Wide variation in quality of sexual health screening across Europe; countries with specialised clinics do better

In the majority of European countries, most sexual health check-ups for men who have sex with men (MSM) do not include basic physical examinations or diagnostic procedures that would enable clinicians to diagnose rectal gonorrhoea, chlamydia or warts, Axel J. Schmidt and Johanna Rankin told the 14th annual CHAPS conference in Manchester last week.

But some countries perform much better than others - and these countries have well developed networks of specialised sexual health clinics.

Moreover, men whose most recent HIV test took place in a specialised sexual health clinic or at a community testing service were more likely to be satisfied with the experience in terms of confidentiality and the opportunity to discuss their sexual behaviour.

These data are some of the first to come from the European MSM Internet Sex Survey (EMIS), an internet-based questionnaire that was made available in 25 languages across Europe in 2010. With a total of a total of 180,988 responses, it is probably the largest international study of the sexual health of gay and bisexual men ever conducted. The response rate was particularly high in Germany, Switzerland, Luxembourg, Ireland, Portugal, Slovenia and Austria. It was lowest in Turkey, Moldova and Russia.

Depending on the country, between 20 and 50% of men had had a sexually transmitted infection (STI) check-up in the previous twelve months. Men in central European countries were particularly unlikely to have had a recent check-up. In general, testing took place in the absence of symptoms.

Men who had been tested for sexually transmitted infections other than HIV were asked for more detail about what happened, specifically the kind of diagnostic procedures that were performed. While in all countries 80% or more of check-ups included blood tests, the authors point out that apart from HIV, the only sexually transmitted infections which can be detected this way are syphilis and viral hepatitis.

In 33 of the 38 countries surveyed, less than 40% of check-ups included an inspection of the anal and penile area. In over half the European countries, less than 20% of check-ups included this type of examination.

Similarly, in 32 countries, less than 40% of check-ups included “something inserted in the anus” (an anal swab). In over two-thirds of European countries, less than 20% of check-ups featured anal swabs. The countries which didn’t perform physical examinations were generally the same ones which didn’t do anal swabs.

The researchers point out that in these countries, there is a high chance that anal warts, genital warts, rectal chlamydia and rectal gonorrhoea remain profoundly under-diagnosed. As a result, men’s sexual health will suffer, the risk of HIV infection or transmission is greater and comparisons of STI rates in different countries will be misleading.

Four countries had notably better performance in these areas than the others - Malta, Ireland, the United Kingdom and Sweden. The researchers pointed out that each country has a network of specialised sexual health clinics.

Some rich countries such as Germany and France had particularly poor performance. Taking men in Germany as a point of comparison, men in the UK or Ireland were over six times more likely to have had a genital and anal examination during their last check-up. Moreover men in Ireland were eight times more likely to have had an anal swab, and men in the UK were almost ten times more likely to have had one. Men in France were even less likely than those in Germany to have been given an anal swab. (These figures do not include men with diagnosed HIV, who tend to have more sexual health check-ups).

Men completing the survey were asked a separate set of questions about HIV testing, including where they had had their most recent test.

Overall, around 35% had taken an HIV test in the previous twelve months. Testing for HIV in the last year was most common in Spain, Portugal, Belgium and France. In each of these countries, the most common place to test was with a practice-based physician (such as a family doctor). In several countries of central and eastern Europe, the most common place for men who have sex with men to take an HIV test was at a community service such as a testing site run by a gay community organisation. In Bulgaria, the most common place to test was at a mobile outreach van.

Across Europe, measures of the quality of the testing experience varied depending on the place where testing occurred. In terms of confidentiality, the highest levels of dissatisfaction were among those testing as an in-patient at a hospital or clinic (13.5%), followed by those testing as an out-patient (9.3%). There was less dissatisfaction among those testing with a practice-based physician (5.2%), at a community service (4.0%) or at a sexual health clinic (3.3%).

Respondents were also asked if they had been given the opportunity to talk about their sexual behaviour when they tested and, if they had done so, whether they had mentioned that they have sex with men. This was least likely to be the case when testing as an in-patient (23%), as an out-patient (28%) or with a practice-based physician (30%). Discussions of sex were far more common when testing at a community service (52%) or at a sexual health clinic (64%).

Ford Hickson also presented data on the answers to the survey question, “Are you happy with your sex life?”. Across Europe, 61% said they were happy, 39% that they were not. Men in France, the Netherlands, Switzerland, Belgium and Spain were most likely to be satisfied.  Conversely, less than half of men in Bosnia, Macedonia, Croatia, Cyprus, Belarus, Ukraine, Estonia, Serbia, Russia and Hungary said they were happy with their sex lives.

On average, men who had a steady partner were happier than those who did not, and those in a new relationship were the happiest of all. Men who had tested for HIV were happier than those who had never done so. Men who had tested HIV-positive were just as happy as those whose last test result was negative.

When those who weren’t happy were asked why not, the most common responses were because the respondent wanted a steady relationship (25%), wanted more sex with his current partner (15%), was not as sexually confident as he wanted to be (15%), was worried about picking up HIV or an STI (13%) or wanted more sexual partners (12%).

Schmidt AJ. “Differences in STI testing in selected European countries”, 14th CHAPS conference, Manchester, 10 March 2010.

Hickson F. “European MSM Internet Sex Survey (EMIS)”, 14th CHAPS conference, Manchester, 9 March 2010.

There is more information about EMIS here.