Perceptions and Attitudes regarding Sexually Transmitted Infection (STIs) and Family Planning among Adolescents in Northern Madagascar

The prevalence of sexually transmitted infections (STIs) and early pregnancy are high among adolescents in Madagascar. 

We applied a qualitative descriptive approach to evaluate perceptions, attitudes, and misconceptions regarding STIs and contraception among female and male adolescents ages 15-19 years (n = 43) in Northern Madagascar in 2014 using focus group discussions with open-ended questions. Data were coded and analyzed for major themes. Participants were in the 6th to 12th grade in school; 53% were female. 

Despite high levels of awareness, significant stigma against and misconceptions about STIs, condom use, and sexual practices existed. Many participants did not know how to use condoms and felt uncomfortable suggesting condoms with regular partners, despite acknowledging infidelity as a frequent problem. 

Male participants were more willing to use condoms as contraception for unwanted pregnancy than for prevention of STIs. Most participants held misconceptions about side effects of contraceptives, including infertility, cancer, and preventing bad blood from leaving the woman's body. Systematic and community-wide health education and formal reproductive health curricula in schools may improve attitudes and stigma regarding STIs and family planning. 

These strategies need to be developed and employed via collaboration among faith-based, community and non-governmental organizations, schools, and governmental health and social service agencies.

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By:  Klinger A1, Asgary R2.

• 1 Department of Internal Medicine , Beth Israel Deaconess Medical Center , Boston , Massachusetts , USA.
• 2 Departments of Population Health and Medicine , New York University School of Medicine , New York , New York , USA. 
• Women Health. 2016 Apr 19.

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Prevalence & Risk Factors of Three Curable Sexually Transmitted Infections among Women in Nairobi, Kenya

BACKGROUND:

Sexually transmitted infections (STIs) are a major public health problem, especially in developing countries. The complications of untreated STIs in the female genital tract and their role in adverse pregnancy and perinatal outcomes have been well documented. The prevalence of STIs in Kenya among women in the general population has not been extensively studied and there is a lack of guidelines for screening of non-pregnant women. Knowledge of the prevalence of curable STIs among this population can provide a basis for integrating STI screening in family planning clinics.

METHODS:

A cross-sectional study was conducted between May and September 2013 at the family planning (FP) clinic at Kenyatta National Hospital (KNH) in Nairobi, Kenya. A total of 261 participants aged 18-49 years were enrolled; with data from 249 participants being analysed. An interviewer-administered questionnaire was used to gather socio-demographic data and assess for risk factors. Each participant was screened for Trichomonas vaginalis (TV) by wet mount microscopy; Neisseria gonorrhoeae (GC) by culture and Chlamydia trachomatis (CT) by PCR.

RESULTS:

The prevalence of CT was 13 % (33/249), TV 0.4 % (1/249) and GC 0 % (0/249). All the infected women reported having had only one sexual partner in the previous 1 year. The age group prevalence for CT was highest in the 25-29 years age group (21 %). The syndromic approach to the management of STIs showed a low specificity (vaginal discharge, 65.7 %; lower abdominal pain, 60.6 %) and positive predictive value (vaginal discharge, 14 %; lower abdominal pain, 11.5 %) for the two commonly used symptoms when compared to the gold standard of CT PCR.

CONCLUSION:

A high prevalence of CT was identified among women attending the FP Clinic at KNH. The study reinforces the need to implement regular screening for STIs among FP clinic attendants. It also reveals the need to review the usage of the syndromic approach for the management of STIs.

Characteristics of CT positive participants

Characteristics	Chlamydia infections/n	Prevalence (%)	P value
Age group
<25	1/13	8
25–29	6/28	21
30–34	6/56	11
35–39	10/67	15
40–44	8/48	17
45–49	2/37	5
Marital status
Married	29/211	14	0.59
Not married	4/38	11
Education level
Primary and below	11/67	16	0.37
Above primary	22/182	12
Occupation
Paid employment	11/83	13	0.9
Self employed	16/127	13
Unemployed	6/39	15
Coitarche
≤20 years	21/160	13	0.95
>20 years	10/78	13
Treated STIs
No	32/224	14	0.22
Yes	1/25	4

Full article at:   http://goo.gl/zLt0e0

By:  Maina AN1, Kimani J2, Anzala O3.

• 1Department of Medical Microbiology, University of Nairobi, P.O BOX 19676-00202, Nairobi, Kenya. acnmaina@yahoo.com.
• 2Kenya AIDS Control Project, University of Manitoba/Nairobi Collaborative Research Group, P.O BOX 19676-00202, Nairobi, Kenya.
• 3KAVI Institute of Clinical Research, University of Nairobi, P.O BOX 19676-00202, Nairobi, Kenya.
• BMC Res Notes. 2016 Mar 29;9(1):193. doi: 10.1186/s13104-016-1990-x. 

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Food Insecurity Is Associated with HIV, Sexually Transmitted Infections & Drug Use among Men in the U.S.

OBJECTIVE:

To examine the population-level association between food insecurity, HIV risk factors, and HIV serostatus among men, the group representing the majority of HIV diagnoses in the United States (US).

DESIGN:

Cross-sectional secondary data analysis using the National Health and Nutrition Examination Survey (NHANES) 1999-2012, a nationally representative survey of the civilian non-institutionalized US population.

METHODS:

Logistic regression with design weights and complex survey commands was used to estimate nationally-representative associations between food insecurity and HIV serostatus (primary outcome), herpes simplex virus 2 (HSV-2), self-reported STIs, and past-year illicit drug use among men, adjusting for potential confounders. Food security was measured using the 18-item Household Food Security Survey.

RESULTS:

We analyzed data for 9150 men representing 61 million individuals in the US. Unadjusted HIV prevalence was 1.5% among food insecure men, compared to 0.4% among food secure men (p < 0.001). In adjusted models, food insecure men had over 2 times higher odds of HIV seropositivity compared to food secure men (adjusted odds ratio (AOR) = 2.10; 95% CI 1.01-4.37; p < 0.05). Food insecurity was associated with higher odds of HSV-2 seropositivity (AOR = 1.28; 95% CI 1.04-1.57; p < 0.05), self-reported STIs (AOR = 1.54; 95% CI 1.08-2.20; p < 0.05), and illicit drug use (AOR = 1.57; 95% CI 1.14-2.15; p < 0.01). Results were robust to sensitivity analyses restricted to lower incomes.

CONCLUSIONS:

Food insecurity is associated with prevalent HIV, STIs and illicit drug use among men in the US. Further research is needed to establish whether and through what mechanisms improved food security may help prevent new HIV infections.

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By:  Palar K1, Laraia B, Tsai AC, Johnson M, Weiser SD.

• 1 Division of HIV, ID and Global Medicine, Department of Medicine, University of California, San Francisco (UCSF), San Francisco, CA 
• School of Public Health, University of California Berkeley, Berkeley, CA 
• Massachusetts General Hospital, MGH Global Health, Boston, MA 
• Center for AIDS Prevention Studies, Department of Medicine, UCSF.
• AIDS. 2016 Mar 16. 

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Screening for Asymptomatic Gonorrhea and Chlamydia in the Pediatric Emergency Department

BACKGROUND:

Because adolescents rely heavily on emergency services for health care, a pediatric emergency department (PED) visit may be their only opportunity for sexually transmitted infection (STI) screening. The primary objectives of this study were to determine the proportion of Neisseria gonorrheae (GC) and Chlamydia trachomatis (CT) infections in asymptomatic PED adolescents and patient-perceived barriers to STI screening.

METHODS:

A convenience sample of patients aged 14 to 21 years presenting to an urban PED with nongenitourinary complaints was offered screening for GC and CT. Regardless of declining or accepting screening, all were asked to complete a questionnaire designed to identify barriers to screening.

RESULTS:

Sixty-eight percent of those approached participated (n = 719). Those who agreed to STI screening were more likely to be nonwhite (61.4% vs. 38.6%, P = 0.001) and publically insured (63.3%) versus privately insured (29.3%) or no insurance (7.58%). Four hundred three (56%) participants provided urine samples, and of those, 40 (9.9%) were positive for an STI. Controlling for other demographics, race was a significant predictor, with the odds of testing positive for nonwhite participants 5.90 times that of white participants. Patients who refused testing were more likely to report not engaging in sexual activity (54.3% vs. 42.4%, P = 0.009) and less likely to perceive that they were at risk for STIs.

CONCLUSIONS:

There are high proportions of GC and CT among asymptomatic adolescents visiting an academic urban PED. A universal PED STI screening program may be an important component of STI reduction initiatives, especially among adolescents who do not perceive that they are at risk and may not receive testing elsewhere.

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By:  Schneider K1, FitzGerald M, Byczkowski T, Reed J.

• 1From the*Division of Emergency Medicine, Cincinnati Children's Hospital, Cincinnati, OH; and †Division of Pediatric Emergency Medicine, University of Minnesota Children's Hospital, Minneapolis, MN. 
• Sex Transm Dis. 2016 Apr;43(4):209-15. doi: 10.1097/OLQ.0000000000000424.

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Public Housing Relocations and Partnership Dynamics in Areas with High Prevalences of Sexually Transmitted Infections

BACKGROUND:

We investigated the implications of one structural intervention-public housing relocations-for partnership dynamics among individuals living areas with high sexually transmitted infection (STI) prevalence. High-prevalence areas fuel STI endemicity and are perpetuated by spatially assortative partnerships.

METHODS:

We analyzed 7 waves of data from a cohort of black adults (n = 172) relocating from 7 public housing complexes in Atlanta, Georgia. At each wave, data on whether participants' sexual partners lived in the neighborhood were gathered via survey. Participant addresses were geocoded to census tracts, and measures of tract-level STI prevalence, socioeconomic conditions, and other attributes were created for each wave. "High-prevalence tracts" were tracts in the highest quartile of STI prevalence in Georgia. Descriptive statistics and hierarchical generalized linear models examined trajectories of spatially assortative partnerships and identified predictors of assortativity among participants in high-prevalence tracts.

RESULTS:

All 7 tracts containing public housing complexes at baseline were high-prevalence tracts; most participants relocated to high-prevalence tracts. Spatially assortative partnerships had a U-shaped distribution: the mean percent of partners living in participants' neighborhoods at baseline was 54%; this mean declined to 28% at wave 2 and was 45% at wave 7. Participants who experienced greater postrelocation improvements in tract-level socioeconomic conditions had a lower odds of having spatially assortative partnerships (adjusted odds ratio, 1.55; 95% confidence interval [95% CI], 1.06-2.26).

CONCLUSIONS:

Public housing relocation initiatives may disrupt high-prevalence areas if residents experience significant postrelocation gains in tract-level socioeconomic conditions.

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By:  Cooper HL1, Bonney L, Luo R, Haley DF, Linton S, Hunter-Jones J, Ross Z, Wingood GM, Adimora AA, Rothenberg R.

• 1From the *Department of Behavioral Sciences and Health Education, Rollins School of Public Health at Emory University, Atlanta, GA; †Division of General Medicine, Emory University School of Medicine, Atlanta, GA; ‡Institute of Public Health at Georgia State University, Atlanta, GA; §ZevRoss Spatial Analysis, Ithaca, New York; 
• Department of Sociomedical Sciences, Columbia University School of Public Health, New York, NY; and ∥University of North Carolina Schools of Medicine and Gillings School of Global Public Health, Chapel Hill, NC. 
• Sex Transm Dis. 2016 Apr;43(4):222-30. doi: 10.1097/OLQ.0000000000000419.

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Behaviors on Drug-Abuse & Prevalence of Sexually Transmitted Diseases among Drug Users in Tianjin, China, from 2011 to 2015

OBJECTIVE:

To understand the change of behavioral characteristics among drug users (DUS) in Tianjin and the prevalence rates of major sexually transmitted disease infections. A series of cross-sectional surveys were used.

METHODS:

Between April and June, 2011 to 2015, a cross-sectional survey with face to face interview, was undertaken. Interview was conducted among DUS who entered the drug rehabilitation center and blood samples were drawn to test for HIV/syphilis/HCV infections. Multivariate logistic regression analysis was used to analyze the relationship between the infection of major sexually transmitted diseases and drug abuse or sexual behavior.

RESULTS:

2 000 DUS were included during the 5-year study, with the average age of the DUS as 34.5 ± 8.7. Female accounted for 17.9% and club drug (new drugs) users accounted 45.4% of the participants, with its proportion increasing over the years. Comparing to traditional drug users, club drug users showed more sexual activities with partners, but lower proportion of condom use. Prevalence rates of HIV/Syphilis and HCV were 1.3%, 11.0%, 52.0%, respectively. The prevalence of syphilis among club drug users was significantly higher than those on traditional-drug use (χ(2)=67.778,P<0.001). Data from Binary logistic regression analysis showed that club drug use (adjusted OR=1.607, 95% CI:1.191-2.170) and females (adjusted OR=5.287, 95%CI: 3.824-7.311) were associated with syphilis infection among DUS.

CONCLUSION:

Drug abuse behavior changed among the drug abuse in Tianjin. Proportion of club drug use continued to increase so as the risk of infected sexually transmitted diseases.

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By:  Guo Y1, Zhou N1, Li J2, Ning TL1, Guo W3.

• 1Department of AIDS/STD Prevention and Control, Tianjin Center for Disease Control and Prevention, Tianjin 300011, China.
• 2Department of AIDS/STD Prevention and Control, Tianjin Hebei District Center for Disease Control and Prevention, Tianjin 300150, China.
• 3Division of Epidemiology, National Center for AIDS/STD Control and Prevention, Chinese center for Disease Control and Prevention, Beijing 102206, China.
• Zhonghua Liu Xing Bing Xue Za Zhi. 2016 Feb 10;37(2):202-5. doi: 10.3760/cma.j.issn.0254-6450.2016.02.010. 

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Herpes Simplex Virus Seroprevalence & Seroconversion among Active Duty US Air Force Members with HIV Infection

BACKGROUND:

Herpes simplex virus (HSV) infection is associated with an increased risk of both HIV transmission and acquisition. We evaluated longitudinal HSV serology and sexually transmitted infections (STIs) among active duty US Air Force (USAF) members with HIV infection.

METHODS:

USAF members diagnosed with HIV between 1996 and 2012 were included and divided into 2 groups: 1996-2004 (n=131) and 2005-2012 (n=266). HSV-1 and -2 serology was evaluated at HIV diagnosis. Longitudinal HSV-1 and -2 serology and ICD-9 codes for HSV and non-HSV STIs were also examined for those with ≥1 year of follow-up.

RESULTS:

Patients were most commonly Caucasian (44.2%) or African American (43.4%) men with a median age of 28 years at HIV diagnosis. HSV-2 seroprevalence at HIV diagnosis decreased from the period of 1996-2004 (48.8%) to 2005-2012 (30.1%). Odds of HSV-2 seropositivity was significantly greater for non-Caucasians and for HIV diagnosis between 1996 and 2004, with a trend observed for those age >30 years at HIV diagnosis. 

A total of 81 (20.4%) patients developed STIs by ICD-9 codes, including 24 (6.1%) new genital herpes diagnoses, during a median follow-up of 4.6 years. HSV-2 seroconversion occurred in 33 of 253 (13.0%) with an incidence rate of 5.07 per 100 person-years.

CONCLUSION:

Although HSV-2 seroprevalence at HIV diagnosis decreased over time, high-risk sexual behaviors were ongoing as evidenced by the high proportion of new STI diagnoses and HSV-2 seroconversions. Continued education to reduce risk behaviors is warranted to prevent acquisition and transmission of STIs in HIV-infected persons.

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By:  Cohen JA1, Sellers A2, Sunil TS2, Matthews PE3, Okulicz JF4.

• 1San Antonio Military Medical Center, Department of Internal Medicine, JBSA Fort Sam Houston, TX, United States.
• 2Institute for Health Disparities Research, University of Texas at San Antonio, San Antonio, TX, United States.
• 3Mike O'Callaghan Federal Medical Center, Infectious Disease Service, Nellis AFB, NV, United States.
• 4San Antonio Military Medical Center, Infectious Disease Service, JBSA Fort Sam Houston, TX, United States. Electronic address: jason.f.okulicz.mil@mail.mil.
• J Clin Virol. 2016 Jan;74:4-7. doi: 10.1016/j.jcv.2015.11.012. Epub 2015 Nov 14.

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The Prevalence of Sexually Transmitted Infections on Teen Pregnancies & Their Association to Adverse Pregnancy Outcomes

INTRODUCTION:

Based on our population data, the teen pregnancy rate and the prevalence of sexually transmitted infections (STIs) reported during pregnancy are worrisome. STIs appear to pose a threat to pregnancy outcomes including preterm birth (PTB), neonatal low birth weight (NLBW) and premature rupture of membranes (PROM). The objective of this study is to determine the prevalence of STIs in pregnant teens and the association of this variable to adverse pregnancy outcomes.

METHODS:

We performed a cross sectional study to assess the prevalence of STIs among pregnant teens during a 4-year period at our institution. Birth outcomes such as gestational age at delivery, PROM and NLBW were analyzed and compared with adults.

RESULTS:

In the four years of our study, teen pregnancy rate fluctuated from 21.7% in 2010 to 16.8% in 2013. The rate of STIs for adult and teen pregnancies was similar, 21% and 23%, respectively. Chlamydia was the most common STI (67.3%) for both groups. PTB was more prevalent among adults affected with STIs than teens, 13.8% and 11.5%, respectively. NLBW was similar among teens and adults with STIs. PROM complicated 9.1% of teen pregnancies with STIs, compared to 6.7% in adults.

CONCLUSION:

There was no significant correlation between the STIs and adverse pregnancy outcomes on teen pregnancies for our population, except for PROM. This age group is associated with a high-risk sexual behavior and poor adherence to treatment. They would benefit from efforts to prevent unintended pregnancies and infectious diseases.

Full (PDF) article at:   http://goo.gl/vRh1qd

By:  Rodriguez Gonzalez ZM, Leavitt K, Martin J, Benabe E, Romaguera J, Negrón I.

Bol Asoc Med P R. 2015 Jul-Sep;107(3):89-94.

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Global Estimates of the Prevalence and Incidence of Four Curable Sexually Transmitted Infections in 2012 Based on Systematic Review and Global Reporting

Background

Quantifying sexually transmitted infection (STI) prevalence and incidence is important for planning interventions and advocating for resources. The World Health Organization (WHO) periodically estimates global and regional prevalence and incidence of four curable STIs: chlamydia, gonorrhoea, trichomoniasis and syphilis.

Methods and Findings

WHO’s 2012 estimates were based upon literature reviews of prevalence data from 2005 through 2012 among general populations for genitourinary infection with chlamydia, gonorrhoea, and trichomoniasis, and nationally reported data on syphilis seroprevalence among antenatal care attendees. Data were standardized for laboratory test type, geography, age, and high risk subpopulations, and combined using a Bayesian meta-analytic approach. Regional incidence estimates were generated from prevalence estimates by adjusting for average duration of infection. In 2012, among women aged 15–49 years, the estimated global prevalence of chlamydia was 4.2% (95% uncertainty interval (UI): 3.7–4.7%), gonorrhoea 0.8% (0.6–1.0%), trichomoniasis 5.0% (4.0–6.4%), and syphilis 0.5% (0.4–0.6%); among men, estimated chlamydia prevalence was 2.7% (2.0–3.6%), gonorrhoea 0.6% (0.4–0.9%), trichomoniasis 0.6% (0.4–0.8%), and syphilis 0.48% (0.3–0.7%). These figures correspond to an estimated 131 million new cases of chlamydia (100–166 million), 78 million of gonorrhoea (53–110 million), 143 million of trichomoniasis (98–202 million), and 6 million of syphilis (4–8 million). Prevalence and incidence estimates varied by region and sex.

Conclusions

Estimates of the global prevalence and incidence of chlamydia, gonorrhoea, trichomoniasis, and syphilis in adult women and men remain high, with nearly one million new infections with curable STI each day. The estimates highlight the urgent need for the public health community to ensure that well-recognized effective interventions for STI prevention, screening, diagnosis, and treatment are made more widely available. Improved estimation methods are needed to allow use of more varied data and generation of estimates at the national level.

Below:  Estimated prevalence (and 95% UI) of chlamydia, gonorrhoea, trichomoniasis, and syphilis in women and men aged 15–49 years by WHO region, based on 2005–2012 data

Below:  Incidence (and 95% UI) of chlamydia, gonorrhoea, trichomoniasis, and syphilis in women and men aged 15–49 years by WHO region, based on 2005 to 2012 data

Full article at:  http://goo.gl/pSlqZk

By:   

Lori Newman, Sami Gottlieb, James Kiarie, Marleen Temmerman

Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland

Jane Rowley, Stephen Vander Hoorn, Nalinka Saman Wijesooriya

Consultant to Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland

Stephen Vander Hoorn

Statistical Consulting Centre, University of Melbourne, Melbourne, Australia

Magnus Unemo

WHO Collaborating Centre for Gonorrhoea and other STIs, Department of Laboratory Medicine, Örebro University Hospital and Örebro University, Örebro, Sweden

Nicola Low

Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland

Gretchen Stevens

Department of Health Statistics and Information Systems, World Health Organization, Geneva, Switzerland

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Barriers to Preventing Unintended Pregnancies & Sexually Transmitted Infections as Experienced by Women in Fort Dauphin, Southeast Madagascar

As part of a broader investigation into maternal and child health, this study aimed to explore barriers to preventing unintended pregnancies and sexually transmitted infections (STIs) for women in southeast Madagascar, in order to inform the development of interventions by a local non-governmental organisation. 

A year-long mixed methods study was conducted. Qualitative information was obtained from 246 participants through focus groups, single-event and serial qualitative interviews. Quantitative data was collected through a closed-ended questionnaire with a sample of 373 women of reproductive age. Data was analysed using pre-determined and emerging themes. 

Family planning and sexual health services are not well integrated into other health services, nor routinely offered. Barriers to contraceptive use include actual or perceived side effects of hormonal methods, inaccurate information from health providers, and lack of support from partners or family members. STI prevalence is high, concurrent sexual relationships are common, and condom use is limited. 

Women's ability to prevent unintended pregnancies and STIs could be improved through measures aiming to dispel misconceptions about eligibility for and perceived risks of hormonal contraceptives, increase support for family planning among partners and families, and reframe the socio-cultural meaning of condom use in sexual relationships.

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By:  Robson L1, Morris J1, Andriatsihosena M1.

• 1 Community Health Department , ONG Azafady, Fort Dauphin , Madagascar.

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Changes in Chlamydia Control Activities in Europe Between 2007 & 2012: A Cross-National Survey

In 2012, the levels of chlamydia control activities including primary prevention, effective case management with partner management and surveillance were assessed in 2012 across countries in the European Union and European Economic Area (EU/EEA), on initiative of the European Centre for Disease Control (ECDC) survey, and the findings were compared with those from a similar survey in 2007.

Experts in the 30 EU/EEA countries were invited to respond to an online questionnaire; 28 countries responded, of which 25 participated in both the 2007 and 2012 surveys. Analyses focused on 13 indicators of chlamydia prevention and control activities; countries were assigned to one of five categories of chlamydia control.

In 2012, more countries than in 2007 reported availability of national chlamydia case management guidelines (80% vs. 68%), opportunistic chlamydia testing (68% vs. 44%) and consistent use of nucleic acid amplification tests (64% vs. 36%). The number of countries reporting having a national sexually transmitted infection control strategy or a surveillance system for chlamydia did not change notably. In 2012, most countries (18/25, 72%) had implemented primary prevention activities and case management guidelines addressing partner management, compared with 44% (11/25) of countries in 2007.

Overall, chlamydia control activities in EU/EEA countries strengthened between 2007 and 2012. Several countries still need to develop essential chlamydia control activities, whereas others may strengthen implementation and monitoring of existing activities.

Below:  EU/EEA countries with a national strategy or plan about STI control in 2012. CT = chlamydia. UK situation based on England. Adapted from ECDC Report7

Below:  Map of Europe indicating the level of chlamydia control based on the countries’ accomplishments of key indicators assessed in the survey in 2012. UK situation based on England. Adapted from ECDC Report7

Full article at: http://goo.gl/nWGa1D

By: van den Broek IV1, Sfetcu O2, van der Sande MA3, Andersen B4, Herrmann B5, Ward H6, Götz HM7, Uusküla A8, Woodhall SC9, Redmond SM10, Amato-Gauci AJ2, Low N10, van Bergen JE11.

• 1Unit of Epidemiology and Surveillance, RIVM/Centre for Infectious Disease Control Netherlands, Bilthoven, The Netherlands ingrid.van.den.broek@rivm.nl.
• 2European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden.
• 3Unit of Epidemiology and Surveillance, RIVM/Centre for Infectious Disease Control Netherlands, Bilthoven, The Netherlands Julius Centre, UMC Utrecht, Utrecht, The Netherlands.
• 4Department of Public Health, Randers Hospital, Skovlyvej, Randers, Denmark.
• 5Section of Clinical Bacteriology, Department of Medical Sciences, Uppsala University, Uppsala, Sweden.
• 6Infectious Diseases Epidemiology, School of Public Health, Imperial College London, St Mary's Campus, Norfolk Place, London, UK.
• 7Department of Infectious Disease Control, Municipal Public Health Service Rotterdam-Rijnmond, Rotterdam, The Netherlands.
• 8Department of Public Health, University of Tartu, Tartu, Estonia.
• 9HIV & STI Department, National Centre for Infectious Disease Surveillance and Control, Public Health England, London, UK.
• 10Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.
• 11Unit of Epidemiology and Surveillance, RIVM/Centre for Infectious Disease Control Netherlands, Bilthoven, The Netherlands Department of General Practice, University of Amsterdam, Amsterdam, The Netherlands STI AIDS Netherlands, Amsterdam, The Netherlands.  

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