Improvements in sexual health testing among gay men in Sydney,Australia,2003–2007

INTRODUCTION

Regular screening for sexually transmitted infection (STI) has been a cornerstone of sexual health promotion for gay men for over three decades ¹ and is central in STI and HIV prevention. ² To be effective STI screening needs to be comprehensive, based on the clients' sexuality, partnerships and risk practices. ³ However, achieving this is difficult in some contexts, particularly when busy general practitioners (GP) are unable to take detailed sexual histories, or clients are uncomfortable discussing their sexual lifestyles. ⁴

In New South Wales, Australia, since 2000 incidence rates of bacterial STI among men who have sex with men (MSM) increased dramatically. ⁵ Importantly, a recent general population survey in Australia found that participants were most likely to seek STI screening, treatment and care from their usual GP than from other specialist services. ⁶ In 2002, evidence-based clinician guidelines for STI testing of MSM were developed and widely disseminated to inner Sydney general practices and specialist sexual health services. ⁷ The guidelines were accompanied by community education campaigns. ⁷ We explored time trends and comprehensiveness of STI testing in a sample of gay men interviewed for behavioural surveillance surveys in Sydney between 2003 and 2007.

METHODS

Data from the Sydney Gay Community Periodic Surveys (SGCPS) conducted between 2003 and 2007 were used. The study protocol was approved by the Human Research Ethics Committee of the University of New South Wales, Australia. Details of the survey methods are described elsewhere. ⁸ Briefly, gay men recruited each year in community locations and sexual health clinics are administered short cross-sectional surveys on HIV serostatus, sexual practices and drug use, HIV and STI testing practises, and sociodemographic characteristics. Consistent recruitment procedures ensure maximum sample stability and facilitate comparisons across time. Over time, participation rates have ranged between 67% and 85%. ⁹ Data from the first round of each biannual survey were included in this analysis. Men recruited from sexual health clinics were excluded to avoid overestimation of STI testing rates.

In each survey, respondents were asked the date and result of their last HIV test. Beginning in 2003, participants were asked: ‘Which of the following sexual health tests have you had in the last 12 months: anal, throat, penile swabs, urine sample, blood test other than for HIV?’ (no/yes for each). A change in response options in 2005 to reflect testing frequency did not result in a change in prevalence of testing and therefore we combined options to correspond with the previous categories. Men were also asked whether they ‘never’, ‘occasionally’ or ‘often’ engaged as a receptive or insertive partner in anal intercourse with a condom, without a condom with ejaculation, and without a condom with withdrawal before ejaculating. From this we constructed a binary variable of unprotected anal intercourse with casual partners (UAIC) (some/none). In addition, men were asked to report their HIV-serostatus, age and number of sex partners in the past six months. We used χ ² test for trend in reporting each of the tests separately, any listed tests excluding blood tests (other than for HIV), and any of all listed tests. Using 2007 data, we explored the prevalence of reporting any of the sexual health tests (anal, throat, penile swabs, urine sample and blood test other than for HIV) in the past 12 months with respect to sociodemographic and behavioural characteristics. We present unadjusted prevalence ratios (PR) and 95% confidence intervals (95% CI). In all cases, we applied a two-sided P value of 0.05. All data analyses were executed using STATA 10.0 (Stata Corp LP, College Station, TX, USA).

RESULTS

During 2003–2007, 10,104 participants were recruited in non-clinic settings (on average 2021 men per year, range: 1672–2342). HIV testing was the most commonly reported testing (among men who had previously never tested HIV-positive) and remained stable over the period (66% in 2003; 68% in 2007, P = 0.164). Among other tests for STI, blood tests and urine samples were most common (Table 1). Substantially fewer men reported with swabs of any type. Prevalence of reporting STI testing in the past 12 months increased significantly between 2003 and 2007: anal swabs from 23% to 42% (19 percentage points), throat swabs from 31% to 45% (14 percentage points), penile swabs from 24% to 35% (11 percentage points) and urine tests from 40% to 52% (12 percentage points). Only blood tests other than for HIV remained stable at about 51–52%. Data on testing frequency collected since 2005 suggested no significant changes (data not shown).

A remarkable increase was observed in use of any swabs or urine tests (from 46% in 2003 to 56% in 2007), but the overall proportion of men who reported any STI test including blood increased modestly (from 63% to 67%, respectively). Approximately one-third of men in each survey did not report having any STI testing.

Among HIV-positive men, there was increase over time in the use of anal and throat swabs and urine tests, but not penile swabs or blood tests for STI other than HIV (Table 1). During the same time-period, the use of all swabs and urine tests among HIV-negative men increased while testing blood for STI other than HIV remained stable.

Table 2 shows that in 2007 there were no differences in reporting any testing in the past 12 months by age group. HIV-positive men reported any STI testing more frequently than other groups. The proportion of men tested for any STI other than HIV increased with the number of casual partners men had had: 50.9% among men with 0–1 partners, 71.9% among men with two to 10 partners and 82.6% among men with 11 or more partners in the past six months. Sexual risk behaviours significantly associated with STI testing included: reporting having had casual partners, higher number of partners and engaging in UAIC with casual partners in the last six months.

DISCUSSION

These results indicate that comprehensive STI testing in gay men in Sydney increased during 2003–2007 in parallel with rises in STI incidence and prevalence. ⁵ In particular, increases were observed in the use of anal, throat and penile swabs and urine samples. At the same time, the rates of testing blood for STIs other than HIV increased only modestly. These increases are most likely explained by improved screening and comprehensive testing in line with the STI testing guidelines provided by GPs and public sexual health services. ⁷ The possibility that the changes also reflect the impact of education campaigns cannot be ignored, but without any significant increase in the overall proportion of men being STI tested annually, it would seem that the same proportions of men were using the services and/or were being offered/requesting more comprehensive STI screening.

Of concern is the steady one-third of men who do not report any STI testing in the last year. In our sample only half as many HIV-negative men and even fewer unknown HIV-serostatus men were routinely screened compared with HIV-positive men; the latter were tested more frequently, during their routine contact with services. The discrepancy in STI testing based on HIV status shows considerable room for additional community health promotion.

Our results support other studies that have found men engaging in risky sexual practices frequently undergoing sexual health screens; however, encouraging all sexually active MSM to seek regular STI testing is still important. Providing an appropriate and comprehensive screening is essential for STI screening to deliver any significant sexual health dividend. This should not be taken for granted in the context of increasing STI incidence globally among MSM.