Urgent need to improve sexually transmitted infection screening for MSM in Europe

Lack of anal swabs and physical examinations likely to leave infections undiagnosed
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Across 40 large European cities, less than one third of men who have sex with men (MSM) have been screened for sexually transmitted infections (STIs) in the past year, according to a study in the November issue of Sexually Transmitted Infections. Whereas blood tests were commonly performed, the number of men tested for genital or anal infections, or being physically examined, was generally low and varied substantially between cities.

Poor results were reported by men living in several cities which have a large gay commercial scene, including Berlin, Brussels, Cologne, Barcelona, Zurich, Madrid and Paris. Less surprisingly, men in cities such as Istanbul, Tallinn and Ljubljana had received inadequate screening.

Much better results were reported by men living in cities in England, the Netherlands and Scandinavia.



Chlamydia is a common sexually transmitted infection, caused by bacteria called Chlamydia trachomatis. Women can get chlamydia in the cervix, rectum, or throat. Men can get chlamydia in the urethra (inside the penis), rectum, or throat. Chlamydia is treated with antibiotics.


Studies aim to give information that will be applicable to a large group of people (e.g. adults with diagnosed HIV in the UK). Because it is impractical to conduct a study with such a large group, only a sub-group (a sample) takes part in a study. This isn’t a problem as long as the characteristics of the sample are similar to those of the wider group (e.g. in terms of age, gender, CD4 count and years since diagnosis).


The last part of the large intestine just above the anus.


Having no symptoms.


Refers to the mouth, for example a medicine taken by mouth.

“Our data suggest that in most major European cities, anal/genital warts and rectal gonorrhoea and Chlamydia infections are profoundly underdiagnosed among MSM”, write the investigators. This means that countries’ reported STI rates cannot easily be compared – high figures may reflect health services which screen in the absence of symptoms and which employ comprehensive diagnostic procedures.

Incomplete screening

The data come from the European Men Who Have Sex with Men Internet Survey (EMIS), which collected a wealth of data from a large sample of men who have sex with men living in Europe in 2010.

For this analysis, data were included on 52,430 respondents living in 40 large cities. Selected cities had both a population of over 500,000 and at least 300 survey respondents.

Overall 29.7% of respondents had been screened (i.e. had a test for a sexually transmitted infection, in the absence of symptoms) in the past year. The proportion ranged from 8.9% in Istanbul to 48.0% in Amsterdam.

Men who had been screened were then asked, in non-medical language, what the screening consisted of.

Most men who had been screened said that they had given a blood sample (92.1% overall, and over 85% in every city). Blood tests can detect HIV, syphilis and viral hepatitis.

“However, a blood test alone does not constitute a sexual health screening, and a range of asymptomatic STIs will remain undiagnosed if this is the only procedure performed”, comment the investigators.

In order to detect chlamydia or gonorrhoea in the penis, a sample is needed either from urine or from a swab of the urethra (“having something inserted into your penis”, in the language of the survey). However, less than half (48.7%) of all screenings included such a procedure.

In a few cities, these procedures were common – Amsterdam, Birmingham, London and Manchester (all above 88%).

But fewer than 40% of screened men reported the procedure in the following cities – Athens, Barcelona, Belgrade, Budapest, Lyon, Milan, Paris, Sofia, Valencia and Warsaw.

To diagnose rectal chlamydia or gonorrhoea, a sample is needed from an anal swab, especially as there often aren’t noticeable symptoms. But just 16.0% of screened men reported anal swabbing. The procedure was more commonly reported by men living in Amsterdam, London and Manchester (all above 65%).

In contrast, fewer than 10% of men who had been screened in the following cities had had an anal swab – Belgrade, Brussels, Bucharest, Istanbul, Lyon, Paris, Porto, Valencia and Warsaw.

Similarly fewer than 20% of screened men in these cities reported it – Athens, Barcelona, Budapest, Cologne/Bonn, Kiev, Lisbon, Milan, Munich, Riga, Rome, Sofia, and Zurich.

Manifestations of anal or genital warts may only be identified and treated if there is a physical examination of both the penis and anus. However, this only occurred for 17.9% of the men who had been screened.

Performance was relatively good for men living in Amsterdam, Dublin, London, Manchester and Stockholm (all above 50%).

But fewer than 20% of screened men in these cities reported a physical examination – Athens, Barcelona, Belgrade, Brussels, Bucharest, Cologne/Bonn, Istanbul, Kiev, Lisbon, Lyon, Madrid, Milan, Munich, Paris, Porto, Riga, Rome, Sofia, Tallinn, Valencia and Warsaw.

There was a strong correlation between anal swabs and physical examinations – sexual health services appear to offer neither or both.

The authors note that gonorrhoea can be transmitted during oral sex between men, and that throat swabs are needed to detect it, although their survey did not ask about this procedure.

All of the diagnostic procedures were more likely to be performed on men with diagnosed HIV and men with a greater number of sexual partners.

Underlining the concern raised by the results, another paper in Sexually Transmitted Infections demonstrates that testing just one anatomical site will lead to infections being missed. Over a three-year period clinicians in Geleen, the Netherlands tested all 2436 men who have sex with men attending their STI clinic for chlamydia and gonorrhoea with samples from three sites – the urethra, the rectum and the throat.

There were 254 cases of chlamydia and 154 of gonorrhoea. For both, a majority of infections were identified in samples from the rectum and/or throat, but not the urethra – 68.5% and 76.0%, respectively.

Inaccessible services

Returning to the Europe-wide study, it also showed that one third of respondents did not know whether free or affordable STI screening was available where they lived. Whereas fewer than 10% of respondents in the English cities and in Copenhagen said that services were inaccessible, over 40% of men reported this in Brussels, Rome and Lisbon, as well as in many cities in eastern Europe, central Europe and the Balkans.

Unsurprisingly, there was a strong correlation between low rates of screening and a perception of services being inaccessible.

The authors note the wide range of patterns of service delivery, specific to each country. Whereas some countries have networks of open-access sexual health clinics, services in other countries are frequently delivered in primary care or by the private sector. While there has been a growth in the provision of community HIV testing services, they rarely provide comprehensive sexual health screening. Furthermore, services are provided by a range of medical specialities – general practitioners, dermato-venereologists, gynaecologists, urologists, HIV specialists and infectious disease physicians.

In an editorial linked to the Europe-wide study, epidemiologists from Public Health England and the Institut de Veille Sanitaire comment: “Ensuring the provision of easily accessible services for MSM offering a comprehensive sexual health screen is essential and the challenge is to establish and promote such clinical services in at least all the major European cities.”


Schmidt AJ et al. Comparison of the performance of STI Screening Services for gay and bisexual men across 40 European cities: results from the European MSM Internet Survey Sexually Transmitted Infections 89:575-582, 2013. (Full text freely available online.)

Nardone A & Semaille C We need to improve screening for sexually transmitted infections in men who have sex with men in Europe Sexually Transmitted Infections 89:539-540, 2013.

van Liere GAFS et al. Evaluation of the anatomical site distribution of chlamydia and gonorrhoea in men who have sex with men and in high-risk women by routine testing: cross-sectional study revealing missed opportunities for treatment strategies. Sexually Transmitted Infections, online ahead of print, 2013.