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

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

Delayed linkage to care in one-third of HIV-positive individuals in the Netherlands.

OBJECTIVES: To determine time to linkage to HIV care following diagnosis and to identify risk factors for delayed linkage. METHODS: Patients newly diagnosed with HIV at sexually transmitted infections (STI) clinics in the Netherlands were followed until linkage to care. Data were collected at the time of diagnosis and at first consultation in care, including demographics, behavioural information, CD4+ counts and HIV viral load (VL) measurements. Delayed linkage to care was defined as >4 weeks between HIV diagnosis and first consultation. RESULTS: 310 participants were included; the majority (90%) being men who have sex with men (MSM). For 259 participants (84%), a date of first consultation in care was known; median time to linkage was 9 days (range 0-435). Overall, 95 (31%) of the participants were not linked within 4 weeks of diagnosis; among them, 44 were linked late, and 51 were not linked at all by the end of study follow-up. Being young (<25 years), having non-Western ethnicity or lacking health insurance were independently associated with delayed linkage to care as well as being referred to care indirectly. Baseline CD4+ count, VL, perceived social support and stigma at diagnosis were not associated with delayed linkage. Risk behaviour and CD4+ counts declined between diagnosis and linkage to care. CONCLUSIONS: Although most newly diagnosed patients with HIV were linked to care within 4 weeks, delay was observed for one-third, with over half of them not yet linked at the end of follow-up. Vulnerable subpopulations (young, uninsured, ethnic minority) were at risk for delayed linkage. Testing those at risk is not sufficient, timely linkage to care needs to be better assured as well.

TLR9 KO mice, haplotypes and CPG indices in Chlamydia trachomatis infection.

Previous studies have investigated the role of Toll-like receptor (TLR)2 and TLR4 in susceptibility to and severity of Chlamydia trachomatis infections. In this study we employ a unique integrated approach to study the role of the intracellular CpG DNA receptor: we use a murine knockout (KO) model to assess TLR9 relevance, study human TLR9 genotypes and haplotypes in sexually transmitted disease (STD) patients and subfertile women with or without tubal pathology and use in silico TLR9 CpG index calculations to assess potential immunostimulatory properties of the Chlamydia bacterium. Although no significant differences in the course of initial infections were observed between KO mice and wild-type mice the TLR9 KO mice showed a significant level of protection upon reinfection (P = 0.02). We did not observe significant differences in genotype frequencies between C. trachomatis-positive and C. trachomatisnegative women (STD patients). However, haplotype analyses revealed a trend between C. trachomatis-positive and C. trachomatis-negative women in the carriage of haplotype IV (P = 0.061; OR: 2.6; 95% CI: 1.0-6.8). In women with subfertility, odds ratios between 2 and 3 were found for tubal pathology risk, but they did not reach significance due to cohort size limitations. Finally, CpG sequence analysis showed mildly immunostimulatory properties for the genomic sequences of Chlamydia serovars B and D. Based on the murine model, human immunogenetic studies and in silico CpG index analyses, TLR9 seems to play a modest role in C. trachomatis infections. Extension of the human cohorts is necessary to significantly prove the effect in humans.

TLR4 in Chlamydia trachomatis infections: knockout mice, STD patients and women with tubal factor subfertility.

Chlamydia trachomatis is the most prevalent sexually transmitted bacterium in the world with almost 100 million new cases each year, some of which will develop tubal pathology. Clear differences in its clinical course of infections have been observed, and recently it has been shown that 40% is based on host genetic factors. We used an integrated approach based on infection of Toll-like receptor 4 (TLR4) knockout mice and immunogenetic analysis of female sexually transmitted disease (STD) patients (susceptibility) and women with C. trachomatis-associated tubal factor subfertility (severity). The results in TLR4 knockout mice suggest that the protection against reinfection is more solid in normal as compared to the TLR4-deficient mice. In humans the functional TLR4 single nucleotide polymorphism studied was not involved in the susceptibility to infection. However, C. trachomatis immunoglobulin (Ig) G-positive subfertile women with tubal pathology were more than twice as likely to be carriers of the mutant TLR4 +896 G allele as compared to those without tubal pathology; however this observation did not reach statistical significance. In conclusion, both the murine model and the human immunogenetics studies show a slight effect upon TLR4 deficiency in the severity of infection but not in the susceptibility to infection.

Nurse-led sexually transmitted disease clinics: staff perceptions concerning the quality of the service.

The aim of this study was to evaluate staff perception of a nurse-led sexually transmitted infection (STI) clinical service. The staff at the Amsterdam STI clinic were interviewed using a standardized questionnaire. A series of eight questions was designed to determine the perceived advantages or disadvantages of nurse-led clinics, based on personal experience, using a Likert scale. After completion of the structured interview, the staff were offered the opportunity of providing comments. All 36 members of staff completed the survey. Twenty-seven (75%) agreed or strongly agreed that nurse-led clinics provided more time with patients. Sixty-four percent agreed or strongly agreed that such a service provided greater confidentiality and 94% agreed or strongly agreed that 'nurse-led clinics provided a high level of job satisfaction for nurses.' In contrast, only 64% agreed or strongly agreed that nurse-led clinics provided a high level of job satisfaction for doctors. When staff comments were evaluated, four common themes emerged. First, that this was an efficient way of providing services; second, that the clinic was a pleasant environment, there was excellent teamwork and greater job satisfaction; third, that a good deal of rivalry existed between doctors and nurses and finally, that there was a need for and importance of protocols, rules and staff training and development. In conclusion, there was a high level of staff satisfaction with the service. Nurse-led STI clinics may be a useful adjunct to existing STI facilities.

Opting out increases HIV testing in a large sexually transmitted infections outpatient clinic.

OBJECTIVES: In January 2007, opt-out HIV testing replaced provider-initiated testing at the sexually transmitted infections (STI) outpatient clinic in Amsterdam, The Netherlands. The effect of the opt-out strategy on the uptake of HIV testing was studied and factors associated with refusal of HIV testing were identified. STUDY DESIGN: Data routinely collected at the STI clinic were analysed separately for men who have sex with men (MSM) and heterosexuals. Logistic regression analysis was used to identify factors associated with opting out. RESULTS: In 2007, 12% of MSM and 4% of heterosexuals with (presumed) negative or unknown HIV serostatus declined HIV testing. Refusals gradually decreased to 7% and 2% by the year end. In 2006, before the introduction of opt-out, 38% of MSM and 27% of heterosexuals declined testing. The proportion of HIV-positive results remained stable among MSM, 3.4% in 2007 versus 3.7% in 2006, and among heterosexuals, 0.2% in 2007 versus 0.3% in 2006. In both groups factors associated with opting out were: age >or=30 years, no previous HIV test, the presence of STI-related complaints and no risky anal/vaginal intercourse. Among heterosexuals, men and non-Dutch visitors refused more often; among MSM, those warned of STI exposure by sexual partners and those diagnosed with gonorrhoea or syphilis refused more often. CONCLUSIONS: An opt-out strategy increased the uptake of HIV testing. A sharp increase in testing preceeded a more gradual increase, suggesting time must pass to optimise the new strategy. A small group of visitors, especially MSM, still opt out. Counselling will focus on barriers such as fear and low risk perception among high-risk visitors considering opting out.

[High time for wide application of an opting-out strategy for HIV testing]. / Hoog tijd voor brede toepassing van 'opting-out'-strategie bij hiv-tests.

--Despite the current active HIV test policy, the effects of the former policy are still visible, i.e. a relatively low number of individuals that have ever been tested for HIV. --The number of HIV tests and knowledge of current HIV status has increased among visitors to the STI clinic in Amsterdam. --Nevertheless, anonymous HIV surveillance among visitors to the STI clinic shows that a considerable proportion of HIV-infected individuals (24% of men who have sex with men (MSM) and 80% of heterosexuals) are unaware of the infection. --A new opting-out strategy for HIV testing in STI clinics is recommended. --The opting-out strategy may also be applicable to other medical settings, especially those that treat target populations such as MSM, heterosexuals with STI-related symptoms, and persons originating from AIDS-endemic regions. --The opting-out system was initiated in the Amsterdam STI clinic in 2007 in order to further reduce the number of undiagnosed HIV infections.

[The rise in fluoroquinolone-resistant Neisseria gonorrhoeae among people attending the Municipal Health Service's clinic for sexually transmitted diseases in Amsterdam, the Netherlands; cefotaxime now first-choice treatment for uncomplicated gonorrhoea]. / Toename van fluorochinolonresistentie bij Neisseria gonorrhoeae onder bezoekers van de soa-polikliniek in Amsterdam; cefotaxim nu als eerste keus aanbevolen voor ongecompliceerde gonorroe.

OBJECTIVE: To report the incidence of gonorrhoea and the development of resistance to Neisseria gonorrhoeae among attendees at the Municipal Health Service's STD-clinic in Amsterdam, The Netherlands, 2000-2003. DESIGN: Descriptive. METHOD: Urethral or cervical swabs for culture for N. gonorrhoea were taken from attendees at the STD-clinic. Depending on reported sexual techniques throat and rectal swabs were also taken. The disk diffusion technique in combination with a beta-lactamase test were used for sensitivity testing. RESULTS. The number of Neisseria gonorrhoeae (NG) isolates collected at the Amsterdam Municipal Health Service's STD-clinic decreased from 1047 in 2002 to 772 in 2003. The number of fluoroquinolone-resistant NG (FRNG) isolates rose from 3 in 2000 to 56 in 2003 (p < 0.001). FRNG isolates amongst men who have sex with men increased from 1 in 568 isolates (0.2%) in 2000 to 50 in 478 isolates (10.5%) in 2003 (p < 0.001). Amongst heterosexual men, FRNG rose from 2 per 275 (0.7%) in 2000 to 16 per 297 (5.4%) in 2002 and dropped to 6 per 190 (3.4%) in 2003 (p = 0.146). No FRNG isolates were found in women in 2003 (2000: 0/180 (0.0%); 2001: 2/160 (1.3%); 2002: 4/183 (2.2%). CONCLUSION: The recent incidence of FRNG among men who have sex with men to over 5% makes ciprofloxacin and other fluoroquinolones obsolete as the first-choice treatment option for uncomplicated gonorrhoea if no antibiogram is available. It is advised to use cefotaxim when an antibiogram is not available (yet).

[Inguinal lymphogranuloma venereum in a man having sex with men: perhaps an example of the missing link to explain the transmission of the recently identified anorectal epidemic]. / Inguïnale lymphogranuloma venereum bij een man die seks heeft met mannen; wellicht een voorbeeld van de ontbrekende schakel ter verklaring van de transmissie bij de recent vastgestelde anorectale epidemie.

A 38-year-old man who had sex with men, presented at the outpatient department for Sexually Transmitted Diseases in Amsterdam with a painful, red, fluctuating swelling in the left groin and general discomfort. He had been sexually active in the population of men who have sex with men, in which an anorectal lymphogranuloma venereum (LGV) epidemic has recently been discovered. Unlike other cases where there was anorectal involvement, this patient was the first case of LGV with the classical inguinal presentation although he had not visited the tropics where the inguinal form of LGV occurs as an STD. Routine investigation using PCR on material from urethra and rectum and from the urine, repeatedly failed to detect LGV. However, PCR on pus aspirated from the enlarged lymph node demonstrated Chlamydia trachomatis serovar type L2. Treatment with doxycycline 100 mg twice daily was started. This case illustrates that routine analysis from urethra and rectum and of urine may fail to detect LGV. Furthermore, this case of a patient who probably had LGV initially in the urethra may be the missing link in explaining the route of transmission of the anorectal LGV epidemic.

[HIV-infection and AIDS in the Netherlands: prevalence and incidence, 1987-2001]. / HIV-infectie en aids in Nederland: prevalentie en incidentie, 1987-2001.

OBJECTIVE: To describe the results of HIV-surveillance activities in the Netherlands between 1987 and 2001. DESIGN: Descriptive. METHOD: Data were obtained from HIV-surveillance at STI-clinics, laboratory-surveillance in the region Arnhem, surveillance among injecting drug users, the AIDS-notification, STI-registration and the Amsterdam cohort studies on HIV/AIDS. RESULTS: In the Netherlands, the highest HIV-prevalences were found among injecting drug users (1-26%) and homo- and bisexual men (0-17%). In these high-risk populations, an increase in HIV-prevalence and--incidence, respectively, was found among injecting drug users in Heerlen and homosexual men (> 35 years of age) in Amsterdam. The HIV-prevalence was lower among heterosexuals in the Netherlands (0-2%). However, in certain local populations an increase was seen. In both Amsterdam and Rotterdam, the HIV-prevalence was higher in individuals tested anonymously than in those tested by name. CONCLUSION: Local increases in HIV-infections have been observed recently, in both high- and medium-risk populations.

[Syphilis epidemic and an increase of the number of HIV infections among homosexual men attending the Amsterdam venereal disease clinic]. / Syfilisepidemie en stijging van het aantal HIV-infecties onder homoseksuele mannen op de Amsterdamse SOA-polikliniek.

The registered number of cases of early infectious syphilis and of (ano)genital gonorrhoea among the attendees of the outpatient clinic for sexually transmitted diseases of the Amsterdam municipal health service shows a strong increase for both diagnoses in the period 1990-2001, notably in the last few years. Nearly all of this increase is accounted for by homosexual men. Syphilis increased mostly among men aged 35 years and over, gonorrhoea mostly among younger men. The population of older men also showed a distinct increase since 1997 in HIV incidence.

[Increased Neisseria gonorrhoeae quinolone resistance in Amsterdam]. / Toename van chinolonresistentie bij Neisseria gonorrhoeae in Amsterdam.

In addition to a rise in the number of cases of gonorrhoea, the susceptibility of Neisseria gonorrhoeae to antibiotics is also a cause for concern. After a period of high resistance rates to penicillin and tetracycline between 1985 and 1995, resistance rates have dropped considerably in recent years, probably due to changes in treatment regimens. However, recently we have seen an increasing number of quinolone-resistant N. gonorrhoeae isolates in Amsterdam, the Netherlands, a development that has previously been reported in other parts of the world. Some form of national resistance monitoring for gonococci is therefore urgently required to allow timely detection of changes in N. gonorrhoeae resistance.

Cost-effectiveness of HIV screening of patients attending clinics for sexually transmitted diseases in Amsterdam.

OBJECTIVE: To estimate the cost-effectiveness of universal HIV screening of patients attending a clinic for sexually transmitted diseases (STD) in Amsterdam. DESIGN: Cost effectiveness analysis. METHODS: A Bernoulli model for the secondary transmission of HIV was linked with epidemiological data on infection with HIV and other STD in patients attending a STD clinic in Amsterdam from 1991 to 1997. This gave estimates of the number of secondary HIV infections caused by attenders of the STD clinic. Combined with data on the health and monetary benefits of averting HIV infection and costs of HIV screening, we assessed the cost-effectiveness of HIV-screening of attenders of the STD clinic. RESULTS: Increased risk for HIV infection was found in STD clinic attendees infected with other STD. (odds ratio, 2.07). The risk differed for specific STD: the highest odds ratios were found for syphilis and gonorrhoea. Screening of all attendees was estimated at net costs of 82,552 Euro per secondary infection averted. The cost-effectiveness ranges between 680 Euro and 9335 Euro per life-year gained, depending on the value of key parameters used in the model. CONCLUSION: Compared to other interventions in infectious diseases control in the Netherlands, screening of STD clinic attendees for HIV has an acceptable cost-effectiveness.

Increase in sexually transmitted infections among homosexual men in Amsterdam in relation to HAART.

OBJECTIVES: We investigated if a rise in rectal gonorrhoea and early syphilis among men who have sex with men (MSM) in Amsterdam coincided with the introduction of highly active antiretroviral therapies (HAART) in July 1996 and determined risk factors for these sexually transmitted infections (STI). METHODS: Subjects were patients of the STI clinic of the municipal health service in Amsterdam. Surveillance data (1994-9) represented consultations (n=11 240) of MSM (n=6103). For analyses we used logistic regression. RESULTS: Comparing the periods before and after the introduction of HAART, the infection rate for rectal gonorrhoea increased from 4% to 5.4% (p=.001) and for syphilis, from 0.5% to 0.8% (p = 0.050). Independent risk factors for rectal gonorrhoea (younger age, western nationality, and concurrent infection with another STI) and for early syphilis (non-western nationality and concurrent infection with rectal gonorrhoea) did not change after HAART became available. For rectal gonorrhoea, however, the infection rate increased only among men who had exclusively homosexual contacts (OR 1.38, p<0.01), compared with bisexual men. For early syphilis, the infection rate increased only among men of western nationality (OR 3.38, p<0.01) compared to men of non-western nationality. CONCLUSIONS: Infection rates of rectal gonorrhoea and early syphilis increased, indicating a change in sexual behaviour, possibly as a result of the introduction of HAART. For now, it is important to find out how sexual behaviour is changing and to keep monitoring trends in STIs (including HIV) among MSM in Amsterdam.

[Substantial increase in gonorrhea and syphilis among clients of Amsterdam Sexually Transmitted Diseases Clinic]. / Sterke toename van gonorroe en syfilis onder bezoekers van de Amsterdamse SOA-polikliniek.

In the Sexually Transmitted Diseases (STD) clinic of the Amsterdam Municipal Health Service standardized data are collected about all visitors, which makes it possible to gain insight into the STD trends. In 1999, 706 new cases of gonorrhoea and 76 new cases of infectious syphilis were diagnosed, increases of 46% and 111% respectively compared with 1998. The largest increase was seen among men who had sex with men. In this group the number of diagnosed cases of anorectal gonorrhoea in 1999 was twice as high as in 1998 (186 versus 94) and the number of infectious syphilis cases four times as high (40 versus 9). These data indicate an increase in unsafe sexual behaviour, possibly because of a change in attitudes about AIDS, now that effective antiretroviral treatment is available.

HIV surveillance among sexually transmitted disease clinic attenders in Amsterdam, 1991-1996.

OBJECTIVE: To determine trends in HIV prevalence among attenders of a clinic for sexually transmitted diseases (STD), with emphasis on heterosexuals who did not have a history of injecting drug use. METHODS: Anonymous unlinked HIV surveys with individual consent, conducted each half year from 1991 to 1996 (except 1993) among STD clinic attenders who came for evaluation of a possible new STD episode. RESULTS: Of 10,940 eligible attenders 10,046 (92%) accepted HIV testing. Of all tested attenders, 312 (3.1%) were HIV-infected. Overall HIV prevalence decreased significantly from 4.6% in 1991 to 2.8% in 1996. HIV prevalence among heterosexual men and women who were not injecting drug users was less than 1% in all but one survey period. Except for one woman, none of the 48 HIV-infected heterosexuals was aware of their current serostatus. Among HIV-infected heterosexuals, 21 out of 28 males (75%) and 18 out of 20 females (90%) were of non-Dutch origin. HIV prevalence was 16% among all homosexual men, and 12% among young homosexual men aged < 30 years. HIV prevalence among young homosexual men decreased significantly over time. Among HIV-infected homosexual men, 58% of older men and 59% of younger men were not aware of their current HIV infection. Rates of current STD were generally significantly higher among HIV-infected participants compared with non-HIV-infected participants. CONCLUSIONS: Although HIV prevalence among heterosexual clinic attenders is low, there is a clear potential for ongoing sexual HIV transmission. Most heterosexually acquired HIV infections are found in non-Dutch persons. This observation suggests migration of HIV-infected heterosexuals or the separation of Dutch and non-Dutch heterosexual networks. Awareness of serostatus is almost non-existent among HIV-infected heterosexuals, and is low among male homosexual clinic attenders. To increase awareness of current HIV serostatus and possibly decrease risk behaviour, HIV counselling and testing should be offered actively to all clinic attenders.

[Surveillance of AIDS and HIV infections in Amsterdam, 1997]. / Surveillance van aids en HIV-infectie in Amsterdam, 1997.

Data were collected in Amsterdam in 1997 from the aids surveillance, from the HIV surveillance among pregnant women and visitors of a clinic for sexually transmitted diseases (STD), and from two 'alternative' HIV test sites, using various survey systems. The findings were compared with those of previous years. Aids was diagnosed in 1997 in 123 patients, in 194 in 1996. Of the 354 patients in whom aids was diagnosed in 1993-1997 in a hospital recording additional information, 113 patients (32%) only learned that they had an HIV infection when aids was diagnosed in them. In 1997, out of 225 pregnant women with an increased risk of HIV infection, 10 were HIV seropositive (4.4%); in 1996, this proportion was 3/285 (1.1%). Among those attending STD clinics, HIV infection was observed approximately as frequently as in earlier years: about 1% of heterosexual men and women.

Clinical sexually transmitted diseases among human immunodeficiency virus-infected and noninfected drug-using prostitutes. Associated factors and interpretation of trends, 1986 to 1994.

OBJECTIVES: To describe among drug-using prostitutes from the Amsterdam cohort study: 1) trends in clinical sexually transmitted disease (STD) diagnoses from 1986 through 1994; 2) identify factors associated with STD incidences; and 3) determine explanatory factors for time trends in STD. METHODS: Sexual behavior data and human immunodeficiency virus (HIV) serostatus from the cohort study were linked to diagnoses of gonorrhea (GC), Chlamydia trachomatis infection (CT), and trichomoniasis (TV) made at a special STD clinic for drug-using prostitutes. Diagnosis-specific incidences were calculated per 100 person-years of follow-up. Factors associated with STD incidence were determined bivariately. Crude time trends in incidences were determined and then multivariately adjusted for sets of potential explanatory factors using Poisson regression. RESULTS: Cohort data from 229 current prostitutes were linked to clinical STD diagnoses. During the study period, a fivefold decline in GC was found, and CT declined twofold; trends in TV initially declined, but tended to increase after 1991. Higher incidences for STD were associated with inconsistent condom use, higher numbers of clients, shorter history of prostitution, younger age, non-Dutch nationality, and HIV infection. About half of the decline in STD could be explained by changes toward safer commercial sexual behaviours or changes in the characteristics of the study population. CONCLUSIONS: From 1986 through 1994, the incidence in clinical STD declined significantly among drug-using prostitutes in Amsterdam. Trends in STD were only partly due to risk reduction in commercial sexual contacts. Thus, it may be hazardous to use trends in STD as markers for sexual risk behavior. Other factors probably played a substantial role in the observed declines, including declining STD prevalence among male clients, changes in health-seeking behaviors, and improved quality of STD control.