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BackgroundAnorectal infections with Chlamydia trachomatis (CT) are common in women visiting STI outpatient clinics. We here evaluated the risk posed by sexual exposure and by alternate anatomical site infection for incident anorectal and urogenital CT.MethodsProspective multicentre cohort study, FemCure. Participants were treated for CT, and after 4, 6, 8, 10 and 12 weeks, they self-collected anorectal and urogenital samples (swabs) for CT-DNA testing. We calculated the proportion with incident CT, that is, CT incidence (at weeks 6–12) by 2-week time-periods. Compared with no exposure (A), we estimated the risk of incident CT for (B) sexual exposure, (C) alternate site anatomic site infection and (D) both, adjusted for confounders and expressed as adjusted ORs with 95% CIs.ResultsWe analysed data of 385 participants contributing 1540 2-week periods. The anorectal CT incidence was 2.9% (39/1343) (95 CI 1.8 to 3.6); 1.3% (A), 1.3% (B), 27.8% (C) and 36.7% (D). The ORs were: 0.91 (95% CI 0.32 to 2.60) (B), 26.0 (95% CI 7.16 to 94.34) (C), 44.26 (95% CI 14.38 to 136.21) (D).The urogenital CT incidence was 3.3% (47/1428) (95% CI 2.4 to 4.4); 0.7% (A), 1.9% (B), 13.9% (C) and 25.4% (D). The ORs were: 2.73 (95% CI 0.87 to 8.61) (B), 21.77 (95% CI 6.70 to 70 71) (C) and 49.66 (95% CI 15.37 to 160.41) (D).ConclusionsAfter initial treatment, an alternate anatomical site CT infection increased the risk for an incident CT in women, especially when also sex was reported. This may suggest a key role for autoinoculation in the re-establishment or persistence of urogenital and anorectal chlamydia infections.

Since May 2022, over 21,000 mpox cases have been reported from 29 EU/EEA countries, predominantly among men who have sex with men (MSM). The Netherlands was the fourth most affected country in Europe, with more than 1,200 cases and a crude notification rate of 70.7 per million population. The first national case was reported on 10 May, yet potential prior transmission remains unknown. Insight into prolonged undetected transmission can help to understand the current outbreak dynamics and aid future public health interventions. We performed a retrospective study and phylogenetic analysis to elucidate whether undetected transmission of human mpox virus (hMPXV) occurred before the first reported cases in Amsterdam and Rotterdam. In 401 anorectal and ulcer samples from visitors to centres for sexual health in Amsterdam or Rotterdam dating back to 14 February 2022, we identified two new cases, the earliest from 6 May. This coincides with the first cases reported in the United Kingdom, Spain and Portugal. We found no evidence of widespread hMPXV transmission in Dutch sexual networks of MSM before May 2022. Likely, the mpox outbreak expanded across Europe within a short period in the spring of 2022 through an international highly intertwined network of sexually active MSM.

Background The central sexual health centre (SHC) in the greater Rotterdam area in the Netherlands helps finding people unaware of their STI/HIV status. We aimed to determine a possible association between SHC utilization and travel distance in this urban and infrastructure-rich area. Insight in area-specific utilization helps adjust outreach policies to enhance STI testing. Methods The study population consists of all residents aged 15–45 years in the greater Rotterdam area (2015–17). We linked SHC consultation data from STI tested heterosexual clients to the population registry. The association between SHC utilization and distance was investigated by multilevel modelling, adjusting for sociodemographic and area-specific determinants. The data were also stratified by age (aged Results We found large area variation in SHC utilization (range: 1.13–48.76 per 1000 residents). Both individual- and area-level determinants determine utilization. Travel distance explained most area variation and was inversely associated with SHC utilization when adjusted for other sociodemographic and area-specific determinants [odds ratio (OR) per kilometre: 0.95; 95% confidence interval (CI): 0.93–0.96]. Similar results were obtained for residents Conclusions Living further away from a central SHC shows a distance decline effect in utilization. We recommend to enhance STI testing by offering STI testing services closer to the population.

ObjectivesThe clinical and public health relevance of widespread case finding by testing for asymptomatic chlamydia infections is under debate. We wanted to explore future directions for chlamydia control and generate insights that might guide for evidence-based strategies. In particular, we wanted to know the extent to which we should pursue testing for asymptomatic infections at both genital and extragenital sites.MethodsWe synthesised findings from published literature and from discussions among national and international chlamydia experts during an invitational workshop. We described changing perceptions in chlamydia control to inform the development of recommendations for future avenues for chlamydia control in the Netherlands.ResultsDespite implementing a range of interventions to control chlamydia, there is no practice-based evidence that population prevalence can be reduced by screening programmes or widespread opportunistic testing. There is limited evidence about the beneficial effect of testing on pelvic inflammatory disease prevention. The risk of tubal factor infertility resulting from chlamydia infection is low and evidence on the preventable fraction remains uncertain. Overdiagnosis and overtreatment with antibiotics for self-limiting and non-viable infections have contributed to antimicrobial resistance in other pathogens and may affect oral, anal and genital microbiota. These changing insights could affect the outcome of previous cost–effectiveness analysis.ConclusionThe balance between benefits and harms of widespread testing to detect asymptomatic chlamydia infections is changing. The opinion of our expert group deviates from the existing paradigm of ‘test and treat’ and suggests that future strategies should reduce, rather than expand, the role of widespread testing for asymptomatic chlamydia infections.

UNSTRUCTURED Contact tracing (CT) is considered one of the most essential strategies for containing the transmission of infectious diseases. The COVID-19 pandemic has revealed that with high infection rates, health services conducting CT can become overburdened, leading to limited or incomplete CT. Existing and future digital CT technologies may help to alleviate the burden on public health professionals (PHPs) and to mitigate the spread of the virus. Various digital contact tracing support tools (DCTS-tools) have been and are being designed to mimic the traditional CT process by facilitating the ability of index cases to collect contact details and notify their contacts themselves. Little is known about the potential effects of these types of tools on CT. Besides saving time for health services, transferring the tasks of CT into the hands of citizens may lead to the recollection of more contacts, more contact details, and speed up the contact notification process. The aim of this paper is to provide a framework that contributes to the comprehensive assessment of DCTS-tools. This framework can provide guidance for other researchers and policymakers in designing their own evaluation studies and in determining the extent to which DCTS-tools should be implemented as part of the CT strategy to contain future infectious disease outbreaks. This framework, based on expert opinions and scientific literature, contains research questions and study designs covering the evaluation of various important aspects of CT, including its speed, comprehensiveness, effectiveness with regard to contact notification, positive case detection, potential workload reduction of PHPs, its demographic adoption and reach, and the user experiences of PHPs, index cases and contacts.

Since May 2022 over 20.000 human monkeypox virus (hMPXV) cases have been reported from 29 EU/EEA countries, predominantly among men who have sex with men. With over 1200 cases, and a crude notification rate of 70.7 per million population, the Netherlands was in the top 5 European countries most affected. The first national case was reported from May 10th, yet potential prior transmission remains unknown. Insight into prolonged undetected transmission can help to understand the current outbreak dynamics and aid future public health interventions. We therefor performed a retrospective study to elucidate whether undetected transmission of hMPXV occurred prior to the first reported cases in Amsterdam and Rotterdam. In 401 anorectal- and ulcer samples from visitors of the Centers for Sexual Health of Amsterdam and Rotterdam dating back to February 14th, we identified 2 new cases, the earliest from the first week of May (week 18), 2022. This coincides with the first cases reported in the United Kingdom, Spain and Portugal. We found no evidence of widespread hMPXV transmission in Dutch sexual networks of MSM prior to May 2022. Likely, the hMPXV outbreak expanded across Europe within a short period in the spring of 2022 in an international highly intertwined network of sexually active MSM.Ethical statementThe Amsterdam University Medical Centre Ethical committee approved the study and deemed a full review not necessary according to the Medical Research Involving Human Subjects Act (reference letter: W22_257 # 22.313, dd July 14, 2022). Samples included from Rotterdam were required to be collected more than 3 weeks prior to the analysis (i.e. the duration of quarantine in case of a positive result) as they were deemed to be of no consequence for the index or his/her contacts. All samples and collected data were fully de-identified before sample analysis assuring anonymity.

Background Gonococcal antimicrobial resistance is emerging worldwide and is monitored in the Netherlands in 18 of 24 Sexual Health Centres (SHC). Aim To report trends, predictors and regional variation of gonococcal azithromycin resistance (AZI-R, minimum inhibitory concentration (MIC) > 1 mg/L) and ceftriaxone decreased susceptibility (CEF-DS, MIC > 0.032 mg/L) in 2013–2019. Methods SHC reported data on individual characteristics, sexually transmitted infection diagnoses, and susceptibility testing (MIC, measured by Etest). We used multilevel logistic regression analysis to identify AZI-R/CEF-DS predictors, correcting for SHC region. Population differences’ effect on regional variance of AZI-R and CEF-DS was assessed with a separate multilevel model. Results The study included 13,172 isolates, predominantly (n = 9,751; 74%) from men who have sex with men (MSM). Between 2013 and 2019, annual proportions of AZI-R isolates appeared to increase from 2.8% (37/1,304) to 9.3% (210/2,264), while those of CEF-DS seemed to decrease from 7.0% (91/1,306) to 2.9% (65/2,276). Among SHC regions, 0.0‒16.9% isolates were AZI-R and 0.0−7.0% CEF-DS; population characteristics could not explain regional variance. Pharyngeal strain origin and consultation year were significantly associated with AZI-R and CEF-DS for MSM, women, and heterosexual men. Among women and heterosexual men ≥ 4 partners was associated with CEF-DS, and ≥ 10 with AZI-R. Conclusions No resistance or decreasing susceptibility was found for CEF, the first line gonorrhoea treatment in the Netherlands. Similar to trends worldwide, AZI-R appeared to increase. Regional differences between SHC support nationwide surveillance with regional-level reporting. The increased risk of resistance/decreased susceptibility in pharyngeal strains underlines the importance of including extragenital infections in gonococcal resistance surveillance.

ObjectivesGeneral practitioners (GPs) and sexual health centres (SHCs) are the main providers of HIV testing and diagnose two-thirds of HIV infections in the Netherlands. We compared regional HIV testing and positivity by GPs versus SHCs to gain insight into strategies to improve HIV testing, to enable timely detection of HIV infections.MethodsLaboratory data (2011–2018) on HIV testing by GPs and SHCs in five Dutch regions with varying levels of urbanisation were evaluated. Regional HIV testing rates per 10 000 residents ≥15 years (mean over period and annual) were compared between providers using negative binomial generalised additive models and additionally stratified by sex and age (15–29 years, 30–44 years, 45–59 years, ≥60 years). χ2 tests were used to compare positivity percentage between the two groups of providers.ResultsIn the study period, 505 167 HIV tests (GP 36%, SHC 64%) were performed. The highest HIV testing rates were observed in highly urbanised regions, with large regional variations. The HIV testing rates ranged from 28 to 178 per 10 000 residents by GPs and from 30 to 378 per 10 000 by SHCs. Testing rates by GPs were lower than by SHCs in three regions and comparable in two. In all regions, men were tested less by GPs than by SHCs; for women, this varied by region. Among those aged 15–29 years old, GPs’ testing rates were lower than SHCs’, while this was reversed in older age categories in four out of five regions. The overall mean HIV positivity was 0.4%. In contrast to other regions, positivity in Amsterdam was significantly higher among individuals tested by GPs than by SHCs.ConclusionsThis retrospective observational study shows that besides SHCs, who perform opt-out testing for key groups, GPs play a prominent role in HIV testing, especially in non-key populations, such as women and older individuals. Large regional variation exists, requiring region-specific interventions to improve GPs’ HIV testing practices.

ObjectivesEuropean guidelines advise the use of dual nucleic acid amplification tests (NAAT) in order to minimise the inappropriate diagnosis of Neisseria gonorrhoeae (Ng) in urogenital samples from low prevalence areas and in extragenital specimens. In this cross-sectional study, we investigated the effect of confirmatory testing and confirmation policy on the Ng-positivity in a population visiting the sexual health clinic in Rotterdam, the Netherlands.MethodsApart from urogenital testing, extragenital (oropharyngeal/anorectal) testing was performed for men who have sex with men (MSM) and according to sexual exposure for women and heterosexual men. Ng detection using NAAT was performed using BD Viper and for confirmatory testing BD MAX. Sexual transmitted infection consultation data were merged with diagnostic data from August 2015 through May 2016.ResultsIn women (n=4175), oral testing was performed in 84% and 22% were tested anally. In MSM (n=1828), these percentages were 97% and 96%, respectively. Heterosexual men (n=3089) were tested urogenitally. After confirmatory testing, oropharyngeal positivity rates decreased from 7.3% (95% CI 6.5 to 8.2) to 1.5% (95% CI 1.1 to 1.8) in women and from 13.9% (95% CI 12.3 to 15.5) to 5.4% (95% CI 4.3 to 6.4) in MSM. Anorectal positivity rates decreased from 2.6% (95% CI 1.6 to 3.7) to 1.8% (95% CI 0.9 to 2.6) in women and from 9.3% (95% CI 7.9 to 10.7) to 7.2% (95% CI 6.0 to 8.5) in MSM. Urogenital Ng-positivity rate ranged between 3.0% and 4.4% and after confirmation between 2.3% and 3.9%. When confirming oropharyngeal samples, Ng-positivity was 3.8% in women, 3.0% in heterosexual men and 12.5% in MSM. Additional confirmation of urogenital and anorectal samples led to 3.0% Ng positivity in women, 2.7% in heterosexual men and 11.4% in MSM.ConclusionsConfirmation of urogenital and anorectal samples reduced the Ng-positivity rates, especially for women. However, as there is no gold standard for the confirmation of Ng infection, the dilemma within public health settings is to choose between two evils: missing diagnoses or overtreatment. In view of the large decrease in oropharyngeal positivity, confirmation Ng-positivity in oropharyngeal samples remains essential to avoid unnecessary treatment.

A previous chlamydia infection did not result in fewer pregnant women, but among women with a pregnancy intention, time to pregnancy was longer compared with women without a previous infection. Supplemental digital content is available in the text., Background A Chlamydia trachomatis infection (chlamydia) can result in tubal factor infertility in women. To assess if this association results in fewer pregnant women, we aimed to assess pregnancy incidences and time to pregnancy among women with a previous chlamydia infection compared with women without one and who were participating in the Netherlands Chlamydia Cohort Study (NECCST). Methods The NECCST is a cohort of women of reproductive age tested for chlamydia in a chlamydia screening trial between 2008 and 2011 and reinvited for NECCST in 2015 to 2016. Chlamydia status (positive/negative) was defined using chlamydia screening trial–nucleic acid amplification test results, chlamydia immunoglobulin G presence in serum, or self-reported chlamydia infections. Data on pregnancies were collected via questionnaires in 2015–2016 and 2017–2018. Overall pregnancies (i.e., planned and unplanned) and time to pregnancy (among women with a pregnancy intention) were compared between chlamydia-positive and chlamydia-negative women using Cox regressions. Results Of 5704 women enrolled, 1717 (30.1%; 95% confidence interval [CI], 28.9–31.3) women was chlamydia positive. Overall pregnancy proportions were similar in chlamydia-positive and chlamydia-negative women (49.0% [95% CI, 46.5–51.4] versus 50.5% [95% CI, 48.9–52.0]). Pregnancies per 1000 person-years were 53.2 (95% CI, 51.5–55.0) for chlamydia negatives and 83.0 (95% CI, 78.5–87.9) for chlamydia positives. Among women with a pregnancy intention, 12% of chlamydia-positive women had a time to pregnancy of >12 months compared with 8% of chlamydia negatives (P < 0.01). Conclusions Overall pregnancy rates were not lower in chlamydia-positive women compared with chlamydia-negative women, but among women with a pregnancy intention, time to pregnancy was longer and pregnancy rates were lower in chlamydia-positive women. Trial registration number: Dutch Trial Register NTR-5597.

ObjectivesSpontaneous clearance of Chlamydia trachomatis (CT) infections can occur between diagnosis and treatment. We followed CT patients to assess clearance using a conventional definition (no total CT-DNA, assessed by routine quantitative PCR methods) and a definition accounting for viability, assessed by viability PCR testing.MethodsThree outpatient STI clinics included CT-diagnosed women (The Netherlands, 2016–2017, FemCure study); participants had vaginal CT (vCT) and rectal CT (rCT) (group A: n=155), vCT and were rectally untested (group B: n=351), single vCT (group C: n=25) or single rCT (group D: n=29). Follow-up (median interval 9 days) vaginal and rectal samples underwent quantitative PCR testing (detecting total CT-DNA). When PCR positive, samples underwent V-PCR testing to detect ‘viable CT’ (CT-DNA from intact CT organisms; V-PCR positive). ‘Clearance’ was the proportion PCR-negative patients and ‘clearance of viable CT’ was the proportion of patients testing PCR negative or PCR positive but V-PCR negative. We used multivariable logistic regression analyses to assess diagnosis group (A–D), age, days since initial CT test (diagnosis) and study site (STI clinic) in relation to clearance and clearance of viable CT.ResultsClearance and clearance of viable CT at both anatomic sites were for (A) 0.6% and 3.9%; (B) 5.4% and 9.4%; (C) 32.0% and 52.0% and (D) 27.6% and 41.4%, respectively. In multivariate analyses, women with single infections (groups C and D) had higher likelihood of clearance than women concurrently infected with vCT and rCT (pOf rectally untested women (group B), 76.9% had total CT-DNA and 46.7% had viable CT (V-PCR positive) at the rectal site.ConclusionsOf untreated female vCT patients who had CT also at the rectal site, or who were rectally untested, only a small proportion cleared CT (in fact many had viable CT) at their follow-up visit (median 9 days). Among single site infected women clearance was much higher.Trial registration numberNCT02694497.

BackgroundChlamydia trachomatis (CT) is routinely diagnosed by nucleic acid amplification tests (NAATs), which are unable to distinguish between nucleic acids from viable and non-viable CT organisms.ObjectivesWe applied our recently developed sensitive PCR (viability PCR) technique to measure viable bacterial CT load and explore associated determinants in 524 women attending Dutch sexual health centres (STI clinics), and who had genital or rectal CT.MethodsWe included women participating in the FemCure study (Netherlands, 2016–2017). At the enrolment visit (pre-treatment), 524 were NAAT positive (n=411 had genital and rectal CT, n=88 had genital CT only and n=25 had rectal CT only). We assessed viable rectal and viable genital load using V-PCR. We presented mean load (range 0 (non-viable) to 6.5 log10 CT/mL) and explored potential associations with urogenital symptoms (coital lower abdominal pain, coital blood loss, intermenstrual bleeding, altered vaginal discharge, painful or frequent micturition), rectal symptoms (discharge, pain, blood loss), other anatomical site infection and sociodemographics using multivariable regression analyses.ResultsIn genital (n=499) CT NAAT-positive women, the mean viable load was 3.5 log10 CT/mL (SD 1.6). Genital viable load was independently associated with urogenital symptoms—especially altered vaginal discharge (Beta=0.35, p=0.012) and with concurrent rectal CT (aBeta=1.79; p10 CT/mL (vs 3.3 in women without symptoms). Of 436 rectal CT NAAT-positive women, the mean rectal viable load was 2.2 log10 CT/mL (SD 2.0); rectal symptoms were reported by 2.5% (n=11) and not associated with rectal viable load.ConclusionAmong women diagnosed with CT in an outpatient clinical setting, viable genital CT load was higher in those reporting urogenital symptoms, but the difference was small. Viable genital load was substantially higher when women also had a concurrent rectal CT.Trial registration numberClinicalTrials.gov NCT02694497.

For the first 3 months of COVID-19 pandemic, COVID-19 was expected to be an immunizing non-relapsing disease. We report a national case series of 11 virologically-confirmed COVID-19 patients having experienced a second clinically- and virologically-confirmed acute COVID-19 episode. According to the clinical history, we discuss either re-infection or reactivation hypothesis. Larger studies including further virological, immunological and epidemiologic data are needed to understand the mechanisms of these recurrences.

Gonococcal antimicrobial resistance is emerging worldwide, and is monitored in the Netherlands in 18 out of 24 Sexual Health Centres (SHC) that perform culture and susceptibility testing for patients with gonorrhoea. This study describes trends, determinants and regional differences in azithromycin resistance and ceftriaxone decreased susceptibility in 2013–2019. Data on person characteristics, STI diagnoses and MIC values (Minimum Inhibitory Concentration, measured by E-test) for gonorrhoea were reported by participating SHC. We describe azithromycin resistance (AZI-R, MIC >1 mg/L) and ceftriaxone decreased susceptibility (CEF-DS, MIC >0.032 mg/L) over time and per SHC. We use multilevel logistic regression analysis to describe determinants of AZI-R/CEF-DS among MSM and heterosexuals, correcting for SHC region. A separate multilevel model was made to quantify the effect of population differences on the regional variance of AZI-R and CEF-DS. A total of 13,000 isolates were included from 2013–2019. AZI-R significantly increased from 2.8% (95% Confidence Interval 2.1–3.9%) to 9.3% (8.2–10.5%). CEF-DS significantly decreased from 7.0% (5.7–8.5%) to 2.9% (2.3–3.6%). Overall, regional differences were seen between SHC: AZI-R varied from 0.0% to 16.9%, CEF-DS from 0.0% to 7.0%. Regional variance could not be explained by population characteristics. Regression analyses found pharyngeal strain origin and year of consultation significantly associated with AZI-R and CEF-DS among MSM and heterosexuals. Among heterosexuals also a high number of partners was associated with AZI-R and CEF-DS. No resistance or decreasing susceptibility was found for ceftriaxone, the first line gonorrhoea treatment in the Netherlands. However, azithromycin resistance is increasing, similar to trends worldwide. Differing levels of resistance/decreased susceptibility per SHC could not be explained by differences in population characteristics. This indicates the need for nationwide surveillance and reporting of results on a regional level. The association of pharyngeal strain origin with resistance/decreased susceptibility underlines the importance of including extragenital infections in gonococcal antimicrobial resistance surveillance.

Background We performed a community-based HIV testing (CBHT) pilot in a multicultural area with high HIV prevalence. Here we evaluate our goals of reaching the population, finding HIV-infections and whether this approach helps to normalize HIV testing, decrease HIV-related stigma, and increase knowledge and open conversation about HIV. Methods Interviewing 37 residents and 6 key figures of community/health organizations outlined our CBHT strategy main conditions: low-threshold, free-of-charge and a general health check (HIV test included). Based on these conditions, and in consultation with community organizations, test actions were developed offering HIV and other health checks. Demographics, HIV testing history, risk perception and openness concerning HIV was obtained via questionnaires. We piloted seven 4-hours test actions at three community organizations (October 2019-February 2020), who also recruited participants. HIV education was offered by health educators, peers and using a game. Each test action was evaluated among participants, the organization and test team members. Results In total, all 140 participants were tested for HIV (74% women, 85% non-western, median age 49yr). For 127 participants HIV testing history was collected; 59% never tested before and 20% tested >1yr ago. With one positive HIV test, the detection rate was 0.7%. 90% of participants perceived no HIV risk. Several participants indicated the test action positively altered their attitude and knowledge about HIV/PLWH. The CBHT was positively evaluated by all parties. The major concerns by test team members were time, language problems and privacy. Participants hardly indicated these concerns. Conclusion This CBHT approach (1) is feasible and well-suited for testing not (recently) tested groups and detect new cases, especially in high prevalent neighborhoods with hard-to-reach populations like non-western migrants, (2) positively seems to contribute to attitudes and knowledge about HIV/PLWH. Nevertheless, it is questionable whether this laborious approach, outweighs finding the last fraction of new HIV cases.

Background Anorectal infections with Chlamydia trachomatis (CT) are prevalent in women visiting STI-clinics. In women, azithromycin treatment in anorectal chlamydia is unsuccessful in about 20%, with the potential of subsequent re-infection of the vagina through autoinoculation. We evaluated the risk for incident urogenital CT, by exposure from the own anorectal site and exposure by sex; and similarly evaluated risks for incident anorectal CT. Methods Prospective multicenter cohort study, FemCure. At 4, 6, 8, 10, and 12 weeks after azithromycin or doxycycline CT treatment, women self-collected anorectal and urogenital swabs for CT-DNA testing. We calculated the proportion with incident CT, at week 6–12, by 2-week time-periods. Compared to no exposure (A), risk of incident urogenital CT was estimated for sexual exposure (B), anorectal CT exposure (C), and both exposures (D), adjusted for confounders by adjusted odds ratios (OR) and 95% confidence intervals (CI). We similarly assessed incident anorectal CT. Results Data comprised 385 participants contributing 1540 two-week periods. Urogenital incidence was 3·3% (47/1428) [95%CI: 2·4–4·4]; 0·7% (A), 1·9% (B), 13·9% (C), and 25·4 (D). ORs were: 2·7 [95%CI:0·9–8·6] (B), 21·8 [95%CI:6·7–70·7] (C), 49·7 [95%CI:15·4–160·4] (D). Anorectal incidence was 2·9% (39/1343) [95CI:1·8–3·6]; 1·3% (A), 1·3% (B), 27·8% (C), and 36·7% (D). ORs were: 0·91 [95%CI:0·32–2·60] (B), 26·0 [95%CI:7·16–94·34] (C), 44·3 [95%CI:14·4–136·2] (D). Of incident CT, 55% urogenital and 70% anorectal infections persisted (>two weeks). Conclusion Between 6–12 weeks after initial treatment, the risk for incident urogenital CT in women increased when women had a recent anorectal CT, especially when also sex was reported. Likewise, the risk for incident anorectal CT increased with urogenital CT and sex exposure. Findings may suggest a key role for auto-inoculation in the re-establishment or persistence of urogenital and anorectal chlamydia infections in treated women, especially in case of suboptimal initial treatment or lack of anorectal testing.

Background Dutch Sexual Health Clinics (SHCs) had to downscale services during the first coronavirus wave, but continued to provide essential STI/PrEP care including testing for persons at highest risk for (symptomatic) gonorrhoea, infectious syphilis (syphilis) and HIV. We describe STI positivity among SHC attendees between 2011–2020. Methods National SHC surveillance data contained information on demographics, sexual behaviour, STI testing and diagnoses. We split 2020 into periods: 1 January-12 March (pre-lockdown), 13 March-31 May (lockdown) and 1 June-31 August (post-lockdown). Chlamydia, gonorrhoea, syphilis and HIV positivity (n positive/N tested) trends were explored by gender and sexual contact. Results In 2020, weekly numbers of consultations varied between 2,803 and 3,515 pre-lockdown, 564 and 1,298 during lockdown and 1,084 and 1,976 post-lockdown. Relatively more MSM, PrEP users and clients notified for or with symptoms of STI were seen during- and post-lockdown compared to pre-lockdown. Chlamydia positivity was around 18% among heterosexual men and 15% among women from 2016–2019, and increased to 21.1% and 16.6% respectively in 2020. Positivity increased during lockdown, up to 32% among heterosexual men, followed by decreases post-lockdown to pre-lockdown levels. Among MSM, the increase during lockdown was smaller, only slightly affecting overall positivity in 2020. Gonorrhoea positivity also increased during lockdown, causing further increasing trends among heterosexuals from 1.8% in 2011 to 2.2% in 2020 and among MSM from 9.0% to 12.1%. Syphilis positivity among MSM fluctuated between 2.0% and 2.9% in 2011–2020. Positivity peaked (6.7%) during lockdown, while the number of diagnoses was similar to pre-lockdown. In contrast, HIV positivity continued to decrease from 2,0% to 0,3% among MSM in 2011–2020. Conclusion Prioritising persons at highest risk caused decreases in diagnoses, especially chlamydia and gonorrhoea, but increases in positivity. More information is needed to understand transmission dynamics, including testing at GPs, self-testing and sexual behaviour during coronavirus pandemic.

Background General practitioners (GPs) and sexual health centres (SHCs) are the main providers of STI and HIV testing in the Netherlands. We compared HIV testing by GPs versus SHCs to gain insight in strategies to improve HIV testing, stimulating timely HIV diagnosis. Methods Laboratory data (2011–2018) on HIV testing by GPs and SHCs in five Dutch regions with varying levels of urbanisation were used. Mean regional HIV testing rates per 10,000 residents ≥15 years were compared between providers using negative binomial generalised additive models, and additionally stratified by sex and age (15–29y, 30–44y, 45–59y, ≥60y). Chi-squared tests were used to compare percentage positive between providers. Results Analysed data included 507,197 HIV tests (GP 36%, SHC 64%). The highest HIV testing rates and positivity were observed in highly urbanised regions, with large variation between regions. The HIV testing rates ranged from 28–178/10,000 residents by GPs and from 30–379/10,000 residents by SHCs. Testing rates by GPs were lower than by SHCs in two regions, while these rates were comparable in the others. In all regions, men were tested less by GPs than by SHCs; for women this varied per region. Among 15–29 year olds, GPs’ testing rates were lower than SHCs’, while this was reversed in older age categories. The overall mean HIV positivity was 0.5% for GPs and 0.4% for SHCs. In Amsterdam, positivity was higher among individuals tested by GPs, but in the other regions no difference was observed. Conclusion This is the first study comparing HIV testing by GPs versus SHCs using laboratory data in the Netherlands. Our results show that besides SHCs, GPs also play a key role, especially in some subgroups, but large regional variation exists. Regional-specific interventions to improve GPs’ HIV testing practices are needed for populations not attending the SHCs to ensure timely HIV diagnosis.

Background Syphilis rates are increasing globally among men who have sex with men (MSM). Repeat infections within core groups could contribute to ongoing transmission of syphilis. The aim of this study was to measure the frequency and to explore predictors of repeat infectious syphilis infection among MSM attending Sexual Health Centres (SHCs) in the Netherlands. Methods We analysed national SHC surveillance data between July 2014 and December 2019. A unique identifier enabled individual level analysis of repeat consultations and infections. Infectious syphilis (syphilis) included primary, secondary and early latent syphilis diagnoses. Repeat infection was defined as having two syphilis diagnoses during the study period. Multivariable logistic regression analyses were used to explore predictors of repeat syphilis infection. MSM with at least one syphilis diagnosis and one following consultation were included. Age, education level, ethnicity, HIV infection, having symptoms related to syphilis/HIV, being notified for STI, prior STI, condom use and number of partners at first infectious syphilis diagnosis were included in the analysis. Results There were 184,621 consultations registered among 41,210 MSM who tested repeatedly. Among 3,504 MSM, 4,282 syphilis infections were diagnosed. At first syphilis diagnosis median age was 39 (IQR: 29–49), 32.4% was known HIV positive and 41.4% had 10 or more partners in the past 6 months. Repeat infection occurred in 647 MSM (18.5%; median time to repeat infection: 468 days (IQR: 287–808)). Being HIV positive (aOR: 2.02 [95% CI: 1.69–2.42]) and being notified for STI (aOR: 1.21 [95% CI: 1.01–1.46]) were statistically significant predictors of repeat infection. Conclusion This study showed that repeat infection was common and that HIV infection and being notified for STI at first syphilis diagnosis were predictors of repeat infection among MSM who tested repeatedly. Preventive strategies, including adequate partner management, for repeat syphilis are needed, especially for HIV-positive MSM.

This study aimed to assess whether educational level is an independent determinant for sexually transmitted infections (STIs) among clients consulting Dutch sexual health centres (SHCs). With data from the National STI surveillance database (2015–2017), generalized estimating equations corrected for (sexual) risk factors were used to estimate associations between educational level and chlamydia and gonorrhoea among women ( n = 146,020), heterosexual men ( n = 82,882) and men who have sex with men (MSM) ( n = 52,149) and syphilis and HIV among MSM. Compared to the highest educational level (bachelor/master), all lower educational levels were associated with gonorrhoea among women (adjusted odds ratio 1.40; 95% CI 1.18–1.66 for higher general/pre-university level to 3.57; 95% CI 2.66–4.81 for no education/elementary school level) and heterosexual men (respectively 1.36; 1.06–1.74 to 3.84; 2.89–5.09). Women with no education/elementary school level (1.37; 1.17–1.62) and heterosexual clients with (pre-)vocational secondary educational level were more likely to test positive for chlamydia (women: 1.43; 1.39–1.48 and heterosexual men: 1.31; 1.26–1.37) than clients with higher general/pre-university level or bachelor/master level. In MSM, (pre-)vocational secondary educational level was associated with chlamydia (1.16; 1.11–1.22), gonorrhoea (1.15; 1.10–1.21) and syphilis (1.18; 1.08–1.29), and both (pre-)vocational secondary educational level (1.48; 1.25–1.76) and no education/elementary school level (1.81; 1.09–3.00) were associated with HIV. Lower educational levels were independent determinants of STI in SHC clients. Sexual health centres could facilitate STI testing and care among lower educated people by prioritizing their access.

Many adolescents use their electronic devices to send each other sexually explicit texts, photos, and videos of themselves—commonly known as sexting. This can be fun and is not usually problematic. However, if the intended recipient decides to share these sexts with a broader audience, the consequences for the depicted can be detrimental. The purpose of this study was to investigate the prevalence of (non-consensual) sext-sharing among Dutch adolescents and explore the characteristics of those who do, to gain a better understanding of factors involved in dissemination. We used data from “Sex under the age of 25,” a representative national survey on sexual health among a sample of 20,834 Dutch 12–24-year-olds. The prevalence of sext-sharing was estimated using Complex Samples. Logistic regressions were used to assess associations between demographics, school-based sexting education, sexual- and online behavior, and mental health and sext-sharing. About 4% of the adolescents reported having shared someone else's sext in the last six months. Being male, aged 12–14 years, frequent social media usage, watching online porn, sexual experience, and being subjected to sext-sharing themselves associated most strongly with sext-sharing. Our findings show that the likelihood of sext-sharing is lower in older adolescents and that it associates with the extent of adolescents' sexual curiosity and online activity. The overlap between sharing sexts of others and having one's own sext shared suggests that dissemination of personal sexual content might be normalized or used as an act of retribution. Further research could be helpful to explain the mechanisms underlying this overlap. The results of this study illustrate the importance of exposing adolescents to evidence based preventive educational interventions on sexting from 12 years onwards and not just within the context of traditional school-based sex education, but also as a part of the (online) media-literacy curriculum.

Introduction: Surveillance for recent HIV infections was implemented at Dutch sexual health centres (SHCs) for planning and evaluation of HIV prevention initiatives. The study objective is twofold: (1) to explore trends in recent HIV infections and associated socio-demographic and behavioural risk factors among men who have sex with men (MSM )attending SHCs, to gain insight into subgroups at risk for acquiring HIV and(2) to illustrate how comparison with different reference groups affect associations with these risk factors. Methods: Residual plasma or serum samples from MSM newly HIV diagnosed at SHCs in 2014–2017 were tested with an avidity assay. Multinomial regression was used to analyse risk factors for recent HIV infections among MSM with established HIV infections among MSM and with HIV-negative MSM as reference groups. Results: Of newly diagnosed MSM, 33% were classified as recent HIV infection with avidity testing. Combining HIV-negative test results with avidity outcomes resulted in 54% recent infections. Recent infection was associated with having an STI in the past, multiple partners and condom use for both reference groups of MSM. Additionally, relative to the HIV-negative MSM, recent infection was associated with education and having a non-Western origin. In contrast, relative to MSM with established HIV infections, recent infection was associated with Western origin. Conclusion: Our results suggest ongoing but declining transmission of HIV and high uptake of HIV testing among MSM visiting SHCs. The identification of risk factors for recent infections can help healthcare professionals to target subgroups eligible for PrEP or condom use promotion. Differentiation by the reference group in explanatory models for recent infections is important as different risk factors were identified. Likely, associations relative to HIV-negative MSM follow those of acquiring HIV infection in general, whereas the comparison with the established HIV infection reference rather reflects the frequent testing behaviour of subgroups of MSM.

Anorectal infections withProspective multicentre cohort study, FemCure. Participants were treated for CT, and after 4, 6, 8, 10 and 12 weeks, they self-collected anorectal and urogenital samples (swabs) for CT-DNA testing. We calculated the proportion with incident CT, that is, CT incidence (at weeks 6-12) by 2-week time-periods. Compared with no exposure (A), we estimated the risk of incident CT for (B) sexual exposure, (C) alternate site anatomic site infection and (D) both, adjusted for confounders and expressed as adjusted ORs with 95% CIs.We analysed data of 385 participants contributing 1540 2-week periods. The anorectal CT incidence was 2.9% (39/1343) (95 CI 1.8 to 3.6); 1.3% (A), 1.3% (B), 27.8% (C) and 36.7% (D). The ORs were: 0.91 (95% CI 0.32 to 2.60) (B), 26.0 (95% CI 7.16 to 94.34) (C), 44.26 (95% CI 14.38 to 136.21) (D).The urogenital CT incidence was 3.3% (47/1428) (95% CI 2.4 to 4.4); 0.7% (A), 1.9% (B), 13.9% (C) and 25.4% (D). The ORs were: 2.73 (95% CI 0.87 to 8.61) (B), 21.77 (95% CI 6.70 to 70 71) (C) and 49.66 (95% CI 15.37 to 160.41) (D).After initial treatment, an alternate anatomical site CT infection increased the risk for an incident CT in women, especially when also sex was reported. This may suggest a key role for autoinoculation in the re-establishment or persistence of urogenital and anorectal chlamydia infections.

BackgroundThe sole sexual health centre (SHC) in the greater Rotterdam area, the Netherlands, is instrumental in finding people unaware of their STI/HIV status. We hypothesized that travel distance to the SHC is inversely associated with SHC utilisation. Insight in area-specific utilisation is needed for potential new outreach policies to enhance STI testing. MethodsThe study population consists of all residents aged 15 to 45 years in the greater Rotterdam area (2015-2017). We linked SHC consultation data from STI tested heterosexual clients to the population registry. The association between SHC utilisation and distance was investigated by multilevel modelling, adjusting for sociodemographic and area-specific determinants. The data was also stratified by age (aged below 25) and migratory background (non-Western), since SHC triage may affect their utilisation. We used straight-line distance between the centroid of the postal code area and SHC address as a proxy for travel distance. ResultsWe found large area variation in SHC utilisation (ranged from 1.13 to 48.76 per 1,000 residents). Both individual and area level determinants determine utilisation. Travel distance explained most area variation and was inversely associated with SHC utilisation when adjusted for other sociodemographic and area-specific determinants (odds ratio [OR] per kilometre: 0.95; 95% CI: 0.93-0.96). Similar results were obtained for residents aged below 25 (OR: 0.95; 95% CI: 0.94-0.96), but not for non-Western residents (OR: 0.99; 95% CI: 0.99-1.00). ConclusionLiving further away from the sole SHC in the greater Rotterdam area decreases utilisation. This provides evidence for local policy to enhance STI testing, for example by offering STI testing services closer to the population.

We present an in-depth analysis of data from drive through testing stations using rapid antigen detection tests (RDT’s), RT-PCR and virus culture, to assess the ability of RDT’s to detect infectious cases. We show that the detection limits of five commercially available RDT’s differ considerably, impacting the translation into the detection of infectious cases. We recommend careful fit-for-purpose testing before implementation of antigen RDT’s in routine testing algorithms as part of the COVID-19 response.

Patient-initiated partner therapy (PIPT) for Chlamydia is not practiced in the Netherlands. We aimed to explore PIPT-willingness in patients infected with Chlamydia and persons notified for Chlamydia (partners) at sexual health clinics (SHCs) and general practitioners’ offices. We performed interviews among 20 heterosexual patients and 21 partners regarding real or hypothetical situations. The interviews were taped, transcribed verbatim and coded using ATLAS.ti7 software for qualitative research. Despite challenges in notifying partners in some cultural groups and some partner types, most patients and partners would cooperate with PIPT. Perceived barriers included unnecessary treatment, risking untreated other sexually transmitted infections and breaking the notification chain. Most patients and partners opted for home-based test-kits before treatment. Partners desired proper packaging of the test and the medication, along with an information insert, a supportive letter from the SHC, information on the internet and the possibility to contact a professional. Although PIPT may support partner notification (PN), many patients and partners prefer a diagnosis before treatment. PIPT with medication or a prescription combined with a home-based test-kit may be the way forward. However, PN seems to be influenced by type of partner and cultural background, requiring differentiated PN and partner therapy methods.

Women attending STI clinics are not routinely tested for oropharyngealWomen with vaginal or rectal CT (n=560) were recruited at STI clinics in 2016-2017, as part of the FemCure study (prospective cohort study). We included participants' data from week -1, that is, the diagnosis at initial visit, when clinics applied selective oropharyngeal testing. At week -1, a total of 241 women were oropharyngeally tested (30 positive) and 319 were untested. All FemCure participants provided nurse-collected oropharyngeal samples at study enrolment, that is, week 0, just prior to treatment (n=560), and after treatment at weeks 4 (n=449), 8 (n=433) and 12 (n=427). Samples were tested by nucleic acid amplification test, and at week 0 also by viability testing by viability PCR. Proportions of oropharyngeal CT test results were presented to represent spontaneous clearance and cure.Of 30 women diagnosed with oropharyngeal CT at week -1, fifteen (50%) were negative at week 0 after a median of 9 days, that is, 'spontaneous clearance'. At week 0, a total of 560 participants were tested, and 46 (8.8%) were oropharyngeal CT positive; 12 of them (26.1%) had viable CT. Of the 46 positive, 36 women had an oropharyngeal test after treatment; 97.2% (35/36) were negative at week 4, that is, 'cure'. Of all women with follow-up visits, the proportion of oropharyngeal CT positive was between 0.5% and 1.6% between weeks 4 and 12. Of those not tested at week -1 (n=319), 8.5% (n=27) were oropharyngeal positive at week 0.The clinical importance of oropharyngeal CT in women is debated. We demonstrated that spontaneous clearance of oropharyngeal CT among women is common; of those who did not clear for CT, three-quarters had non-viable CT. After regular treatment with azithromycin or doxycycline, cure rate (97%) of oropharyngeal CT is excellent.NCT02694497.

European guidelines advise the use of dual nucleic acid amplification tests (NAAT) in order to minimise the inappropriate diagnosis ofApart from urogenital testing, extragenital (oropharyngeal/anorectal) testing was performed for men who have sex with men (MSM) and according to sexual exposure for women and heterosexual men. Ng detection using NAAT was performed using BD Viper and for confirmatory testing BD MAX. Sexual transmitted infection consultation data were merged with diagnostic data from August 2015 through May 2016.In women (n=4175), oral testing was performed in 84% and 22% were tested anally. In MSM (n=1828), these percentages were 97% and 96%, respectively. Heterosexual men (n=3089) were tested urogenitally. After confirmatory testing, oropharyngeal positivity rates decreased from 7.3% (95% CI 6.5 to 8.2) to 1.5% (95% CI 1.1 to 1.8) in women and from 13.9% (95% CI 12.3 to 15.5) to 5.4% (95% CI 4.3 to 6.4) in MSM. Anorectal positivity rates decreased from 2.6% (95% CI 1.6 to 3.7) to 1.8% (95% CI 0.9 to 2.6) in women and from 9.3% (95% CI 7.9 to 10.7) to 7.2% (95% CI 6.0 to 8.5) in MSM. Urogenital Ng-positivity rate ranged between 3.0% and 4.4% and after confirmation between 2.3% and 3.9%. When confirming oropharyngeal samples, Ng-positivity was 3.8% in women, 3.0% in heterosexual men and 12.5% in MSM. Additional confirmation of urogenital and anorectal samples led to 3.0% Ng positivity in women, 2.7% in heterosexual men and 11.4% in MSM.Confirmation of urogenital and anorectal samples reduced the Ng-positivity rates, especially for women. However, as there is no gold standard for the confirmation of Ng infection, the dilemma within public health settings is to choose between two evils: missing diagnoses or overtreatment. In view of the large decrease in oropharyngeal positivity, confirmation Ng-positivity in oropharyngeal samples remains essential to avoid unnecessary treatment.

Introduction Lymphogranuloma venereum (LGV), an invasive form of Chlamydia trachomatis infection, has been reported among (mainly HIV-positive) men who have sex with men (MSM) since 2003. In the Netherlands, LGV testing recommendations changed from selective to universal testing in 2015. Changes in tested populations could have led to incomparable LGV positivity rates over time. Aim We investigated LGV trends among MSM attending Centres for Sexual Health using surveillance data between 2011 and 2017. Methods LGV positivity was calculated among MSM tested for rectal Chlamydia infection and MSM tested specifically for LGV. With multivariable logistic regression analysis, the association between years and LGV was adjusted for testing indicators and determinants. Results We included 224,194 consultations. LGV increased from 86 in 2011 to 270 in 2017. Among LGV-positives, proportions of HIV-negative and asymptomatic MSM increased from 17.4% to 45.6% and from 31.4% to 49.3%, respectively, between 2011 and 2017. Among MSM tested for rectal chlamydia, LGV positivity increased from 0.12% to 0.33% among HIV-negatives and remained stable around 2.5% among HIV-positives. Among LGV-tested MSM, LGV positivity increased from 2.1% to 5.7% among HIV-negatives and from 15.1% to 22.1% among HIV-positives. Multivariable models showed increased odds ratios and significant positive associations between years and LGV. Conclusions Although increased testing and changes in LGV incidence are difficult to disentangle, we found increasing LGV trends, especially when corrected for confounding. LGV was increasingly attributed to HIV-negative and asymptomatic MSM, among whom testing was previously limited. This stresses the importance of universal testing and continuous surveillance.

We applied our recently developed sensitive PCR (viability PCR) technique to measure viable bacterial CT load and explore associated determinants in 524 women attending Dutch sexual health centres (STI clinics), and who had genital or rectal CT.We included women participating in the FemCure study (Netherlands, 2016-2017). At the enrolment visit (pre-treatment), 524 were NAAT positive (n=411 had genital and rectal CT, n=88 had genital CT only and n=25 had rectal CT only). We assessed viable rectal and viable genital load using V-PCR. We presented mean load (range 0 (non-viable) to 6.5 logIn genital (n=499) CT NAAT-positive women, the mean viable load was 3.5 logAmong women diagnosed with CT in an outpatient clinical setting, viable genital CT load was higher in those reporting urogenital symptoms, but the difference was small. Viable genital load was substantially higher when women also had a concurrent rectal CT.ClinicalTrials.gov NCT02694497.

Background Due to rising costs caused by increasing demand for sexually transmitted infection (STI) care, the Dutch government changed the funding of STI clinics. In 2015, a more restrictive testing policy was introduced with syphilis and HIV tests only on indication for younger, heterosexual clients. We evaluated intended savings and missed syphilis and/or HIV infections and explored efficiency of possible test policies. Methods Using surveillance data from 2011 to 2013 with extensive testing for all, we estimated effects of restrictive testing on test costs, number of infections missed, costs per Quality Adjusted Life Year (QALY) lost, and calculated the net monetary benefit from a government perspective. Results The 2015 policy led to estimated savings of €1.1 million, while missing approximately three HIV infections and seven syphilis infections annually. Savings were €435,000/QALY lost. If testing second-generation immigrants for syphilis and HIV, savings rose to €525,000/QALY lost. Offering an HIV test when diagnosed with chlamydia or gonorrhoea savings were €568,000/QALY lost. In a sensitivity analysis, the willingness-to-pay threshold had the highest impact on results. Conclusions The 2015 testing policy resulted in a modest decline of detected HIV and syphilis infections, generating substantial savings. Syphilis and HIV tests for both first- and second-generation immigrants and an HIV test in case of positive chlamydia or gonorrhoea diagnosis could reduce missed infections in a cost-effective way.

Background Correct identification of blood borne viral infections, such as hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV) is crucial in detection and follow up of infection in patients. Objectives We evaluated the diagnostic performance of the DiaSorin LIAISON XL (LIAISON XL) for screening of HBV, HCV and HIV infection. In addition, we investigated the variability of the signal-to-cuttoff ratio (S/CO) of the LIAISON XL HIV Ag/Ab assay and it’s predictive value in subsequent confirmation of HIV-1 infection. Study design We analyzed 16,497 blood samples on which HBV, HCV and HIV screening was performed. We defined A) archived samples previously tested with an arbitrary result in the Abbott ARCHITECT i2000SR system; B) prospectively collected samples which were simultaneously tested on the LIAISON XL and ARCHITECT i2000SR; C) prospectively collected serum samples for HIV testing which were tested solely on the LIAISON XL. Results The agreements of HBV-, HCV-, and HIV markers between the two compared systems are remarkably high. Among the samples which were prospectively tested for HIV Ab/Ag on the LIASON XL, 229 (1.6%) were reactive of which 141 (61.6%) could be confirmed. Increasing the signal-to-cutoff value to 4 could increase the positive predictive value (PPV) to 88.1% without decreasing sensitivity. Conclusions The LIAISON XL system proved to be an excellent system for diagnosing HBV, HCV, and HIV. Our data for the first time showed that increasing the HIV S/CO ratio was safe and increased the PPV for confirmed HIV infection in the tested population.

Background Of newly diagnosed HIV positive men who have sex with men (MSM) in the Netherlands, 29% have a non-Western migration background (MSM-NW). Among MSM-NW, HIV positivity rates are high (0.8%-2.0%), as is the proportion of late stage infections (39%). Factors such as HIV and sexual orientation–related stigma may form barriers for timely testing. Innovative approaches for HIV testing are needed to better reach MSM-NW. Social network testing (SNT) for HIV is an evidence-supported approach where peer recruiters identify persons (network associates) who could benefit from testing in their social or sexual networks. Web-supported SNT might be particularly promising for reaching people who may not be reached by regular care. Objective The purpose of this paper is to describe the design of our pilot PREVENT (Peer-Empowered Voluntary Extended Network Testing). In this pilot, we will explore whether SNT using HIV self-tests is feasible and acceptable among MSM-NW in the Netherlands and whether it reaches those who were never or not recently tested for HIV (>1 year ago). Methods The project aims to include 50 to 60 MSM and MSM-NW peers who will distribute 4 to 5 oral HIV self-tests each aiming to reach 200 network associates (NAs). Enrollment of peers includes 4 steps: (1) fostering interest in becoming a peer by health care professionals at sexual health clinics, HIV treatment clinics, and community settings; (2) sending peer contact information to the peer coordinator; (3) registering peers and giving program instructions by the peer coordinator and referring to the Web-based training at time2test; and (4) receiving precoded HIV self-tests for distribution in the peers’ networks. NAs who receive the self-test will log in with their test package code in the time2test application for step-by-step test instructions. After testing is complete, NAs receive tailored follow-up information depending on their test result. Results Between January and May 2019, 10 STI clinics and 7 HIV treatment clinics started recruiting peers. Results of the PREVENT pilot are expected in December 2020. Conclusions This is the first Web-supported peer-driven SNT pilot using HIV self-tests in the Netherlands and one of the first in Europe. Implementation is considered successful if it reaches MSM-NW who were never or not recently tested for HIV. Additionally, it may encourage conversations within the networks about risk behavior and barriers to HIV testing, potentially contributing to the Joint United Nations Programme on HIV/AIDS goal of zero HIV infections. Trial Registration Netherlands Trial Registry NL7424; https://www.trialregister.nl/trial/7424 International Registered Report Identifier (IRRID) DERR1-10.2196/14743

Effective sexually transmitted infection (STI) control requires opportunities for appropriate testing, counselling and treatment. In the Netherlands, people may attend general practitioners (GPs) and sexual health centres (SHCs; also known as STI clinics) for STI consultations. We assessed the contribution of GPs and SHCs to STI consultations in five Dutch regions with different urbanization levels, using data of urogenital Chlamydia trachomatis (CT) testing. Data (2011–2016) were retrieved from laboratories, aggregated by gender and age group (15–24 and 25–64 years). Results show that test rates and GP contribution varied widely between regions. GP contribution decreased over time in Amsterdam (60–48%), Twente (79–61%), Maastricht (60–50%) and Northeast-Netherlands (82–77%), but not in Rotterdam (65–67%). Decreases resulted from increases in SHC test rates and slight decreases in GP test rates. GPs performed more tests for women and those aged 25–64 years compared to SHCs (relative risks ranging from 1.49 to 4.76 and 1.58 to 7.43, respectively). The average yearly urogenital CT positivity rate was 9.2% at GPs and 10.7% at SHCs. Overall, GPs accounted for most STI consultations, yet SHC contribution increased. Continued focus on good quality STI care at GPs is essential, as increasing demands for care can not be entirely covered by SHCs.

Prospective studies are key study designs when attempting to unravel health mechanisms that are widely applicable. Understanding the internal validity of a prospective study is essential to judge a study's quality. Moreover, insights in possible sampling bias and the external validity of a prospective study are useful to judge the applicability of a study's findings. We evaluated participation, retention, and associated factors of women in a multicenter prospective cohort (FemCure) to understand the study's validity.Chlamydia trachomatis (CT) infected adult women, negative for HIV, syphilis, and Neisseria gonorrhoeae were eligible to be preselected and included at three sexually transmitted infection (STI) clinics in the Netherlands (2016-2017). The planned follow-up for participants was 3 months, with two weekly rectal and vaginal CT self-sampling and online questionnaires administered at home and at the clinic. We calculated the proportions of preselected, included, and retained (completed follow-up) women. Associations with non-preselection, noninclusion, and non-retention (called attrition) were assessed (logistic and Cox regression).Among the 4,916 women, 1,763 (35.9%) were preselected, of whom 560 (31.8%) were included. The study population had diverse baseline characteristics: study site, migration background, high education, and no STI history were associated with non-preselection and noninclusion. Retention was 76.3% (n = 427). Attrition was 10.71/100 person/month (95% confidence interval 9.97, 12.69) and was associated with young age and low education. In an outpatient clinical setting, it proved feasible to include and retain women in an intensive prospective cohort. External validity was limited as the study population was not representative (sampling bias), but this did not affect the internal validity. Selective attrition, however (potential selection bias), should be accounted for when interpreting the study results.

Spontaneous clearance ofThree outpatient STI clinics included CT-diagnosed women (The Netherlands, 2016-2017, FemCure study); participants had vaginal CT (vCT) and rectal CT (rCT) (group A: n=155), vCT and were rectally untested (group B: n=351), single vCT (group C: n=25) or single rCT (group D: n=29). Follow-up (median interval 9 days) vaginal and rectal samples underwent quantitative PCR testing (detecting total CT-DNA). When PCR positive, samples underwent V-PCR testing to detect 'viable CT' (CT-DNA from intact CT organisms; V-PCR positive). 'Clearance' was the proportion PCR-negative patients and 'clearance of viable CT' was the proportion of patients testing PCR negative or PCR positive but V-PCR negative. We used multivariable logistic regression analyses to assess diagnosis group (A-D), age, days since initial CT test (diagnosis) and study site (STI clinic) in relation to clearance and clearance of viable CT.Clearance and clearance of viable CT at both anatomic sites were for (A) 0.6% and 3.9%; (B) 5.4% and 9.4%; (C) 32.0% and 52.0% and (D) 27.6% and 41.4%, respectively. In multivariate analyses, women with single infections (groups C and D) had higher likelihood of clearance than women concurrently infected with vCT and rCT (p0.001).Of rectally untested women (group B), 76.9% had total CT-DNA and 46.7% had viable CT (V-PCR positive) at the rectal site.Of untreated female vCT patients who had CT also at the rectal site, or who were rectally untested, only a small proportion cleared CT (in fact many had viable CT) at their follow-up visit (median 9 days). Among single site infected women clearance was much higher.NCT02694497.

Background Symptoms have been associated with Chlamydia trachomatis (CT) infections in culture-based studies, in contrast to studies based on nucleic acid amplification tests (NAAT). This may be because NAAT also detect non-viable bacteria. As culturing techniques are insensitive, we developed a sensitive polymerase chain reaction (V-PCR) technique to measure the viable bacterial load. We here assess the association between symptoms and viable load in 524 women with vaginal or rectal CT. Methods Prior to treatment at three STI clinics, we included NAAT-CT-positive adult women (n=411 vaginal and rectal CT; n=88 only vaginal CT; n=25 only rectal CT), who were negative for HIV, syphilis and Neisseria gonorrhoeae (Netherlands, 2016–2017; FemCure). We assessed the viable rectal and vaginal load (log10 CT/ml) using V-PCR. We present the mean viable load (range 0 [non-viable] to 6.5) and tested associations with vaginal symptoms (coital lower abdominal pain, coital blood loss, intermenstrual bleeding, altered discharge, painful or frequent micturition) and rectal symptoms (discharge, pain, blood loss), using multivariable regression techniques adjusting for age and educational level. Results Of 499 vaginal CT NAAT-positive women, mean viable load was 3.5 log10 CT/ml (SD: 1.6). Vaginal symptoms were reported by 50.3% (n=251) of women; women reporting any vaginal symptoms had higher vaginal viable load (mean 3.6 log10 CT/ml) than women without symptoms (mean 3.3 log10CT/ml) (B=0.35, p=0.012) (mainly due to ‘altered discharge’). Of 436 rectal CT NAAT-positive women mean viable load was 2.2 log10 CT/ml (SD: 2.0); rectal symptoms were reported by 4.8% (n=21) and not associated with rectal viable load. Conclusion In an outpatient clinical setting, women diagnosed with vaginal CT have a higher viable load when they have symptoms. Yet, the difference is quite small (0.3 log10 CT/ml) and is therefore unlikely to have a major impact on clinical patient management in women. Disclosure No significant relationships.

Background Rectal infections with Chlamydia trachomatis (CT) are prevalent in women visiting a STI outpatient clinic. While azithromycin is the most used treatment, microbiological treatment failure in rectal CT is common and its drivers remain unclear. Methods This study is part of a prospective multicentre cohort study (FemCure). Current analyses included 112 women clinically-diagnosed (by nucleic acid amplification test [NAAT]) with rectal and vaginal CT, who not vomited and denied rectal and vaginal unprotected sex. Four weeks after azithromycin treatment (1g single dose) participants self-collected vaginal and rectal samples. Samples were tested for CT-DNA (NAAT) and viable CT-load (viability polymerase chain reaction [V-PCR]). We evaluated two endpoints: (1) failure by NAAT-positivity and (2) failure by V-PCR-positivity. Enrolment-risk-factors associated with failure were assessed using multivariable logistic regression; i.e., age, education, migratory-background, previous CT, NAAT Cq-value [marker CT-DNA load], culture, viable CT [V-PCR positive], viable load [log10 copies/ml], vaginal CT. Results (1) Failure by NAAT (21.4%; 24/112) was independently associated with both rectal and vaginal NAAT Cq-values; both aOR: 0.8 per unit decrease in the NAAT Cq-value (95%CI:0.7–0.9, p Conclusion In an outpatient clinical setting, azithromycin rectal CT microbiological treatment failure was common and associated with higher pre-treatment (viable) loads. The lower azithromycin treatment failure in patients with NAAT Cq-values≥36 or non-viable rectal CT might result in different treatment choices. Disclosure No significant relationships.

Background Direct treatment after HIV-diagnosis reduces further transmission and has individual health benefits. A check of HIV referral is therefore crucial. Approximately one third of HIV-infections in the greater Rotterdam area are diagnosed at the Center of Sexual Health (CSH). After notification of HIV-infection and counseling, clients are directly referred to a HIV treatment center (HTC). The HTC informs the CSH if the patient did not attend within 4 weeks. Methods Determinants of linkage to care were assessed in patients with HIV diagnosis (2015–2018). For patients in the Rotterdam HTCs, median time was calculated between testing and diagnosis (T1) and diagnosis and 1st consultation at HTC (T2). Results HIV-infection was found in 208 patients, (7 women, 14 heterosexual men, 187 MSM (18 of whom bisexual); 120 (58%) had a non-Western migratory background. Nineteen (9%) turned out to be known HIV-positive: 17 of those were in care, 2 were referred again. Of 189 newly diagnosed, 172 (91%) were directly referred by the CSH to a HTC of whom 95%(163/172) entered care. Median T1 decreased from 9 to 6.5 days and median T2 decreased from 8 to 5.5 days respectively in 2015 and 2018. Linkage to care was 86%(163/189), 14%(26/189) were lost to follow-up: 7 went abroad, 10 were untraceable, 8 were referred but did not enter care and 1 could not be verified. Linkage to care was lower for those with a non-Western migratory background compared to Western (79% (83/105) vs 95% (80/84); p=0.002). Conclusion By a close collaboration between CSH and HTC we were able to improve linkage to care to 86% of new patients, we also observed a decrease in time to care. However, there is a worrisome loss to follow-up, especially in patients with a migratory background. Reasons for loss to follow-up will be investigated, peer involvement may facilitate linkage to care. Disclosure No significant relationships.

Background Spontaneous resolution (clearance) of Chlamydia trachomatis (CT) infections can occur between diagnosis by nucleic acid amplification assays (NAAT) and treatment. Moreover, viability polymerase chain reaction (V-PCR) techniques showed that part of non-resolved NAAT positives represent non-viable CT. This may impact clinic policies aiming to restrict antibiotic treatment (i.e. to viable CT only). We followed 560 CT diagnosed women to assess the proportion without viable CT at follow-up, and associated risk factors. Methods Vaginal (vCT) or rectal (rCT) NAAT positive adult women, negative for HIV, syphilis and Neisseria gonorrhoeae, who not recently used antibiotics, were included at three STI outpatient-clinics (Netherlands, 2016–2017; FemCure). At clinic-diagnosis women were (a) vCT positive, rCT untested (n=351), (b) vCT, rCT positive (n=155), (c) vCT positive, rCT negative (n=25), (d) vCT negative, rCT positive (n=29). After a median of 8 [IQR:7–12] days, before treatment, samples were tested using NAAT and V-PCR. We present percentages of women without viable CT at follow-up, and tested which factors (group [a-d], age, education, non-western-background, symptoms, anal/vaginal sex, sexpartners) were associated, using logistic regression. Results At follow-up, percentages of women NAAT negative at both anatomic sites were 5.4% (a), 0.6% (b), 32.0% (c), and 27.6% (d). Percentages of women without viable CT (i.e. NAAT negative or NAAT positive and V-PCR undetectable) at both anatomic sites were 9.4% (33/351, a), 3.9% (6/155, b), 52.0% (13/25, c), and 41.4% (12/29, d). Alongside group (p Conclusion Less than ten percent of STI-clinic women diagnosed with vaginal and rectal CT (or were rectally untested) did not have viable CT one week after diagnosis (when they return for treatment). Yet, this percentage was higher in women with single vaginal or rectal infection and in older women; this may affect treatment-choices. Disclosure No significant relationships.

Background The majority of oropharyngeal Neisseria gonorrhoeae (N. gonorrhoeae) infections are asymptomatic, and many oropharyngeal N. gonorrhoeae infections could remain undetected, creating a reservoir for ongoing transmission and drug resistance. It is yet unknown what the optimal testing policy is for oropharyngeal N. gonorrhoeae infections in men who have sex with men (MSM), as data on routine universal screening are missing. Methods Surveillance data from all Dutch STI clinics between 2008–2017 were used (n=271,242 consultations). Oropharyngeal testing policy was defined as routine universal screening, that is ≥85% of MSM consultations included oropharyngeal testing per clinic per year, or as selective testing ( Results Routine universal screening was performed in 90% (n=238,619) of consultations. Oropharyngeal N.gonorrhoeae positivity was higher using routine universal screening (5.5%,95%CI 5.4–5.6, n=12,769) compared to selective testing (4.7%,95% CI 4.4–5.0, n=799, P Conclusion Selective testing missed two fifth of oropharyngeal N. gonorrhoeae infections in MSM, of which more than half would be oropharyngeal-only. Using independent risk factors as testing indicator is not specific. Therefore, routine universal oropharyngeal screening in MSM is feasible and warranted, as is currently advised in the Dutch guidelines. Disclosure No significant relationships.

Background Dutch estimates suggest that general practitioners (GPs) perform two-third of all STI consultations, and centres for sexual health (CSH) account for most of the remaining consultations. Yet, a comparison of consultation rates by both providers is hampered due to separate surveillance systems. We assessed the distribution of STI consultations (defined as urogenital Chlamydia trachomatis (CT) test-rates) in five regions. Methods Data (2011 to 2016) on laboratory testing and diagnosis of urogenital CT were retrieved from CSH at public health services and laboratories in five Dutch geographical regions, aggregated by sex and age category (15–24 and 25–64 years). Regions included Amsterdam, Rotterdam, Northeast –Netherlands (N-NL), Twente and Maastricht. Using negative binomial regression, we tested for time-trends in CT test-rate per 10,000 population at GPs and CSH within five regions and differences between the providers by region. Results The five regions included in this study varied from mostly rural (N-NL) to highly urban (Amsterdam and Rotterdam). The relative contribution of GPs in consultation rate decreased over time in Amsterdam (60.0–47.8%), Twente (78.6–61.4%), Maastricht (59.2–47.2%), N-NL (82.4–76.9%), but not in Rotterdam (65.4–67.0%). This decrease resulted from an increase in all CSH consultation rates and a slight decrease in GP consultation rate (except for Rotterdam). Women and persons aged 25–64 years were more likely to be tested by GPs compared to CSH (relative risks of 5 regions ranging from 1.47–4.76; 1.58–7.43 respectively). All regions combined, the average yearly positivity rate was 9.2% at the GP and 10.7% at the CSH. Conclusion GPs are still a major contributor in STI consultations, yet the CSH- contribution has increased between 2011 and 2016. In urban regions, the CSH has a considerable role, whereas in rural areas the GP provides most consultations. An explanation for differences may be CSH accessibility. Disclosure No significant relationships.