Would men who have sex with men support less frequent screening for asymptomatic chlamydia and gonorrhoea to improve antibiotic stewardship? A qualitative study
Amelia Margaret Wardley
A * , Henrietta Williams B , Jacqueline Coombe A , Cassandra Caddy A , Christopher Kincaid Fairley B and Jane Simone Hocking A
+ Author Affiliations
- Author Affiliations
A Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Vic., Australia.
B Melbourne Sexual Health Centre, Melbourne, Vic., Australia.
Sexual Health 20(2) 148-157 https://doi.org/10.1071/SH22139
Submitted: 25 August 2022 Accepted: 20 February 2023 Published: 16 March 2023
© 2023 The Author(s) (or their employer(s)). Published by CSIRO Publishing. This is an open access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND)
Abstract
Background: Men who have sex with men (MSM) taking pre-exposure prophylaxis (PrEP) are recommended to have screening for asymptomatic chlamydia and gonorrhoea every 3 months with high rates of asymptomatic chlamydia and gonorrhoea detected. However, there is little evidence about the effectiveness of this screening interval and there is increasing concern about antibiotic consumption and its impact on antimicrobial resistance. There have been calls to reconsider this frequent screening for chlamydia and gonorrhoea. We conducted interviews with MSM to assess their attitudes to 3-monthly chlamydia and gonorrhoea screening.
Methods: Individual semi-structured interviews were conducted with MSM living in Victoria, Australia. Participants were aged 20–62 years and had been taking PrEP for at least 6 months. Interviews were audio-recorded and transcribed, and these data were investigated through reflexive thematic analysis.
Results: Thirteen interviews were conducted in August 2021. Participants were hesitant about reducing the screening frequency and reported that testing gave them a sense of security. While MSM recognised antimicrobial resistance was a concern, it did not impact their sexual behaviour, with many participants stating they would rather continue to take antibiotics to treat infections rather than adopt preventative measures such as condom use. Positive attitudes towards screening interval changes are more likely when PrEP patients are informed about the risks and benefits of sexual healthcare recommendations.
Conclusion: While MSM on PrEP were initially hesitant to changes in screening frequency, changes may be acceptable if transparent communication, presenting the benefits and harms of screening and treatment, was delivered by a trusted healthcare professional.
Keywords: AMR, MSM, PrEP, qualitative, sexual behaviour, sexual health, STI, STI screening.
References
[1] Centers for Disease Control and Prevention (CDCP). Sexually transmitted disease surveillance 2019. U.S. Department of Health and Human Services; 2019.[2] Jasek E, Chow EPF, Ong JJ, Bradshaw CS, Chen MY, Hocking JS, et al. Sexually Transmitted infections in Melbourne, Australia from 1918 to 2016: nearly a century of data. Commun Dis Intell Q Rep 2017; 41 E212–E22.
[3] Ramchandani MS, Golden MR. Confronting rising STIs in the era of PrEP and treatment as prevention. Curr HIV/AIDS Rep 2019; 16 244–56.
| Confronting rising STIs in the era of PrEP and treatment as prevention.Crossref | GoogleScholarGoogle Scholar |
[4] Brennan DJ, Welles SL, Miner MH, Ross MW, Rosser BRS, The Positive Connections Team HIV treatment optimism and unsafe anal intercourse among HIV-positive men who have sex with men: findings from the positive connections study. AIDS Educ Prev 2010; 22 126–37.
| HIV treatment optimism and unsafe anal intercourse among HIV-positive men who have sex with men: findings from the positive connections study.Crossref | GoogleScholarGoogle Scholar |
[5] Sullivan PS, Drake AJ, Sanchez TH. Prevalence of treatment optimism-related risk behavior and associated factors among men who have sex with men in 11 states, 2000–2001. AIDS Behav 2007; 11 123–9.
| Prevalence of treatment optimism-related risk behavior and associated factors among men who have sex with men in 11 states, 2000–2001.Crossref | GoogleScholarGoogle Scholar |
[6] Brooks RA, Landovitz RJ, Kaplan RL, Lieber E, Lee S-J, Barkley TW. Sexual risk behaviors and acceptability of HIV pre-exposure prophylaxis among HIV-negative gay and bisexual men in serodiscordant relationships: a mixed methods study. AIDS Patient Care STDs 2012; 26 87–94.
| Sexual risk behaviors and acceptability of HIV pre-exposure prophylaxis among HIV-negative gay and bisexual men in serodiscordant relationships: a mixed methods study.Crossref | GoogleScholarGoogle Scholar |
[7] Golub SA, Kowalczyk W, Weinberger CL, Parsons JT. Preexposure prophylaxis and predicted condom use among high-risk men who have sex with men. J Acquir Immune Defic Syndr 2010; 54 548–55.
| Preexposure prophylaxis and predicted condom use among high-risk men who have sex with men.Crossref | GoogleScholarGoogle Scholar |
[8] Traeger MW, Schroeder SE, Wright EJ, Hellard ME, Cornelisse VJ, Doyle JS, et al. Effects of pre-exposure prophylaxis for the prevention of human immunodeficiency virus infection on sexual risk behavior in men who have sex with men: a systematic review and meta-analysis. Clin Infect Dis 2018; 67 676–86.
| Effects of pre-exposure prophylaxis for the prevention of human immunodeficiency virus infection on sexual risk behavior in men who have sex with men: a systematic review and meta-analysis.Crossref | GoogleScholarGoogle Scholar |
[9] Stenger MR, Pathela P, Anschuetz G, Bauer H, Simon J, Kohn R, et al. Increases in the rate of Neisseria gonorrhoeae among gay, bisexual and other men who have sex with men – findings from the sexually transmitted disease surveillance network 2010–2015. Sex Transm Dis 2017; 44 393–7.
| Increases in the rate of Neisseria gonorrhoeae among gay, bisexual and other men who have sex with men – findings from the sexually transmitted disease surveillance network 2010–2015.Crossref | GoogleScholarGoogle Scholar |
[10] Lehmiller JJ, Ioerger M. Social networking smartphone applications and sexual health outcomes among men who have sex with men. PLoS ONE 2014; 9 e86603
| Social networking smartphone applications and sexual health outcomes among men who have sex with men.Crossref | GoogleScholarGoogle Scholar |
[11] Phillips G, Magnus M, Kuo I, Rawls A, Peterson J, Jia Y, et al. Use of geosocial networking (GSN) mobile phone applications to find men for sex by men who have sex with men (MSM) in Washington, DC. AIDS Behav 2014; 18 1630–7.
| Use of geosocial networking (GSN) mobile phone applications to find men for sex by men who have sex with men (MSM) in Washington, DC.Crossref | GoogleScholarGoogle Scholar |
[12] Zou H, Fan S. Characteristics of men who have sex with men who use smartphone geosocial networking applications and implications for HIV interventions: a systematic review and meta-analysis. Arch Sex Behav 2017; 46 885–94.
| Characteristics of men who have sex with men who use smartphone geosocial networking applications and implications for HIV interventions: a systematic review and meta-analysis.Crossref | GoogleScholarGoogle Scholar |
[13] Schueler K, Ferreira M, Nikolopoulos G, Skaathun B, Paraskevis D, Hatzakis A, et al. Pre-exposure prophylaxis (PrEP) awareness and use within high HIV transmission networks. AIDS Behav 2019; 23 1893–903.
| Pre-exposure prophylaxis (PrEP) awareness and use within high HIV transmission networks.Crossref | GoogleScholarGoogle Scholar |
[14] Brady M, Rodger A, Asboe D, Cambiano V, Clutterbuck D, Desai M, et al. BHIVA/BASHH guidelines on the use of HIV pre-exposure prophylaxis (PrEP) 2018. HIV Med 2019; 20 s2–s80.
| BHIVA/BASHH guidelines on the use of HIV pre-exposure prophylaxis (PrEP) 2018.Crossref | GoogleScholarGoogle Scholar |
[15] Kenyon C. We need to consider collateral damage to resistomes when we decide how frequently to screen for chlamydia/gonorrhoea in preexposure prophylaxis cohorts. AIDS 2019; 33 155–7.
| We need to consider collateral damage to resistomes when we decide how frequently to screen for chlamydia/gonorrhoea in preexposure prophylaxis cohorts.Crossref | GoogleScholarGoogle Scholar |
[16] Kenyon C. Screening is not associated with reduced incidence of gonorrhoea or chlamydia in men who have sex with men (MSM); an ecological study of 23 European countries. F1000Res 2019; 8 160
| Screening is not associated with reduced incidence of gonorrhoea or chlamydia in men who have sex with men (MSM); an ecological study of 23 European countries.Crossref | GoogleScholarGoogle Scholar |
[17] US Preventive Services Task Force Owens DK, Davidson KW, Krist AH, Barry MJ, Cabana M, Caughey AB, et al. Preexposure prophylaxis for the prevention of HIV infection: US preventive services task force recommendation statement. JAMA 2019; 321 2203–13.
| Preexposure prophylaxis for the prevention of HIV infection: US preventive services task force recommendation statement.Crossref | GoogleScholarGoogle Scholar |
[18] Tang EC, Vittinghoff E, Philip SS, Doblecki-Lewis S, Bacon O, Chege W, et al. Quarterly screening optimizes detection of sexually transmitted infections when prescribing HIV preexposure prophylaxis. AIDS 2020; 34 1181–6.
| Quarterly screening optimizes detection of sexually transmitted infections when prescribing HIV preexposure prophylaxis.Crossref | GoogleScholarGoogle Scholar |
[19] McCormack S, Dunn DT, Desai M, Dolling DI, Gafos M, Gilson R, et al. Pre-exposure prophylaxis to prevent the acquisition of HIV-1 infection (PROUD): effectiveness results from the pilot phase of a pragmatic open-label randomised trial. Lancet 2016; 387 53–60.
| Pre-exposure prophylaxis to prevent the acquisition of HIV-1 infection (PROUD): effectiveness results from the pilot phase of a pragmatic open-label randomised trial.Crossref | GoogleScholarGoogle Scholar |
[20] Gross G, Flaig B, Rode S. Syphilis. Part 2: laboratory diagnostics, therapy and prevention. Hautarzt 2013; 64 851–63.
| Syphilis. Part 2: laboratory diagnostics, therapy and prevention.Crossref | GoogleScholarGoogle Scholar |
[21] Lucas S, Nelson AM. HIV and the spectrum of human disease. J Pathol 2015; 235 229–41.
| HIV and the spectrum of human disease.Crossref | GoogleScholarGoogle Scholar |
[22] Chow EPF, Vodstrcil LA, Williamson DA, Maddaford K, Hocking JS, Ashcroft M, et al. Incidence and duration of incident oropharyngeal gonorrhoea and chlamydia infections among men who have sex with men: prospective cohort study. Sex Transm Infect 2021; 97 452–8.
| Incidence and duration of incident oropharyngeal gonorrhoea and chlamydia infections among men who have sex with men: prospective cohort study.Crossref | GoogleScholarGoogle Scholar |
[23] Chow EPF, Camilleri S, Ward C, Huffam S, Chen MY, Bradshaw CS, et al. Duration of gonorrhoea and chlamydia infection at the pharynx and rectum among men who have sex with men: a systematic review. Sex Health 2016; 13 199–204.
| Duration of gonorrhoea and chlamydia infection at the pharynx and rectum among men who have sex with men: a systematic review.Crossref | GoogleScholarGoogle Scholar |
[24] Kenyon C, Vanbaelen T, Van Dijck C. Recent insights suggest the need for the STI field to embrace a more eco-social conceptual framework: a viewpoint. Int J STD AIDS 2022; 33 404–15.
| Recent insights suggest the need for the STI field to embrace a more eco-social conceptual framework: a viewpoint.Crossref | GoogleScholarGoogle Scholar |
[25] Lahra MM, Dillon J-AR, George CRR, Lewis DA, Wi TE, Whiley DM. From zero to zero in 100 years: gonococcal antimicrobial resistance. Microbiol Aust 2016; 37 173–6.
| From zero to zero in 100 years: gonococcal antimicrobial resistance.Crossref | GoogleScholarGoogle Scholar |
[26] Murray GL, Bradshaw CS, Bissessor M, Danielewski J, Garland SM, Jensen JS, et al. Increasing macrolide and fluoroquinolone resistance in Mycoplasma genitalium. Emerg Infect Dis 2017; 23 809–12.
| Increasing macrolide and fluoroquinolone resistance in Mycoplasma genitalium.Crossref | GoogleScholarGoogle Scholar |
[27] Kenyon C, Manoharan-Basil SS, Van Dijck C. Is there a resistance threshold for macrolide consumption? positive evidence from an ecological analysis of resistance data from Streptococcus pneumoniae, Treponema pallidum, and Mycoplasma genitalium. Microb Drug Resist 2021; 27 1079–86.
| Is there a resistance threshold for macrolide consumption? positive evidence from an ecological analysis of resistance data from Streptococcus pneumoniae, Treponema pallidum, and Mycoplasma genitalium.Crossref | GoogleScholarGoogle Scholar |
[28] Baker A, Fleury C, Clarke E, Foley E, Samraj S, Rowen D, et al. Increasing screening frequency in men who have sex with men: impact of guidance on risk profiling on workload and earlier diagnosis of sexually transmitted infection and HIV. Int J STD AIDS 2013; 24 613–7.
| Increasing screening frequency in men who have sex with men: impact of guidance on risk profiling on workload and earlier diagnosis of sexually transmitted infection and HIV.Crossref | GoogleScholarGoogle Scholar |
[29] Kenyon C. Risks of antimicrobial resistance in N. gonorrhoeae associated with intensive screening programs in pre-exposure prophylaxis programs. Clin Infect Dis 2018; 67 154–5.
| Risks of antimicrobial resistance in N. gonorrhoeae associated with intensive screening programs in pre-exposure prophylaxis programs.Crossref | GoogleScholarGoogle Scholar |
[30] Tsoumanis A, Hens N, Kenyon CR. Is screening for chlamydia and gonorrhea in men who have sex with men associated with reduction of the prevalence of these infections? A systematic review of observational studies. Sex Transm Dis 2018; 45 615–22.
| Is screening for chlamydia and gonorrhea in men who have sex with men associated with reduction of the prevalence of these infections? A systematic review of observational studies.Crossref | GoogleScholarGoogle Scholar |
[31] Yeung A, Temple-Smith M, Fairley C, Hocking J. Narrative review of the barriers and facilitators to chlamydia testing in general practice. Aust J Prim Health 2015; 21 139–47.
| Narrative review of the barriers and facilitators to chlamydia testing in general practice.Crossref | GoogleScholarGoogle Scholar |
[32] Vella A, Wilkinson A, Pedrana A, Stoové M. Outcome evaluation of HIV prevention initiatives 2012–2013 in men who have sex with men in Victoria. p. 50. Melbourne: Burnet Institute; 2014.
[33] Lee E, Mao L, von Doussa H, Batrouney C, West M, Prestage G, et al. Gay community periodic survey: Melbourne 2014. Sydney: Centre for Social Research in Health, Victorian AIDS Council/Gay Men’s Health Centre, Department of Health Victoira, The Kirby Institute; 2014.
[34] Galletta A, Cross WE Jr. Mastering the semi-structured interview and beyond: from research design to analysis and publication. New York University Press; 2013.
[35] Serry T, Liamputtong P. The in-depth interviewing method in health. In: Liamputtong P, editor. Research methods in health: foundations for evidence-based practice. Oxford University Press; 2013. pp. 39–53.
[36] Braun V, Clarke V, Hayfield N, Terry G. Thematic analysis. In: Liamputtong P, editor. Handbook of research methods in health social sciences. Springer; 2019. pp. 843–860.
[37] Braun V, Clarke V. One size fits all? What counts as quality practice in (reflexive) thematic analysis? Qual Res Psychol 2021; 18 328–52.
| One size fits all? What counts as quality practice in (reflexive) thematic analysis?Crossref | GoogleScholarGoogle Scholar |
[38] QSR International Pty Ltd. NVivo (released in March 2020). 2020. Available at https://www.qsrinternational.com/nvivo-qualitative-data-analysis-software/home
[39] Brown G, Leonard W, Lyons A, Power J, Sander D, McColl W, et al. Stigma, gay men and biomedical prevention: the challenges and opportunities of a rapidly changing HIV prevention landscape. Sex Health 2017; 14 111–8.
| Stigma, gay men and biomedical prevention: the challenges and opportunities of a rapidly changing HIV prevention landscape.Crossref | GoogleScholarGoogle Scholar |
[40] Brown L, Macintyre K, Trujillo L. Interventions to reduce HIV/AIDS stigma: what have we learned? AIDS Educ Prev 2003; 15 49–69.
| Interventions to reduce HIV/AIDS stigma: what have we learned?Crossref | GoogleScholarGoogle Scholar |
[41] Nyblade LC. Measuring HIV stigma: existing knowledge and gaps. Psychol Health Med 2006; 11 335–45.
| Measuring HIV stigma: existing knowledge and gaps.Crossref | GoogleScholarGoogle Scholar |
[42] Dunn M, Barnett A, McKay FH. Pre-exposure prophylaxis (PrEP) in Australia: are there challenges facing sexual health promotion? Health Promot Int 2022; 37 daab177
| Pre-exposure prophylaxis (PrEP) in Australia: are there challenges facing sexual health promotion?Crossref | GoogleScholarGoogle Scholar |
[43] Holt M, Lea T, Bear B, Halliday D, Ellard J, Murphy D, et al. Trends in attitudes to and the use of HIV pre-exposure prophylaxis by Australian gay and bisexual men, 2011–2017: implications for further implementation from a diffusion of innovations perspective. AIDS Behav 2019; 23 1939–50.
| Trends in attitudes to and the use of HIV pre-exposure prophylaxis by Australian gay and bisexual men, 2011–2017: implications for further implementation from a diffusion of innovations perspective.Crossref | GoogleScholarGoogle Scholar |
[44] Kirby Institute. Monitoring HIV pre exposure prophylaxis uptake in Australia: PBS-subsidised HIV Preexposure Prophylaxis from April 2018 to June 2020. Kirby Institute; 2020.
[45] Kumar S, Haderxhanaj LT, Spicknall IH. Reviewing PrEP’s effect on STI incidence among men who have sex with men – balancing increased STI screening and potential behavioral sexual risk compensation. AIDS Behav 2021; 25 1810–8.
| Reviewing PrEP’s effect on STI incidence among men who have sex with men – balancing increased STI screening and potential behavioral sexual risk compensation.Crossref | GoogleScholarGoogle Scholar |
[46] Sarno EL, Macapagal K, Newcomb ME. “The main concern is HIV, everything else is fixable”: indifference toward sexually transmitted infections in the era of biomedical HIV prevention. AIDS Behav 2021; 25 2657–60.
| “The main concern is HIV, everything else is fixable”: indifference toward sexually transmitted infections in the era of biomedical HIV prevention.Crossref | GoogleScholarGoogle Scholar |
[47] Mabire X, Puppo C, Morel S, Mora M, Rojas Castro D, Chas J, et al. Pleasure and PrEP: pleasure-seeking plays a role in prevention choices and could lead to PrEP initiation. Am J Mens Health 2019; 13 1557988319827396
| Pleasure and PrEP: pleasure-seeking plays a role in prevention choices and could lead to PrEP initiation.Crossref | GoogleScholarGoogle Scholar |
[48] Hui B, Fairley CK, Chen M, Grulich A, Hocking J, Prestage G, et al. Oral and anal sex are key to sustaining gonorrhoea at endemic levels in MSM populations: a mathematical model. Sex Transm Infect 2015; 91 365–9.
| Oral and anal sex are key to sustaining gonorrhoea at endemic levels in MSM populations: a mathematical model.Crossref | GoogleScholarGoogle Scholar |
