tests, STI diagnoses, and sexual health services delivery were collected for the previous year (n–1). Preliminary and descriptive analyses of 2017-2018 data transmitted in 2018 and 2019, respectively, were performed using numbers and proportions for qualitative variables. Results In 2017, 54/320 (16.9%) CeGIDDs transmitted their data. In 2018, this number of participants increased to 143/320 (44.7%) CeGIDDs. The corresponding volume of records increased from 2414 in 2017 to 382,890 in 2018. In 2018, most attendances were hospital based (263,480/382,890, 68.81%). In 2018, attendees were mostly men 227,326/379,921 (59.84%), while 151,963/379,921 (40%) were women 632/379,921 (0.17%) transgenders. The median age was 27 years for men, 23 years for women, and 30 years for transgender. Half of the attendees (81,964/174,932, 46.85%) were heterosexual men, 69,016/174,932 (39.45%) heterosexual women, 20,764/174,932 (11.87%) men who have sex with men, and 3188/174,932 (1.82%) women who have sex with women. A majority of them were born in France (227,698/286,289, 79.53%) and unemployed 115,913/211,707 (54.75%). The positivity rates were 0.37% for 205,348 HIV serologies, 1.31% for 131,551 hepatitis B virus serologies, 7.16% for 161,241 Chlamydia trachomatis PCR, 2.83% for 146,649 gonorrhea PCR, 1.04% for the syphilis combination of treponema and nontreponema serologies, and 5.96% for 13,313 Mycoplasma genitalium PCR. Conclusions Despite challenges, the effectiveness of the SurCeGIDD surveillance based on routine patients’ records was demonstrated. The wide range of information, including socioeconomic determinants, might help to better guide and evaluate the prevention policies and services delivery. However, the growing volumes of information will require adapted tools and algorithms for the data management and analyses.

BACKGROUND Despite high levels of screening for HIV and hepatitis B (HBV) and C (HCV) viruses in France, many people remain undiagnosed. OBJECTIVE In this context, the French national public health agency tested HBV, HCV, and HIV screening in the general population based on home self-collected blood samples on dried blood spot (DBS). METHODS Participants were recruited between January and August 2016 among the interviewees of the 2016-Health Barometer survey who were offered a self-sampling kit at home for free HIV, HBV and HCV screening. (RR1-10.2196/9797) RESULTS The kit was accepted by 73.7% of participants and was returned to the laboratory by half of them. The overall participation rate was 37.3%, with no difference between gender. The factors associated with kit acceptance for both men and women were the place of residence, potential situations of exposure to HIV or HBV and HCV, and opinions about HIV screening. For women, a specific effect of perceived level of income and recent prevention behavior were also associated with kit acceptance. A better return of the DBS to the laboratory was associated with an age over 30yo, being born in France mainland, and a high perceived income for both men and women. For men, however, not knowing their HBV vaccination status was associated with a lower return rate. Nearly 99% of the blood samples could be tested for the three infections. CONCLUSIONS These results demonstrate the high acceptability and feasibility of HBV, HCV, and HIV screening at home using a self-sampling kit with DBS. This solution could be an alternative to other screening methods with unequal access across the country.

International audience; Background : In the last decade, European cities saw the development of “slamming,” a practice related to chemsex that combines three elements: a sexual context, psychostimulant drug use, and injection practices. Epidemiological data on this practice is still sparse and media attention might have unintentionally distorted the size of this phenomenon. Therefore, we Aim :ed to estimate the prevalence of men practicing slam and to identify factors associated with this practice. Methods We used data from the Prevagay 2015 bio-behavioral survey to estimate the prevalence of slamming practices. A time-location sampling was performed among gay-labeled venues in five French cites. Behavioral information was recorded using a self-administered questionnaire. The HIV and HCV serostatus were investigated using ELISA tests on dried blood spots. The factors associated with slamming were assessed using a multiple logistic regression. We applied a weighting mechanism to enhance the generalizability of the estimates. Results Among the 2646 men who have sex with men (MSM) included in our study, 3.1% reported slamming at least once during their lifetime (95% confidence interval (CI) = 2.2–4.3) and 1.6% (95% CI = 1–2.3) said they participated in a slamming session in the last 12 months. In the multivariate analysis, both HCV and HIV biological status were strongly associated with practicing “slam” in the last 12 months (OR = 13.37 (95% CI = 3.26–54.81) and 4.73 (95% CI = 1.58–14.44), respectively). Furthermore, a ten-point decrease in mental health scores was linked with the practice with an OR of 1.37 (95% CI = 1.08–1.73), indicating poorer mental health. Conclusion Even though slamming seems to involve a relatively small proportion of MSM, the vulnerability of this sub-group is high enough to justify setting up harm reduction measures and specific care. Training health professionals and creating services combining sexual health and drug dependence could be an effective response.

Sex between men is the most frequent mode of HIV transmission in industrialised countries. Monitoring risk behaviours among men who have sex with men (MSM) is crucial, especially to understand the drivers of the epidemic. A cross-sectional survey (PREVAGAY), based on time-location sampling, was conducted in 2015 among MSM attending gay venues in 5 metropolitan cities in France. We applied the generalised weight share method (GWSM) to estimate HIV seroprevalence for the first time in this population, taking into account the frequency of venue attendance (FVA). Our objectives were to describe the implementation of the sampling design and to demonstrate the importance of taking into account sampling weights, including FVA by comparing results obtained by GWSM and by other methods which use sample weights not including FVA or no weight. We found a global prevalence of 14.3% (95% CI (12.0–16.9)) using GWSM and an unweighted prevalence of 16.4% (95% CI (14.9–17.8)). Variance in HIV prevalence estimates in each city was lower when we did not take into account either the sampling weights or the FVA. We also highlighted an association of FVA and serological status in the most of investigated cities.

Background Blood donation deferral for men who have sex with men (MSM) in France was reduced from permanent to 12 months in July 2016. To inform a further reduction of the deferral period, an HIV risk assessment was conducted with two scenarios: S1, 4-month deferral; S2, 4-month deferral only in the case of more than one sexual partner (i.e., similar to other blood donors). Methods Baseline HIV residual risk (RR) was calculated from July 2016 to December 2017, using the Incidence Rate-Window Period method. The impact of both scenarios on RR was assessed using data from surveys on MSM and blood donors, to estimate 1) the number of additional MSM expected to donate in each scenario and 2) HIV incidence among these donors. Results Baseline HIV RR was estimated at 1 in 6,380,000 donations. For S1, an additional 733 MSM donors, and an additional 0.09 HIV-positive donations were estimated, yielding an unchanged RR of 1 in 6,300,000. For S2, these numbers were estimated at 3102 and 3.92, respectively, yielding an RR of 1 in 4,300,000. Sensitivity analyses showed that, under worst-case assumptions, the RR would equal 1 in 6,225,000 donations for S1 and 1 in 3,000,000 for S2. Conclusion For both scenarios, the HIV RR remains very low. For S1, the risk is identical to the baseline RR. For S2, it is 1.5 times higher, and sensitivity analysis shows that this estimate is less robust than for S1. The French Minister of Health announced that S1 will be implemented in April 2020.

Background The advent of effective direct-acting antivirals (DAAs), has prompted an assessment of the French Hepatitis C virus (HCV) screening strategy, which historically targeted high-risk groups. One of the options put forward is the implementation of combined (i.e., simultaneous) HCV, Hepatitis B virus (HBV) and HIV screening for all adults at least once during their lifetime (“universal combined screening”). However, recent national survey-based data are lacking to guide decision-making regarding which new strategy to implement. Accordingly, we aimed to provide updated data for both chronic hepatitis C (CHC) and B (CHB) prevalence and for HCV and HBV screening history, using data from the BaroTest and 2016 Health Barometer (2016-HB) studies, respectively. Methods 2016-HB was a national cross-sectional phone based health survey conducted in 2016 among 20,032 randomly selected individuals from the general population in mainland France. BaroTest was a virological sub-study nested in 2016-HB. Data collected for BaroTest were based on home blood self-sampling on dried blood spots (DBS). Results From 6945 analyzed DBS, chronic hepatitis C (CHC) and B (CHB) prevalence was estimated at 0.30% (95% Confidence Interval (CI): 0.13-0.70) and 0.30% (95% CI: 0.13-0.70), respectively. The proportion of individuals aware of their status was estimated at 80.6% (95% CI: 44.2-95.6) for CHC and 17.5% (95% CI: 4.9-46.4) for CHB. Universal combined screening would involve testing between 32.6 and 85.3% of 15-75 year olds according to whether we consider only individuals not previously tested for any of the three viruses, or also those already tested for one or two of the viruses. Conclusions Our data are essential to guide decision-making regarding which new HCV screening recommendation to implement in France. They also highlight that efforts are still needed to achieve the WHO’s targets for eliminating these diseases. Home blood self-sampling may prove to be a useful tool for screening and epidemiological studies.

Background Universal antenatal HIV screening programmes are an effective method of preventing mother-to-child transmission. Aims To assess the coverage and yield of the French programme on a nationally representative sample of pregnant women, and predictive factors for being unscreened or missing information on the performance/ result of a HIV test. Methods Data came from the medical records of women included in the cross-sectional 2016 French National Perinatal Survey. We calculated odds ratios (OR) to identify factors for being unscreened for HIV and for missing information by multivariable analyses. Results Of 13,210 women, 12,782 (96.8%) were screened for HIV and 134 (1.0%) were not; information was missing for 294 (2.2%). HIV infection was newly diagnosed in 19/12,769 (0.15%) women screened. The OR for being unscreened was significantly higher in women in legally registered partnerships (OR: 1.3; 95% CI: 1.1–1.6), with 1–2 years of post-secondary schooling (OR: 1.6; 95% CI: 1.2–2.1), part-time employment (OR: 1.4; 95% CI: 1.1–1.8), inadequate antenatal care (OR: 1.9; 95% CI: 1.5–2.4) and receiving care from > 1 provider (OR: 1.8; 95% CI: 1.1–2.8). The OR of missing information was higher in multiparous women (OR: 1.4; 95% CI: 1.2–1.5) and women cared for by general practitioners (OR: 1.4; 95% CI: 1.1–1.9). Conclusions The French antenatal HIV screening programme is effective in detecting HIV among pregnant women. However, a few women are still not screened and awareness of the factors that predict this could contribute to improved screening levels.

Diagnoses of bacterial sexually transmitted infections (STI) have been increasing in France since their resurgence in the late 1990s. This article presents recent epidemiological trends until 2016 and the patients’ characteristics. STI surveillance relies on sentinel networks: a clinician-based network RésIST (clinical, biological and behavioural data for early syphilis and gonorrhoea), the lymphogranuloma venereum (LGV) network (clinical, biological and behavioural data for rectal LGV, and the laboratory networks Rénachla and Rénago (demographic and biological data for chlamydial infections and gonorrhoea, respectively). Here we describe trends between 2014 and 2016, using data from diagnostic centres which participated regularly during the study period. The number of early syphilis, gonorrhoea and LGV diagnoses increased between 2014 and 2016, particularly in men who have sex with men. An increase in syphilis and gonorrhoea cases was also observed in heterosexuals. Nevertheless, we observed a drop in 2016 for syphilis and chlamydial infections after two decades of increases. Under-reporting and shortage of benzathine penicillin in 2016 may explain this latest evolution. Regular screening of patients and partners, followed by prompt treatment, remains essential to interrupt STI transmission in a context where human immunodeficiency virus (HIV) prevention has expanded towards biomedical prophylaxis.

International audience; BACKGROUND:In a context of increasing use of Nucleic Acid Amplification Test, diagnoses of Neisseria gonorrhoeae and Chlamydia trachomatis infections among men increased in Europe and USA since 2007. We aimed to describe trends in the incidence of male urethritis in France between 2007 and 2017.METHODS:We analysed male urethritis clinical cases reported by the French GPs' Sentinelles network.RESULTS:GPs reported 1944 cases of male urethritis during the study period. The estimated annual incidence rates in men aged 15 years and older remained stable between 226 cases per 100,000 seen in 2007 and 196 in 2017 (P value = 0.9). A third-generation cephalosporin with macrolide or tetracycline was prescribed in 17.5% of cases in 2009 (27/154) and 32.4% in 2017 (47/145) (P value = 0.0327).CONCLUSIONS:The incidence rates for adult male urethritis diagnosed in primary care have remained stable since 2007 in France in contrast with the increasing trend of Neisseria gonorrhoeae and Chlamydia trachomatis infections based on microbiological surveillance. Using stable clinical definition for male urethritis seems essential to follow correctly epidemiological dynamic.

We report a multidrug-resistant Neisseria gonorrhoeae urogenital and pharyngeal infection with ceftriaxone resistance and intermediate resistance to azithromycin in a heterosexual woman in her 20s in France. Treatment with ceftriaxone plus doxycycline failed for the pharyngeal localisation. Whole-genome sequencing of isolate F90 identified MLST1903, NG-MAST ST3435, NG-STAR233, and relevant resistance determinants. F90 showed phenotypic and genotypic similarities to an internationally spreading multidrug-resistant and ceftriaxone-resistant clone detected in Japan and subsequently in Australia, Canada and Denmark.

UNSTRUCTURED Background. Despite substantial screening for HIV, Hepatitis B virus (HBV) and Hepatitis C virus (HCV) infections in France, a great number of infected persons remain undiagnosed. In this context, Santé publique France experimented with a new screening approach for HBV, HCV, and HIV infection, based on home self-sampling using dried blood spot (DBS) for blood collection. The objectives of the BaroTest study were to assess the acceptability and feasibility of this approach and to update the prevalence estimates of HBV, HCV, and HIV infections in the general population. Methods/design. Participants were enrolled using the 2016 Health Barometer, a national cross-sectional telephone survey based on a large representative sample of the general population aged 15 to 75 years (N=15000). Upon completion of the questionnaire, eligible persons were invited to receive a self-sampling kit delivered by standard postal mail and to return the DBS card to the laboratory. The laboratory then was responsible for reporting the results to the study participant. Acceptability of the protocol was based on the percentage of eligible individuals agreeing to receive the self-sampling kit, on the proportion of people returning the DBS card and, finally, on the proportion of participants out of the total eligible population. The feasibility of the approach was based on the number of participants with adequately filled blood spots and the number of participants with blood spots for which at least one virological analysis could be performed. A complex system of reminders was implemented to increase the participation rate. Accordingly, we assumed that 35% of eligible persons would accept and return their DBS card, representing approximately 5,000 individuals. Since the highest expected prevalence was for HBV infection, estimated at 0.65% in 2004, 5,000 persons would make it possible to estimate this prevalence with an accuracy of approximately 0.22%. All indicators can be analysed according to the characteristics of the participants collected in the Health Barometer questionnaire. Discussion. The BaroTest results will help to inform new strategies for HIV, hepatitis B and C screening and - if the study’s acceptability and feasibility results prove conclusive – will encourage the expansion of the current screening offer to include home self-sampling. BaroTest was linked to a randomised telephone survey, which uses a complex call protocol to increase the likelihood of interviewing hard-to-reach individuals and to achieve a high response rate. The Health Barometer provides a reliable updated assessment of the burden of HBV, HCV and HIV infections in the general population in France, while reducing the costs typically associated with this type of research. Trial registration. BaroTest was approved by the French Ethics Committee (05/11/2015) and the Commission on Information Technology and Liberties (24/12/2015). The study has been registered by the French medical authority under number 2015-A01252-47 on 10/11/2015.

Complidon avait pour objectif d’evaluer le non-respect des criteres de selection au don de sang, suite a la modification des criteres en juillet 2016. Complidon a interroge, via Internet, les donneurs de sang (DS) ayant fait un don entre septembre et decembre 2017. Au total, 108 386 questionnaires ont pu etre analyses, permettant d’estimer que 5,6 % des DS auraient du etre ajournes lors de leur dernier don, car presentant au moins une contre-indication (CI) parmi celles interrogees dans l’etude. Les CI les moins respectees etaient le multipartenariat du donneur (1,9 %) et de son partenaire (1,0 %) au cours des 4 mois precedant le don, celles liees aux voyages (1,2 %) et les rapports sexuels entre hommes dans l’annee (0,73 % des hommes). Globalement, les raisons les plus citees pour justifier le non-respect des CI etaient le fait d’en avoir parle lors de l’entretien pre-don et d’avoir ete autorise a donner (49 %), de l’avoir mentionne dans le questionnaire pre-don sans que la question soit re-abordee dans l’entretien (15 %), puis la volonte de ne pas etre exclu du don (11 %). Cependant, ces pourcentages variaient beaucoup selon les CI : les 2 premieres raisons concernaient en majorite les CI relatives aux voyages, alors que ne pas vouloir etre exclu concernait surtout les CI liees a la sexualite. Pour ces dernieres, 34 % des DS justifiaient leur non-respect par l’usage systematique du preservatif. L’etude montre que les CI au don ne sont pas totalement respectees. Cependant, pres de la moitie des repondants declarant une CI dans Complidon en ont parle lors de l’entretien pre-don et ont ete autorises a donner, ce qui suggere que ces DS sont a moindre risque que les candidats ajournes.

Introduction Dans le contexte du projet d’elimination de l’hepatite C en France d’ici 2025, la strategie de depistage de l’hepatite C est actuellement reevaluee par la Haute autorite de sante. L’une des options envisagees consisterait en un depistage combine des virus des hepatites C (VHC) et B (VHB) et du VIH au moins une fois au cours de la vie pour l’ensemble des adultes (« depistage universel et combine ») en complement du depistage cible sur les personnes a risque eleve d’exposition. Notre objectif etait de fournir des donnees nationales recentes sur la prevalence et le depistage des hepatites chroniques C (HCC) et B (HCB) afin de contribuer a l’elaboration de cette nouvelle recommandation. Materiels et methodes Le Barometre sante (BS) est une enquete telephonique, realisee en 2016, aupres d’un echantillon aleatoire de 20 032 personnes âgees de 15–75 ans en population generale metropolitaine. Elle recueillait les expositions a risque vis-a-vis du VHC et du VHB, les antecedents de depistage du VHC, VHB et VIH au cours de la vie et le resultat du dernier test. Une etude virologique (BaroTest) sur le VHC et le VHB, basee sur un auto-prelevement sanguin a domicile depose sur buvard, a ete mise en place aupres des participants eligibles (≥ 18 ans avec une couverture sociale) du BS. La detection des anticorps (Ac) anti-VHC et de l’AgHBs et, en cas d’Ac anti-VHC positifs, la recherche de l’ARN VHC ont ete realisees a partir du sang total depose sur buvard. Resultats Parmi les 17 781 personnes eligibles a BaroTest, 6 945 (39,1 %) ont renvoye un buvard. La prevalence en population generale metropolitaine de 18–75 ans a ete estimee pour l’HCC a 0,30 % (IC95 % : 0,13–0,70), soit 133 466 personnes (IC95 % : 56 880–312 616) et pour l’HCB a 0,30 % (IC95 % : 0,13–0,70), soit 135 706 personnes (IC95 % : 58 224–313 960). Parmi elles, 80,6 % (IC95 % : 44,2–95,6) connaissaient leur statut pour l’HCC et 17,5 % (IC95 % : 4,9–46,4) pour l’HCB. Parmi les participants au BS 2016 âges de 15–75 ans, respectivement 19,2 % (IC95 % : 18,6–19,9), 35,6 % (IC95 % : 34,8–36,5) et 57,8 % (IC95 % : 56,9–58,7) rapportaient avoir ete depistes au moins une fois au cours de la vie pour le VHC, le VHB et le VIH. L’option de depistage universel et combine du VHC, du VHB et du VIH impliquerait de tester 32,6 % a 85,3 % de la population âgee de 15–75 ans, selon que l’on considere uniquement les individus non testes pour les trois virus ou egalement ceux testes pour un ou deux de ces virus. Conclusion Ces resultats, utiles pour guider la nouvelle strategie de depistage de l’hepatite C, soulignent egalement que des efforts importants sont encore necessaires pour atteindre les objectifs d’elimination des hepatites C et B.

Exposure prevention is the primary strategy to reduce the risk of occupational bloodborne pathogen infections in healthcare workers (HCW). HCWs should be made aware of the medicolegal and clinical relevance of reporting an exposure, and have ready access to expert consultants to receive appropriate counselling, treatment and follow-up. Vaccination against hepatitis B virus (HBV), and demonstration of immunisation before employment are strongly recommended. HCWs with postvaccinal anti-HBs levels, 1-2 months after vaccine completion, >10 mIU/mL are considered as responders. Responders are protected against HBV infection: booster doses of vaccine or periodic antibody concentration testing are not recommended. Alternative strategies to overcome non-response should be adopted. Isolated anti-HBc positive HCWs should be tested for anti-HBc IgM and HBV-DNA: if negative, anti-HBs response to vaccination can distinguish between infection (anti-HBs >50 mUI/ml 30 days after 1st vaccination: anamnestic response) and false positive results(anti-HBs >10 mUI/ml 30 days after 3rd vaccination: primary response); true positive subjects have resistance to re-infection. and do not need vaccination The management of an occupational exposure to HBV differs according to the susceptibility of the exposed HCW and the serostatus of the source. When indicated, post-exposure prophylaxis with HBV vaccine, hepatitis B immunoglobulin or both must be started as soon as possible (within 1-7 days). In the absence of prophylaxis against hepatitis C virus (HCV) infection, follow-up management of HCV exposures depends on whether antiviral treatment during the acute phase is chosen. Test the HCW for HCV-Ab at baseline and after 6 months; up to 12 for HIV-HCV co-infected sources. If treatment is recommended, perform ALT (amino alanine transferase) activity at baseline and monthly for 4 months after exposure, and qualitative HCV-RNA when an increase is detected.

EU/EEA HIV Surveillance Network: Daniela Schmid, André Sasse, Dominique Van Beckhoven, Tonka Varleva, Tatjana Nemeth Blazic, Linos Hadjihannas, Maria Koliou, Marek Maly, Susan Cowan, Kristi Rüütel, Kirsi Liitsola, Mika Salminen, Françoise Cazein, Josiane Pillonel, Florence Lot, Barbara Gunsenheimer-Bartmeyer, Stavros Patrinos, Dimitra Paraskeva, Maria Dudas, Haraldur Briem, Gudrun Sigmundsdottir, Derval Igoe, Kate O'Donnell, Darina O'Flanagan, Barbara Suligoi, Šarlote Konova, Sabine Erne, Irma Caplinskiene, Aurélie Fischer, Jackie Maistre Melillo, Tanya Melillo, Eline Op de Coul, Hans Blystad, Magdalena Rosinska, Isabel Aldir, Helena Cortes Martins, Mariana Mardarescu, Peter Truska, Irena Klavs, Asunción Díaz, Maria Axelsson, Valerie Delpech Helena Cortes Martins: Departamento de Doenças Infeciosas do Instituto Nacional de Saúde Doutor Ricardo Jorge. Background: The HIV burden is increasing in older adults in the European Union (EU) and European Economic Area (EEA). We investigated factors associated with HIV diagnosis in older adults in the 31 EU/EEA countries during a 12 year period. Methods: In this analysis of surveillance data, we compared data from older people (aged ≥50 years) with those from younger people (aged 15–49 years). We extracted new HIV diagnoses reported to the European Surveillance System between Jan 1, 2004, and Dec 31, 2015, and stratified them by age, sex, migration status, transmission route, and CD4 cell count. We defined late diagnosis as CD4 count of less than 350 cells per μL at diagnosis and diagnosis with advanced HIV disease as less than 200 cells per μL. We compared the two age groups with the χ² test for difference, and used linear regression analysis to assess temporal trends. Findings: During the study period 54 102 new HIV diagnoses were reported in older adults. The average notification rate of new diagnoses was 2·6 per 100 000 population across the whole 12 year period, which significantly increased over time (annual average change [AAC] 2·1%, 95% CI 1·1–3·1; p=0·0009). Notification rates for new HIV diagnoses in older adults increased significantly in 16 countries in 2004–15, clustering in central and eastern EU/EEA countries. In 2015, compared with younger adults, older individuals were more likely to originate from the reporting country, to have acquired HIV via heterosexual contact, and to present late (p

Author(s): Brand, Denys; Capsec, Jean; Chaillon, Antoine; Cazein, Francoise; Le Vu, Stephane; Moreau, Alain; Pillonel, Josiane; Brunet, Sylvie; Thierry, Damien; Guillon-Grammatico, Leslie; Lot, Florence; Barin, Francis | Abstract: BackgroundTransmitted/founder viruses isolated at the early stage of infection are indicators of the variants that are spreading within a population. The French reporting system for new HIV diagnoses is linked to a virological surveillance using dried serum spots.MethodsWe combined an immunoassay for very recent infection (less than 31 days) to a phylogenetic analysis of transmitted/founder viruses and sociodemographic information to analyze the dynamics of the HIV-1 epidemic during a 3-year period. Bayesian coalescent-based methods were used to explore the temporal and spatial dynamics of the identified clusters.ResultsOf 17 010 dried serum spots collected, 549 very recent infections were identified for which both env sequences and sociodemographic data were available. Non-B transmitted/founder viruses were found in 196 cases (35.7%), belonging to six subtypes and seven circulating recombinant forms. Forty-three dyads/clusters were identified (range 2-11 cases), including 107 individuals (19.5%), mainly MSM. The largest cluster involved MSM infected by a CRF02_AG variant. Reconstruction of viral migrations across time suggests that Paris was the major hub of dissemination.ConclusionThe study shows the feasibility of the surveillance of the HIV epidemic using this methodology. The observation of actively growing spatiotemporal clusters allows identification of specific networks that may be targets for intervention.

The presence of HIV-1 non-B subtypes in Western Europe is commonly attributed to migration of individuals from non-European countries, but the possible role of domestic infections with non-B subtypes is not well investigated. The French mandatory anonymous reporting system for HIV is linked to a virological surveillance using assays for recent infection (env region, followed by phylogenetic analysis and search for transmission clusters. Two hundred thirty-three recent HIV-1 infections with non-B variants were identified. They involved 5 subtypes and 7 circulating recombinant forms (CRFs). Ninety-two cases (39.5%) were due to heterosexual transmissions, of which 39 occurred in patients born in France. Eighty-five cases (36.5%) were identified in men having sex with men (MSM). Forty-three recent non-B infections (18.5%) segregated into 14 clusters, MSM being involved in 11 of them. Clustered transmission events included 2 to 7 cases per cluster. The largest cluster involved MSM infected by a CRF02_AG variant. In conclusion, we found that the spread of non-B subtypes in France occurs in individuals of French origin and that MSM are particularly involved in this dynamic.

Depuis juillet 2016, les HSH sont autorises a donner du sang total s’ils n’ont pas eu de rapports sexuels entre hommes au cours des 12 mois precedant le don. Cette modification n’ayant pas eu d’impact sur le risque residuel (RR) VIH, une ouverture plus large du don de sang aux HSH est envisagee. Deux scenarios sont etudies : S1. ajournement si rapports sexuels entre hommes dans les 4 derniers mois ; S2. ajournement si multipartenariat dans les 4 derniers mois. Le RR VIH de reference a ete estime a 1 pour 6 380 000 dons sur la periode juillet 2016-decembre 2017. Le RR VIH pour chacun des scenarios est base sur l’estimation du nombre de donneurs HSH supplementaires a partir de 3 enquetes (Barometre Sante 2016, Enquete Rapport au Sexe 2017 et Complidon 2017) et sur l’incidence du VIH parmi ces donneurs. Dans S1, l’incidence est celle estimee chez les donneurs HSH avec le critere actuel (ajournement 12 mois). Dans S2, elle est obtenue a partir de l’estimation de l’incidence du VIH chez les HSH monopartenaires en population generale. Dans S1, le RR VIH est estime a 1 pour 6 300 000 dons et l’analyse de sensibilite montre que cette estimation est robuste aux variations des parametres du modele. Dans S2, il est estime a 1 pour 4 300 000 dons, soit 1,5 fois le RR de reference, mais cette estimation est moins robuste puisque le RR maximum serait de 1 pour 3 000 000 dons, 2 fois superieur au RR de reference. Base sur ce type d’analyse de risque, l’Australie et le Canada envisagent un ajournement des HSH de 3 mois et le Royaume-Uni est passe a 3 mois d’ajournement fin 2017. La France devrait prendre une decision sur le choix de l’un des deux scenarios etudies au cours de l’annee 2019.

Depuis juillet 2016, les HSH sont autorises a donner du sang total s’ils n’ont pas eu de rapports sexuels entre hommes au cours des 12 mois precedents. Cette modification s’est accompagnee d’un suivi renforce incluant, en complement de la surveillance epidemiologique des donneurs, une enquete aupres des donneurs de sang (Complidon), afin de mesurer leur adhesion aux nouveaux criteres de selection. Complidon a permis d’estimer que 0,73 % des hommes ayant donne leur sang entre le 10/7/2016 et le 31/12/2017, avaient eu des rapports sexuels entre hommes au cours des 12 mois precedant le don. Les facteurs associes a ce non-respect etaient d’avoir moins de 30 ans, d’avoir eu plus d’un partenaire sexuel dans les 12 derniers mois, d’avoir oublie ou dissimule des informations lors de l’entretien pre-don, de connaitre les contre-indications au don, de travailler dans le domaine de la sante et d’avoir trouve le questionnaire et l’entretien pre-don insuffisamment confidentiels. Malgre ce taux de non-respect au critere HSH 12 mois, l’ouverture du don de sang aux HSH n’a pas eu d’impact, ni sur les taux de dons VIH positifs (0,08 p. 10 000 dons du 1/1/2015 au 9/7/2017 vs. 0,07 du 10/7/2016 au 31/12/2017), ni sur la part des HSH parmi les donneurs VIH positifs (environ 50 % des hommes sur les 2 periodes), ni sur le risque residuel de transmission du VIH par transfusion (1/4 300 000 dons vs. 1/6 400 000 dons). Ces resultats permettent d’envisager une ouverture plus large du don de sang aux HSH. Deux scenarios sont actuellement a l’etude : ajournement en cas de rapports sexuels entre hommes dans les 4 derniers mois ou ajournement si plus d’un partenaire sexuel dans les 4 derniers mois.

L’enquete COMPLIDON a pour objectif principal d’estimer la proportion de non-respect des criteres d’ajournement au don du sang entres en vigueur le 10 juillet 2016 et de mettre en evidence des facteurs associes a ce non-respect. Notamment, depuis cette date, les hommes ayant eu des relations sexuelles avec des hommes (HSH) peuvent, sous certaines conditions, donner leur sang. Cette enquete a ete realisee via Internet, aupres des donneurs ayant fait un don de septembre a decembre 2017. Parmi les 108 386 questionnaires complets, 3,6 % des donneurs ont declare au moins un critere d’ajournement lie au risque de transmission d’un agent infectieux par voie sexuelle, usage de drogues ou tatouage/piercing. Les situations les plus declarees etaient le multipartenariat (1,9 %) et le fait d’avoir eu un partenaire multipartenaire (1,0 %) au cours des 4 mois precedant le don, ainsi que, pour les hommes ayant fait un don de sang total, d’avoir eu un partenaire sexuel masculin dans l’annee (0,73 %). L’analyse multivariee montre que les facteurs associes au critere HSH 12 mois etaient le fait d’etre jeune, d’avoir eu plus d’un partenaire sexuel dans les 12 derniers mois, d’avoir oublie ou dissimule des informations lors de l’entretien pre-don, d’avoir connaissance des contre-indications, de travailler dans le domaine de la sante et d’avoir trouve le questionnaire et l’entretien pre-don insuffisamment confidentiels. Enfin, les motifs d’ajournement lies aux voyages concernaient 1,2 % des donneurs, les antecedents de transfusion 0,69 % et les antecedents de cancer gueri 0,26 % des donneurs. Bien que le taux de dons malgre un critere d’ajournement HSH 12 mois soit eleve, l’ouverture du don de sang aux HSH n’a pas eu d’impact, ni sur la prevalence du VIH, ni sur la part des HSH parmi les donneurs trouves VIH positifs, ni sur le risque residuel de transmission du VIH par transfusion. Les donnees de COMPLIDON vont permettre de poursuivre la reflexion sur l’evolution des criteres de selection.

Background Despite substantial screening for HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV) infections in France, a great number of infected persons remain undiagnosed. In this context, Sante publique France experimented with a new screening approach for HBV, HCV, and HIV infection, based on home self-sampling using dried blood spot (DBS) for blood collection. Objective The objectives of the BaroTest study were to assess the acceptability and feasibility of this approach and to update the prevalence estimates of HBV, HCV, and HIV infections in the general population. Methods Participants were enrolled using the 2016 Health Barometer, a national cross-sectional telephone survey based on a large representative sample of the general population aged 15 to 75 years (N=15,000). Upon completion of the questionnaire, any participant in the Health Barometer aged 18 to 75 years, having medical health insurance, and not under guardianship was invited to receive a self-sampling kit delivered by standard postal mail and to return the DBS card to the laboratory. The laboratory was then responsible for reporting the results to the participants. Acceptability of the protocol was based on the percentage of eligible individuals agreeing to receive the self-sampling kit, on the proportion of people returning the DBS card, and on the proportion of participants out of the total eligible population. The feasibility of the approach was based on the number of participants with adequately filled blood spots and the number of participants with blood spots for which at least one virological analysis could be performed. A complex system of reminders was implemented to increase the participation rate. Accordingly, we assumed that 35.00% (4900/14,000) of eligible persons would accept and return their DBS card. As the highest expected prevalence was for HBV infection, estimated at 0.65% in 2004, 5000 persons would make it possible to estimate this prevalence with an accuracy of approximately 0.22%. All indicators can be analyzed according to the characteristics of the participants collected in the Health Barometer questionnaire. BaroTest was approved by the French Ethics Committee (November 11, 2015) and the Commission on Information Technology and Liberties (December 24, 2015). The study has been registered by the French medical authority under number 2015-A01252-47 on November 10, 2015. Results The results on acceptability and feasibility are expected in the last quarter of 2018 and those on the prevalence estimates in the first semester of 2019. Conclusions The BaroTest results will help to inform new strategies for HIV, HBV, and HCV screening, and the Health Barometer provides a reliable updated assessment of the burden of HBV, HCV, and HIV infections in the general population in France while reducing the costs typically associated with this type of research. Registered report identifier RR1-10.2196/9797.

Introduction In France, surveillance of early syphilis (primary, secondary and early latent) relies on the clinician-based ResIST sentinel network. Although ResIST enables the monitoring of trends, an insight of the complete picture of the syphilis epidemic is not possible. More specifically, cases reported by this network are mostly diagnosed in free STI clinics and hospitals (respectively, 75% and 24%). This study aims to estimate the number and rate of diagnoses made outside these health facilities by exploring health insurance data. Methods An algorithm combining healthcare reimbursements for specific diagnostic tests and recommended treatment was fitted to identify syphilis cases. Sensitivity analyses were used to validate the algorithm. Age and gender standardized diagnosis rates were estimated using census data. The study period was restricted to three years, from January 2011 to December 2013, before the stock depletion of benzathine penicillin G (BPG) in 2014 and 2015. Results Between 2011 and 2013, 12,644 (7.5 cases per 100,000 inhabitants) reimbursements were made for syphilis-related diagnoses. The annual number of cases increased by 22% from 2011 (n = 3771, rate = 6.7/100,000) to 2013 (n = 4589, rate = 8.2/100,000). The rate of syphilis diagnosis increased in men from 12.9/100 000 to 16.0/100,000, while it remained steady in women at approximately 1.8/100,000. The disease burden was greatest in French overseas territories (18.1/100,000) and in the Paris area (11.7 cases/100,000). Conclusion Despite the lack of data on the number of confirmed diagnoses and information about sexual behaviour, these findings demonstrate the relevance of analysing insurance data to help monitor the syphilis epidemic in patients who visit general practitioners and non-hospital-based specialists. With BPG availability, annual rate could be estimated again to carry on epidemiological dynamic analysis and guide prevention actions.