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ObjectivesContinuing high STI positivity among men who have sex with men (MSM) attending centres for sexual health (CSH) indicates that high-risk behaviour is ongoing. The objective of this study was to gain a better insight into risk behaviours among MSM attending CSH and to explore STI and HIV positivity by subgroups.MethodsWe used national data routinely collected during CSH consultations for this study. From September to December 2017, questions on group sex, substance use and sex with HIV-positive partners were asked at each CSH consultation. We analysed latent classes of client-related factors and sexual risk behaviour among MSM attending CSH in this period. We examined STI positivity and prevalence ratios by latent classes.ResultsA total of six classes were identified in order of increasing risk: ‘overall low-risk behaviour’ (n=2974; 22.0%), ‘Western origin and multiple sex partners’ (MSP) (n=4182; 30.9%), ‘Non-Western origin and MSP’ (n=2496; 18.5%), ‘living with HIV’ (n=827; 6.1%), ‘group sex and HIV-positive partners’ (n=1798; 13.3%) and ‘group sex and chemsex’ (n=1239; 9.2%). The any STI positivity ranged from 14.0% in the overall low-risk behaviour class to 35.5% in the group sex and chemsex class. HIV positivity did not differ significantly between classes. The Western origin and MSP class was largest and accounted for the majority of STI and HIV infections.ConclusionsAlthough STI positivity increased with increased risky behaviours, considerable STI positivity was found in all six latent classes. Comparable HIV positivity between classes indicates risk reduction strategies among subgroups engaged in risky behaviours. The differences in risk behaviour and STI positivity require preventive strategies tailored to each subgroup.

Objective: Improving adherence to preexposure prophylaxis (PrEP) by providing automated feedback on self-reported PrEP use via a mobile application (app).Design: Randomized clinical trial among MSM participating in the Amsterdam PrEP demonstration project (AMPrEP).Methods: Eligible participants were randomized 1 : 1 to the control or intervention app. Both allowed daily reporting of sexual behaviour and medication intake; the intervention app also provided visual feedback. Dried blood spots collected at 12 and 24 months yielded intracellular tenofovir diphosphate concentrations (TFV-DP). We assessed proportions of participants with poor (TFV-DP Results: We randomized 229 participants, 118 to the intervention and 111 to the control arm. The primary, per-protocol, analysis included 83 participants per arm. In total, 22/166 (13%) of participants adhered poorly, 144/166 (87%) good and 66/166 (40%) excellently. App feedback did not result in a lower proportion of participants with poor adherence [control: 9 of 83 (11%); intervention: 13 of 83 (16%); P = 0.36]. App feedback did result in a larger proportion of participants with excellent adherence [control: 26/83 (31%); intervention: 40/83 (48%); P = 0.026].Conclusion: In this highly adherent population, app feedback did not improve the proportion of participants with poor adherence to PrEP.

Supplemental digital content is available in the text. In a study on preexposure prophylaxis in Amsterdam, a mobile app for reporting adherence and sexual behavior was used frequently, especially by participants on daily preexposure prophylaxis or recently started., Background We studied the use of a mobile application (app) to measure human immunodeficiency virus (HIV) preexposure prophylaxis (PrEP) adherence and sexual behavior, assessed determinants of app use, and we compared data in app and questionnaires. Methods Men who have sex with men participating in the Amsterdam PrEP project (AMPrEP) on daily or event-driven PrEP at the Public Health Service of Amsterdam completed the data on sexual risk behavior and PrEP adherence through a standard questionnaire every 3 months and on a daily basis using the project's app. Regression analyses were used to assess factors associated with app use. Among those who reported 90% or greater of data in the app, the number of PrEP pills taken and number of unknown casual sex partners were compared between the app and the questionnaires by Wilcoxon signed-rank test. Results Of all participants (n = 374), 94% (352 of 374) reported data in the app at least once; 72% (261 of 362) reported data ≥90% of the days in the sixth month and 62% (222 of 359) in the 12th month following PrEP initiation. Factors associated with reporting data in the app were using daily PrEP and recent initiation of PrEP. The reported numbers of pills taken and unknown sexual partners were comparable between app and questionnaires. Conclusions The AMPrEP app was used frequently, especially by those using a daily PrEP regimen. Data collected by app regarding adherence and sexual risk behavior were consistent with questionnaire data among those who used the app consistently. An app is a promising tool to measure PrEP adherence and sexual risk behavior.

Pre-exposure prophylaxis (PrEP) is a promising strategy to reduce HIV incidence among men who have sex with men (MSM). How and when PrEP is used could in part be influenced by its impact on the sexual well-being of its users. Yet, the impact of PrEP on sexual well-being has received little attention in current literature and is not well-understood. We conducted 43 in-depth interviews (June 2017-June 2018) with HIV-negative MSM who started PrEP within the Amsterdam PrEP study. We used purposive sampling to select participants who (1) reported changes on well-being indicators; (2) switched between PrEP-dosing regimens; (3) neither changed regimens nor changed on well-being indicators. Transcribed interviews were qualitatively analyzed by means of an open-coding process. Results showed that PrEP minimized HIV-related fear, increased self-esteem, and reduced stigma and shame about having condomless anal sex. The psychological relief provided by PrEP also enabled relaxation which reduced pain during anal sex. PrEP use increased the diversity of partner choices and improved the perceived quality of sexual relationships and the ability to develop relationships. Along with this positive impact, almost half of interviewees reported concurrent negative experiences. In some cases, PrEP triggered more extreme sexual behaviors and/or problematic increases in preoccupation with sex and drug use. These were perceived as having a negative impact on sexual relationships, sexual well-being, PrEP adherence, and general health. In conclusion, our findings suggest that PrEP contributes to improvements in sexual well-being that go beyond protection from HIV. Counseling strategies should be devised to help PrEP users mitigate possible co-existing negative consequences of PrEP use.

Objective: HIV pre-exposure prophylaxis (PrEP) use may lead to higher STI incidence via behavioural risk compensation. We examined changes in sexual behaviour between baseline and 6 months after PrEP initiation among MSM and transgender women (TGW). Design: Prospective, open-label demonstration study at a large sexually transmitted infection (STI) clinic in Amsterdam, the Netherlands. Methods: Participants answered questions about sexual behaviour in the preceding 3 months, including number of anal sex partners and frequency of anal sex with and without condom by partner type and were tested for STI. Sexual behaviour at baseline was compared with 6 months after PrEP initiation using Wilcoxon signed rank tests. Logistic regression was used to identify factors associated with an increase in receptive condomless anal sex acts (rCASa) with casual partners. Results: Data were available for 328 (99%) MSM and 2 (1%) TGW. The number of receptive and insertive condomless anal sex acts (CASa) increased (baseline: median 11, interquartile range 4-23; 6 months: median 14, interquartile range 6-26, P < 0.001), whereas the number of anal sex partners (P = 0.2) and anal sex acts (P = 0.8) remained unchanged. Prevalence of STI was stable. Older age, prior engagement in chemsex, recent use of postexposure prophylaxis and choosing a daily PrEP regimen at baseline were associated with an increase in rCASa with casual partners. Conclusion: Over the first 6 months after initiation of PrEP, an increase in insertive and receptive CASa with casual partners was observed. Long-term follow-up data are needed and STI incidence needs to be closely monitored.

Summary Background Pre-exposure prophylaxis (PrEP) with emtricitabine and tenofovir disoproxil fumarate is highly effective against acquisition of HIV infection, and only two cases of infection with a multidrug-resistant virus have been reported under adequate long-term adherence, as evidenced by tenofovir diphosphate concentrations in dried blood spots. We report a case of wild-type HIV-1 infection despite consistent use of emtricitabine and tenofovir disoproxil fumarate. Methods The patient participated in the Amsterdam PrEP project, a demonstration project of daily and event-driven PrEP. We did extensive testing for HIV, including plasma HIV RNA and nested PCR on bulk peripheral blood mononuclear cells (PBMCs) and sigmoid biopsies after seroconversion. Findings A 50-year-old man who has sex with men and had been on daily emtricitabine and tenofovir disoproxil fumarate for 8 months presented with fever, urinary tract infection caused by Escherichia coli , anal lymphogranuloma venereum infection, and a positive fourth-generation HIV test. We found an atypical seroconversion pattern, with initially only gp160 antibodies detected in the western blot. HIV RNA could not be detected in plasma, and nested PCR for HIV RNA and DNA on bulk PBMCs and sigmoid biopsies were negative. PrEP was discontinued; 3 weeks later HIV RNA was detected in plasma. No drug-resistant mutations were detected. Tenofovir diphosphate concentrations in dried blood spots were stable and high. Interpretation To our knowledge, this is the first detailed case report suggesting wild-type HIV-1 infection despite good adherence, evidenced by repeatedly high concentrations of tenofovir diphosphate in dried blood spots. PrEP providers need to be aware that infection can occur despite good adherence. Regular HIV testing and awareness of atypical patterns of seroconversion is highly recommended. Funding ZonMw, National Institute for Public Health and the Environment, Internal GGD research funds, Aidsfonds, Stichting AmsterdamDiner Foundation, Gilead Sciences, Janssen Pharmaceutica, M A C AIDS Fund, and ViiV Healthcare.

Objectives and design:Hepatitis C virus (HCV) has been recognized as an emerging sexually transmitted infection (STI) among HIV-positive MSM. However, HIV-negative MSM at high risk for HIV might also be at increased risk for HCV. We studied the HCV prevalence in HIV-negative MSM who start preexposure prophylaxis (PrEP) in Amsterdam. Phylogenetic analysis was used to compare HCV strains obtained from HIV-negative and HIV-positive MSM.Methods:At enrolment in the Amsterdam PrEP demonstration project, HIV-negative MSM were tested for the presence of HCV antibodies and HCV RNA. If positive for HCV RNA, an HCV NS5B gene fragment (709bp) was sequenced and compared with HCV isolates from HIV-positive MSM (n=223) and risk groups other than MSM (n=153), using phylogenetic analysis.Results:Of 375 HIV-negative MSM enrolled in Amsterdam PrEP, 18 (4.8%, 95% confidence interval 2.9-7.5%) of participants were anti-HCV and/or HCV RNA positive at enrolment; 15 of 18 (83%) had detectable HCV RNA. HCV genotyping showed genotype 1a (73%), 4d (20%), and 2b (7%). All HCV-positive MSM starting PrEP were part of MSM-specific HCV clusters containing MSM with and without HIV.Conclusion:HCV prevalence among HIV-negative MSM who started PrEP was higher than previously reported. All HIV-negative HCV-positive MSM were infected with HCV strains already circulating among HIV-positive MSM. The increasing overlap between sexual networks of HIV-positive and HIV-negative MSM might result in an expanding HCV-epidemic irrespective of HIV-status. Hence, routine HCV testing should be offered to MSM at high risk for HIV, especially for those enrolling in PrEP programs. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved

Pre-exposure prophylaxis (PrEP) is a promising strategy to reduce HIV incidence among men who have sex with men (MSM). How and when PrEP is used could in part be influenced by its impact on the sexual well-being of its users. Yet, the impact of PrEP on sexual well-being has received little attention in current literature and is not well-understood. We conducted 43 in-depth interviews (June 2017-June 2018) with HIV-negative MSM who started PrEP within the Amsterdam PrEP study. We used purposive sampling to select participants who (1) reported changes on well-being indicators; (2) switched between PrEP-dosing regimens; (3) neither changed regimens nor changed on well-being indicators. Transcribed interviews were qualitatively analyzed by means of an open-coding process. Results showed that PrEP minimized HIV-related fear, increased self-esteem, and reduced stigma and shame about having condomless anal sex. The psychological relief provided by PrEP also enabled relaxation which reduced pain during anal sex. PrEP use increased the diversity of partner choices and improved the perceived quality of sexual relationships and the ability to develop relationships. Along with this positive impact, almost half of interviewees reported concurrent negative experiences. In some cases, PrEP triggered more extreme sexual behaviors and/or problematic increases in preoccupation with sex and drug use. These were perceived as having a negative impact on sexual relationships, sexual well-being, PrEP adherence, and general health. In conclusion, our findings suggest that PrEP contributes to improvements in sexual well-being that go beyond protection from HIV. Counseling strategies should be devised to help PrEP users mitigate possible co-existing negative consequences of PrEP use.

Background Men who have sex with men (MSM) are at high risk for both drug abuse and sexually transmitted infections (STI). We aimed to identify subgroups of MSM in Amsterdam with distinctive patterns of drug use during sex and their association with sexual behavior and STI. Methods In this cross-sectional study, data from four different studies on MSM and transfeminine women conducted at the Public Health Service of Amsterdam in 2014–2016 were used. Information on drug use, sociodemographics and sexual risk behavior, including lab-confirmed STI, was collected. K-median cluster analysis was used to identify subgroups with similar drug use patterns, whose association with sexual behavior and STI was examined. Results A total of 1147 individuals were included. Median age was 40 years (IQR=32–47). Five clusters of users were identified: ‘polydrug (n=329)’, ‘erectile dysfunction drugs (EDD) (n=106)’, ‘nitrites/alcohol (n=310)’, ‘alcohol (n=239)’ and ‘no substance (n=163)’ users. Compared to MSM in the ‘no drug’ user cluster, MSM in the ‘polydrug’ user cluster reported a higher number substances used (median 0, IQR=0–0 versus 6, IQR=5–7; p 0.001) and were most often diagnosed with an STI (1.9% vs 22.5%, p Conclusion Drug use among high-risk MSM is prevalent in Amsterdam and could be categorized into five distinctive clusters based on the types of drugs used and was associated with various degrees of STI risk. The identification of drug use clusters might enable tailoring STI screening and prevention programs to drug-use patterns. Disclosure No significant relationships.

Background Optimizing HIV pre-exposure prophylaxis (PrEP) roll-out requires insight in dosing regimen preferences, frequency and determinants of regimen switches, and PrEP discontinuation. We assessed user-initiated switches and factors associated with switching or stopping daily (dPrEP) or event-driven (edPrEP) PrEP regimens among men who have sex with men (MSM) participating in a PrEP demonstration project in Amsterdam. Methods At enrolment, participants could choose either dPrEP or edPrEP. Participants were able to switch regimens at each quarterly study visit. We evaluated transition intensities (TI) and (time-varying) factors associated with switching (i) between edPrEP and dPrEP and (ii) from either PrEP regimen to discontinuing PrEP, using a continuous-time, multi-state Markov model. Results Of 367 enrolled participants with follow-up, 73.3% chose dPrEP and 26.7% edPrEP at enrolment. During a median follow-up of 2.6 years (IQR=2.4–2.7), 114 (cumulative proportion=36.5%) switched their PrEP regimen at least once. In total, 85 switches from edPrEP to dPrEP (TI=0.41, 95%CI=0.33–0.50) and 98 from dPrEP to edPrEP (TI=0.17, 95%CI=0.14–0.20) occurred, with transitions from edPrEP to dPrEP 2.43-times more likely (95%CI=1.84–3.22) than vice versa. In multivariable analysis, switching from edPrEP to dPrEP was associated with lower age, higher number of sex acts with casual partners, chemsex and living alone, whereas switching from dPrEP to edPrEP was associated with lower age, lower number of casual partners, higher number of sex acts with casual partners and lower score on the New Sexual Satisfaction Scale. A total of 61 individuals discontinued PrEP, with no difference from which regimen: edPrEP (n=22, TI=0.10, 95%CI=0.06–0.15) and dPrEP (n=39, TI=0.06, 95%CI=0.04–0.08). PrEP discontinuation was only associated with lower age (from dPrEP). Conclusion Switching between PrEP regimens is common and more frequent among younger MSM and MSM with higher number of sex acts, who may benefit from client-centered counseling. Rates of PrEP discontinuation are low and are linked to younger age. Disclosure No significant relationships.

Background Men who have sex with men (MSM) constitute a risk group for sexual transmitted infections(STI). Syndemic theory holds that psychosocial problems often co-occur, interact and mutually reinforce each other, thereby increasing risk behavior. We studied the prevalence of psychosocial problems and whether raising awareness of these psychosocial problems increases help seeking behavior. Methods An open-label randomized controlled trial was conducted among MSM with high risk behavior recruited from the STI clinic of Amsterdam (NCT02859935). Inclusion criteria were: either two STI or PEP treatment for HIV negative MSM or one STI for HIV positive MSM in the last 24 months. The following syndemic domains were explored: alcohol, drugs and sex addiction (AUDIT, DUDIT, SCS), anxiety disorder(HADS), depression(HADS), childhood sexual abuse and partner violence. Participants received trimonthly standard STI care for one year. Additionally, the intervention group received face-to-face feedback on syndemic questionnaires. Results Between September 2016 and August 2017 155 MSM were included. Median age was 43(IQR [34–51]), and 103/155(66%) were HIV positive. At baseline, 37/155(24%) tested positive for chlamydia, gonorrhea or syphilis, 1/52(2%) for HIV, 138/148(93%) reported using drugs during sex in the preceding 3 months, and 51/155(33%) self-reported help seeking behavior. In total, 114/155(75%) scored positive for at least 1 questionnaire: 47/154(31%) for alcohol use disorder, 76/154(49%) for drug use disorder, 28/154(18%) for sexual compulsivity, 47/154(30%) for anxiety disorder, 26/154(17%) for depression, 17/154(11%) for sexual abuse and 12/154(8%) for partner violence. Between the intervention and control group, we found no significant difference in self-reported help seeking behavior (35% vs 24% p=0.168), or in number of partners(13 IQR[5.5–30] vs 8.5 IQR[5–15] respectively, p=0.128). Conclusion Psychosocial and addiction related problems are alarmingly high in high risk MSM, and a syndemic approach seems necessary. Preliminary results indicate that our intervention did not increase self-reported help seeking behavior. Data collection on confirmed help seeking is ongoing. Disclosure No significant relationships.

Introduction In settings where both daily and event‐driven pre‐exposure prophylaxis (PrEP) are offered to men who have sex with men (MSM), a clear understanding of the motives to choose between the different dosing‐regimens can facilitate more effective PrEP implementation. We therefore studied the motives for choosing for, switching between, and stopping daily or event‐driven PrEP. Methods We used data (August 2015‐June 2017) from the prospective, longitudinal, open‐label Amsterdam PrEP demonstration study, in which daily (dPrEP) and event‐driven PrEP (edPrEP) were offered to 374 HIV‐negative MSM and two transgender persons. Participants self‐selected the preferred PrEP‐regimen at baseline and could switch regimens at three‐monthly follow‐up visits. We measured motives for choosing PrEP‐regimen at baseline and for switching and stopping PrEP at follow‐up visits. Open‐ and closed‐end items were combined and qualitatively analysed. Results Choices of PrEP‐regimens were determined by personal and contextual factors, involving the perceived self‐efficacy concerning adherence, the risk‐context, and the anticipated impact of PrEP on physical and sexual wellbeing. dPrEP was preferred because of the anticipated better adherence and the fear of side‐effects relating to edPrEP re‐initiations. Moreover, dPrEP was perceived to be more effective than edPrEP. Motives to choose edPrEP were the expected physical burden of dPrEP, anticipated side‐effects of dPrEP, and fear to forget daily doses. Regarding the risk‐context: dPrEP was preferred for unplanned and/or frequent sex, while edPrEP was chosen when risk was predictable and/or less frequent. While some chose for dPrEP to gain more sexual freedom, others chose for edPrEP to minimize sexual risk episodes. Changes in the above factors, such as changing risk patterns, changing relationships or changing physical conditions, resulted in switching regimens. Choices to stop PrEP were related to lower sexual risk, adherence issues and side‐effects. Conclusions The great diversity of motives illustrates the importance of offering a choice of PrEP‐regimens. In counselling of MSM starting PrEP, choices for PrEP‐regimens may be addressed as a continuum of flexible and changeable options over time. This may help individuals choose the PrEP‐regimen that best fits their current sexual context, priorities and personal capabilities and therefore will be more easily adhered to.

Summary Background Pre-exposure prophylaxis (PrEP) for HIV might induce risk compensation, defined as increased sexual risk behaviour leading to increased incidence of bacterial sexually transmitted infections (STIs). We examined the incidence of HIV, STIs, and sexual behaviour after initiating daily and event-driven PrEP. Methods AMPrEP is a demonstration study that assessed the incidence of HIV and bacterial STIs and sexual behaviour among PrEP users at the STI clinic of the Public Health Service of Amsterdam (Amsterdam, the Netherlands). Eligible adults (aged ≥18 years) were HIV-negative men who have sex with men (MSM) and transgender people who had reported one or more of the following in the previous 6 months: condomless anal sex with casual partners, at least one bacterial STI, use of post-exposure prophylaxis after a sexual risk incident, or an HIV-positive sexual partner with detectable viral load. Participants were given a choice of daily PrEP or event-driven PrEP regimens. Participants were seen every 3 months for HIV and STI testing. Participants also completed self-administered questionnaires about sexual behaviour at each visit. Over the first 2 years, we assessed the number and incidence rate of HIV and chlamydia, gonorrhoea, and syphilis, including STIs diagnosed in between study visits and assessed changes in incidence over time using piecewise exponential survival models. The number of sexual acts and sexual partners were also analysed and changes over time were assessed using negative binomial regression models. This study is ongoing; the data cutoff for this analysis was June 30, 2018. Findings Between Aug 3, 2015, and May 31, 2016, 376 participants were recruited, of whom nine participants were lost to follow-up, thus 367 participants were included in the analysis. Overall, 365 MSM and two transgender women were included, contributing 681·7 person-years of follow-up. At enrolment, 269 (73%) of 367 participants chose daily PrEP and 98 (27%) participants chose event-driven PrEP. Two individuals in the daily PrEP group became HIV-positive; overall HIV incidence rate was 0·30 per 100 person-years (95% CI 0·07–1·19). 253 participants were diagnosed with one or more STI during the first 2 years (incidence rate 90·4 per 100 person-years). STI incidence did not change over time (adjusted incidence rate ratio [aIRR] 1·00 per 3 month follow-up, 95% CI 0·93–1·07). More than a quarter of all STIs were diagnosed from tests done in between study visits. STI incidence was lower in the event-driven PrEP group than the daily PrEP group (aIRR 0·59, 95% CI 0·46–0·75). The number of condomless anal sex acts with casual partners per 3 months increased, but the number of partners and sex acts remained stable. Interpretation Although the overall incidence of STIs did not change during 2 years of PrEP use, the incidence of STIs was higher among participants using daily PrEP than those using event-driven PrEP, which is likely a result of differences in sexual behaviour. This finding suggests the need to tailor STI prevention interventions according to behavioural profiles. Funding ZonMw, H-TEAM, Internal GGD research funds, Aidsfonds, Stichting AmsterdamDiner Foundation, Gilead Sciences, Janssen Pharmaceutica, M A C AIDS Fund, and ViiV Healthcare.

Introduction The Amsterdam PrEP project is a prospective, open-label demonstration study at a large sexually transmitted infection (STI) clinic. We examined the uptake of PrEP; the baseline characteristics of men who have sex with men (MSM) and transgender persons initiating PrEP; their choices of daily versus event-driven PrEP and the determinants of these choices. Methods From August 2015 through May 2016, enrolment took place at the STI clinic of the Public Health Service of Amsterdam, the Netherlands. MSM or transgender persons were eligible if they had at least one risk factor for HIV infection within the preceding six months. Participants were offered a choice between daily or event-driven use of tenofovir/emtricitabine. Baseline data were analysed using descriptive statistics and multivariable analysis was employed to determine variables associated with daily versus event-driven PrEP. Results Online applications were submitted by 870 persons, of whom 587 were invited for a screening visit. Of them, 415 were screened for eligibility and 376 initiated PrEP. One quarter (103/376, 27%) chose event-driven PrEP. Prevalence of bacterial STI was 19.0% and mean condomless anal sex (CAS) episodes in the preceding three months were 11. In multivariable analysis, older age (≥45 vs. ≤34, aOR 2.1, 95% CI 1.2 to 3.9), being involved in a steady relationship (aOR 1.7, 95% CI 1.0 to 2.7), no other daily medication use (aOR 0.6, 95% CI 0.3 to 0.9), and fewer episodes of CAS (per log increase aOR 0.7, 95% CI 0.6 to 0.9) were determinants for choosing event-driven PrEP. Discussion PrEP programmes are becoming one of the more important intervention strategies with the goal of reducing incident HIV-infection and we were unable to accommodate many of the persons applying for this study. Offering a choice of dosing regimen to PrEP users may enable further personalization of HIV prevention strategies and enhance up-take, adherence and cost-effectiveness. Conclusions The majority of participants preferred daily versus event-driven use. Within this majority, a high number of CAS episodes before PrEP initiation was reported and we observed a high prevalence of STI. Determinants of choosing event-driven PrEP were older age, fewer CAS episodes, no other daily medication use, and involved in a steady relationship.

Introduction Since 2000, hepatitis C virus (HCV) has emerged as a sexually transmitted infection among men who have sex with men (MSM). Although the reported HCV epidemic has largely been confined to HIV infected MSM, spread to HIV negative MSM might have gone unnoticed. Methods HIV negative MSM at high risk for acquiring HIV who enrolled in the Amsterdam Pre-Exposure Prophylaxis (AMPrEP) demonstration project at the Public Health Service of Amsterdam were tested for the presence of HCV antibodies and HCV RNA. If positive for HCV RNA, part of the HCV NS5B gene (709 bp) was sequenced. Maximum likelihood phylogenies (GTR substitution model) were constructed to compare HCV sequences from HIV negative AMPrEP participants, Dutch HIV positive MSM with acute or chronic HCV infection (n=246; period 2000–2015) and Dutch risk groups other than MSM (n=153; period 2000–2015). Bootstrap values>70% define robust phylogenetic clusters. Results By June 2016, all 376 HIV negative MSM had been enrolled in AMPrEP; 18 (4.8%, 95% CI 2.8%–7.5%) were positive for anti-HCV or HCV-RNA at baseline. Of those, 15/18 (83%) had detectable HCV-RNA, including one without detectable anti-HCV. HCV genotyping showed genotype 1a (73%), 4d (20%) and 2b (7%). Of the 15 participants with HCV RNA, 13 (87%) were part of 6 robust MSM-specific HCV clades containing MSM with and without HIV. This included 9/11 HIV negative MSM infected with HCV-1a (Figure 1), and all 4 MSM infected with HCV-4d and HCV-2b. Four out of 17 (24%) HCV positive participants reported injecting drugs in the 3 months preceding PrEP start, compared to 11/354 (3.1%) among HCV negative participants. Conclusion The HCV prevalence of 4.8% among HIV-negative MSM eligible for PrEP was higher than the prevalence around 1% previously observed among Dutch HIV negative MSM attending an STI clinic and not on PrEP. HCV-mono-infected MSM were infected with the same MSM-specific HCV strains circulating among HCV/HIV co-infected MSM, suggesting spread from HIV positive to high-risk HIV negative MSM. Routine HCV testing should be offered to MSM at high risk for HIV and included in PrEP guidelines.

Introduction Pre-exposure prophylaxis (PrEP) is an effective prevention measure against HIV. Risk compensation may partially counteract the public health effect of PrEP if this might increase STI incidence. We studied changes in sexual behaviour among men who have sex with men (MSM) and transgender women (TGW) who started daily PrEP In the Amsterdam PrEP (AMPrEP) demonstration project over the first 6 months. Methods Participants completed a questionnaire at baseline and at the 6 mo visit, about sexual behaviour in the preceding 3 mo. At baseline information about demographics and drug use was collected. Sexual behaviour questions concerned frequency of sex, condom use and sexual position (insertive/receptive) by partner type (casual/steady). Reported sexual behaviour at 6 mo was compared to behaviour at baseline using signed rank tests. Logistic regression was used to identify predictors for an increase in receptive condomless anal sex acts (rCAS) with casual partners. Results In 2015–2016, 273 participants started daily PrEP. From this analysis 49 participants were excluded because they switched to intermittent PrEP (n=23), were not due for their 6 months visit yet (n=17), or because of missing data (n=9). The total no. of sex partners (median=15) and no. of anal sex acts (median=24) remained unchanged (p=0.2, p=0.4, respectively). The no. of casual partners increased (median from 14 to 15, p=0.03). The total no. of rCAS increased from a median of 3 to a median of 8 (p Conclusion During the first 6 mo of daily PrEP use, we observed an increase in sexual risk behaviour among MSM and TGW. PrEP users aged ≥35y and those engaging in chemsex were more likely to report an increase in high risk sexual behaviour. Whether risk compensation leads to an increase in STI incidence needs to be closely monitored.

Introduction Men who have sex with men (MSM) constitute a risk group for sexual transmitted infections (STIs), including HIV. Despite counselling interventions, risk behaviour remains high. Syndemic theory holds that psychosocial problems often co-occur, interact and mutually reinforce each other, thereby increasing high risk behaviours and co-occurring diseases. Therefore, if co-occurring psychosocial problems were assessed and treated simultaneously, this might decrease high risk behaviour and disease. Method An open label randomised controlled trial will be conducted among 150 MSM with high risk behaviour recruited from the STI clinic of Amsterdam. Inclusion criteria are: HIV negative MSM with two STI or PEP treatment in the last 24 months or HIV positive MSM with one STI in the last 24 months. All participants get questionnaires on the following syndemic domains: ADHD (ASRS), depression (HADS), anxiety disorder(HADS), alexithymia (TAS) and sex(SCS, Kalichman) and drug addiction(DUDIT and AUDIT). Participants in the control group receive standard care for one year: STI screenings every three months and motivational interviewing based counselling. Participants in the experimental group receive standard care plus additional questionnaires depending on baseline questionnaire scores followed by feedback and referral to a co-located mental health or addiction service in case of a positive indication according to the additional questionnaires. The primary outcome is help seeking behaviour for mental health problems and/or drug use problems. The secondary outcomes are STI incidence and changes in sexual risk behaviour (i.e. condom use, number of anal sex partners, drug use during sex). Conclusion This study will provide information on syndemic domains among MSM who show high risk behaviour and on the effect of screening and referral on help seeking behaviour and health (behaviour) outcomes. Inclusion started in September 2016, on 1 December more than 60 MSM were included with this pace baseline data will be available in July 2017.

Men who have sex with men (MSM) constitute a risk group for sexual transmitted infections (STIs), including HIV. Despite counselling interventions, risk behaviour remains high. Syndemic theory holds that psychosocial problems often co-occur, interact and mutually reinforce each other, thereby increasing high risk behaviours and co-occurring diseases. Therefore, if co-occurring psychosocial problems were assessed and treated simultaneously, this might decrease high risk behaviour and disease. An open label randomized controlled trial will be conducted among 150 MSM with high risk behaviour recruited from the STI clinic of Amsterdam. Inclusion criteria are: HIV negative MSM with two STI and/or PEP treatment in the last 24 months, or HIV positive MSM with one STI in the last 24 months. All participants get questionnaires on the following syndemic domains: ADHD, depression, anxiety disorder, alexithymia and sex- and drug addiction. Participants in the control group receive standard care: STI screenings every three months and motivational interviewing based counselling. Participants in the experimental group receive standard care plus feedback based on the results of the questionnaires. All participants can be referred to co-located mental health or addiction services. The primary outcome is help seeking behaviour for mental health problems and/or drug use problems. The secondary outcomes are STI incidence and changes in sexual risk behaviour (i.e. condom use, number of anal sex partners, drug use during sex). This study will provide information on syndemic domains among MSM who show high risk behaviour and on the effect of screening and referral on help seeking behaviour and health (behaviour) outcomes. Trial Registration at clinicaltrail.gov, identifier NCT02859935 .