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HIV and STI epidemiology in high-risk populations in the Netherlands
van Veen, M.G.
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van Veen, M. G. (2010). HIV and STI epidemiology in high-risk populations in the Netherlands
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STI coinfections among STI clinic attendees
CHAPTER 5
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STI epidemiology among
ARTICLESSTI clinic attendees
sex transm dis [in press]
AQ: 1
STD Coinfections in The Netherlands: Specific Sexual
Networks at Highest Risk
AQ: 4
Maaike G. van Veen, MSc,* Femke D. H. Koedijk, MSc,*
Marianne A. B. van der Sande, MD, PHD,*†and the Dutch STD centres
Background: Specific subpopulations infected with multiple bacterial sexually transmitted diseases (STD) may facilitate ongoing STD
transmission. To identify these subpopulations we determined the extent of concurrent incident STD infections and their risk factors among
the high-risk population seen at Dutch STD clinics.
Methods: STD surveillance data submitted routinely by STD clinics
to the National Institute for Public Health on demographics, sexual
behavior, STD testing, and diagnoses for the period 2004 –2007 were
analyzed.
Results: Bacterial STD coinfections were diagnosed concurrently in
2120 (7%) of the 31,754 incident bacterial STD diagnoses (chlamydia,
gonorrhea, infectious syphilis). In univariate logistic regression analyses, coinfections were significantly more often diagnosed in men having sex with men (MSM, OR � 5.4) than in heterosexuals. Multivariate
analyses showed a significant interaction between age and sexual
preference. Subsequent stratified analyses by sexual preference showed
a linear rise in coinfections with age in MSM. In heterosexuals, by
contrast, bacterial coinfections peaked in those aged 19 or less; they
had 27% of coinfections, while having only 14% of monodiagnoses and
10% of consultations. Heterosexual STD clinic attendees of Surinamese or Antillean origin were significantly at higher risk for coinfection (OR � 6.5) than all other ethnicities.
Conclusions: Attendees belonging to specific sexual networks, such
as MSM, ethnic groups, and young heterosexuals were at increased risk
for STD coinfections. The different trend with age in MSM versus
heterosexuals suggests that these 2 high-risk networks have different
determinants of higher risk, such as age-related sexual risk-taking,
From the *National Institute for Public Health and the Environment
(RIVM), Department Epidemiology and Surveillance, Centre for
Infectious Disease Control, Bilthoven, The Netherlands; and †Academic Medical Centre Utrecht, University of Utrecht, Utrecht, The
Netherlands
The authors thank all Public Health nurses and doctors of the STD
clinics for their contribution in data collection; medical microbiology laboratories for their contribution in STD diagnostics; and L.
Philips for editing this manuscript. The authors also acknowledge
R. A. Coutinho for his comments and critical notes on earlier
versions of the manuscript; and also M. Kretzschmar and J. Wallinga for their comments on the manuscript.
On behalf of Dutch STD centres: A van Daal (East), JSA Fennema
(North-Holland Flevoland), F de Groot (North), CJPA Hoebe (Limburg), M Langevoort (Utrecht), AP van Leeuwen (South-Holland
North), JCAM van de Sande (Zeeland-Brabant), E van der Veen
(South-Holland South).
Correspondence: Maaike G. van Veen, MSc, RIVM National Institute
of Public Health and the Environment, P.O. Box 1, 3720 BA
Bilthoven, The Netherlands. E-mail: [email protected]
Received for publication July 15, 2009, and accepted December 15,
2009.
DOI: 10.1097/OLQ.0b013e3181cfcb34
Copyright © 2010 American Sexually Transmitted Diseases
Association
All rights reserved.
Sexually Transmitted Diseases ●
biologic susceptibility, and insufficient knowledge or compliance with
prevention measures. Prevention should therefore be targeted differently towards specific sexual networks.
I
n Europe, HIV and other sexually transmitted diseases
(STD) remain of major public health importance.1 Ongoing
transmission of many STDs is reflected in persistently high
positivity rates, posing serious risks for individuals and for
public health. In industrialized countries like the Netherlands, surveillance data show yearly high numbers of new
STD diagnoses, despite extensive efforts to control STDs by
targeted prevention, rapid diagnosis, and treatment services.2,3 In the Netherlands, STD testing and treatment is
provided by general practitioners (GPs) and STD clinics. In
2007, about 70% of STD related episodes were seen at GPs
and 30% at STD clinics (van den Broek IV, et al, unpublished data, 2009). The latter offering additional first line
care targeted at high risk populations.
Since STD transmission is uniquely linked to human
behavior, its control depends on the identification of important
risk groups and their risk behaviors associated with STD transmission. Anyone diagnosed with an STD has been at increased
risk for any other STD as well, and simultaneous infection with
more than one STD is common.4,5 Nevertheless, little recent
data have been published on the extent of STD coinfections in
high-risk populations, with the exception of STD in HIVinfected patients5,6 and interactions between HSV-2 and HIV
infections.7,8 We hypothesize that populations coinfected with
STD may have a high transmission potential and therefore need
to be identified.
In this study, we set out to determine the extent of
concurrent incident bacterial STD infections and their risk
factors by using a unique dataset that included data about all
STD clinics in the Netherlands. Our goal was to identify
specific subpopulations, at risk for STD coinfections, who
may facilitate several STD transmission chains. These specific populations may have extremely high risk behavior in
overlapping sexual networks and therefore would need to be
targeted with intensified future interventions to curb this
ongoing STD epidemic.
MATERIALS AND METHODS
In the Netherlands, 32 STD clinics, distributed across
eight regions, offer STD testing and treatment. This includes
HIV testing, free of charge, targeted at high-risk groups, and
people who want to be tested anonymously. Each region has
one STD centre that is responsible for regional coordination
of STD control. All new STD consultations and corresponding diagnoses are rendered anonymous and reported to the
Centre for Infectious Disease Control (RIVM) for surveillance purposes. The reporting of STD consultations is facilitated by a web based application (SOAP) that is nationwide
since 2004.
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van Veen et al.
Study Population
From January 2004 to December 2007, 268,071 new
STD consultations were registered in the national database at
the RIVM. A new STD consultation was defined as a consultation for new symptoms or one resulting from routine
STD screening of asymptomatic cases, both involving laboratory testing and medical examination. Data does not
allow identification of repeat visits in the same individual.
However, only consultations for a new STD episode are
included and follow-up visits in the same individual, e.g., for
treatment genital warts, are not included in the data. Additionally for this study, data were excluded from STD consultations with known HIV-positive STD clinic attendees
(n � 3134) since their awareness of HIV positivity gives
them a distinct risk profile. Concurrent STD in HIV-positive
clinic attendees will be analyzed and described elsewhere
(report in preparation).
Procedures
At each consultation, information on demographics
(gender, year of birth, ethnicity), behavior (sexual preference, STD history, commercial sex contacts, injecting
drugs), diagnostics and clinical outcome is recorded by the
clinician or nurse in the online RIVM registration database.
All clinic attendees are offered testing for chlamydia, gonorrhea, and syphilis. Hepatitis B and HIV testing are optional, however, HIV testing is actively offered and had
increased to 85% in 2007.2 Testing for other STDs, such as
trichomonas, HSV, and genital warts was performed on
clinical indication. Microbiologic diagnostics were carried
out locally at laboratories related to the STD centers in
accordance with standard procedures established in a STD
screening protocol,9 including quality control measures. All
laboratories used nucleic acid amplified tests (NAAT) in
urine or urethral specimens to diagnose Chlamydia. The
method used to diagnose gonorrhea varied among regions.
Some regions used culture tests for Neisseria gonorrhea
(NG) diagnosis in clinic attendees who presented with complaints, whereas they used NAAT as a screening test for NG
for individuals without complaints. Other regions used
NAAT to test for NG for all clinic attendees, regardless of
complaints. Syphilis testing is done using Treponema pallidum particle agglutination assay (TPPA). According to the
STD screening protocol, enzyme immunoassays (EIAs) may
be used as an alternative test to diagnose syphilis. Fluorescent treponemal antibody absorption (FTA-ABS) test is recommended for confirmation.9 An STD coinfection was
defined as diagnosis of two or more incident bacterial STDs.
We included only the STDs that are routinely screened for at
each consultation (chlamydia, gonorrhea, and infectious
syphilis). Additionally, we conducted a second analysis that
included all diagnoses, including newly detected HIV infections, acute hepatitis B infections and those tested for on
clinical indication (genital warts and genital herpes in both
sexes, and trichomonas in women).
Statistical Analyses
We used logistic regression analyses to study associations of patient characteristics and individual behavior in
cases of incident bacterial STD coinfections among clinic
attendees. First, we studied associations with (a) STD mono
diagnosis (chlamydia, gonorrhea, or infectious syphilis), and
(b) STD coinfections (chlamydia, gonorrhea, and/or infectious syphilis), comparing these 2 groups with STD clinic
2
106
attendees having no infection. We then tested for potential
interactions between the identified risk factors, and stratified
our further analyses by sexual preference, as heterosexual
attendees and MSM attendees had different risk profiles. A
multivariate model was built by selecting variables that were
statistically significant (P � 0.05) in univariate analysis.
Finally, we repeated our analyses, using all STD diagnoses
including newly detected HIV infections, acute hepatitis B
infections and STD found by testing after clinical indication
(genital warts, genital herpes, and trichomonas in women).
Analyses were carried out using the SAS software 9.1.3
(SAS Institute, Inc., Cary, NC).
RESULTS
Over 4 recent years, the annual number of new STD
consultations in the Netherlands increased by 34%, rising
steadily from 58,288 in 2004 to 78,062 in 2007 (P � 0.0001).
Women accounted for 49% of consultations, heterosexual men
for 37%, MSM for 13%, and transgendered persons for 0.04%
of all consultations (Table 1). The majority of clinic attendees
were Dutch (78%), 4% were of other European origin, 6% were
from Surinam or the Netherlands Antilles, 2% were Turkish or
Moroccan, 2% were from Sub Saharan Africa, and 8% were
from other countries. Of the total, 40% were younger than 25
years of age.
Overall, a bacterial STD was diagnosed in 12% of STD
visits. Concurrent STD infections including coinfections of
chlamydia, gonorrhea, and infectious syphilis were diagnosed
in 2120 (7%) of all 31,754 incident bacterial STD diagnoses
(Table 1). Of the STD coinfections, 83% were concurrent
chlamydia and gonorrhea infections (Table 2). About half
(44%) of the STD coinfections were diagnosed in MSM, although MSM accounted for 13% of consultations and 20% of
mono diagnoses. Of the ethnic groups, the Surinamese/Antillean group had the most STD coinfections (19%), with 10% of
mono diagnoses and 6% of consultations. If we included all
STD diagnoses, including newly detected HIV infections, acute
hepatitis B infections and STD diagnosed on clinical indication
(genital warts, genital herpes, and trichomonas in women), we
calculated 3766 STD coinfections.
T1
T2
Associations for STD Coinfections
Logistic regression analyses among all STD clinic
attendees who were HIV-negative or not aware of their HIV
status showed that MSM were at higher risk for STD coinfections than heterosexuals (unadjusted OR � 5.4; 95% CI:
4.9 –5.9). The youngest age group (below 19 years) was at
higher risk for STD coinfections compared to older age
groups. However, we found significant interaction between
sexual preference and age (P � 0.001) and therefore stratified our analyses by sexual preference in a multivariate
analysis. When analyses were repeated for associations with
coinfections, including newly detected HIV infections, acute
hepatitis B infections and STD found on testing after clinical
indication, similar associations were found in all groups
(data not shown).
Associations for STD Coinfections, Stratified by
Sexual Preference
An analysis stratified by sexual preference, yielded an
age distribution that differed between MSM and heterosexuals. As shown in Figure 1A, MSM showed an increasing
linear age trend (P � 0.0001 �2 trend) in coinfections,
monodiagnoses, and consultations. In heterosexuals, how-
Sexually Transmitted Diseases ●
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STD Coinfections in The Netherlands
TABLE 1.
Characteristics of New STD Consultations, Monodiagnoses, and STD Coinfections in the Netherlands, 2004 –2007
Consultations
N
Total
Gender and sexual preference
MSM
Male heterosexuals
Female
Transgenders
Unknown
Ethnicity
Dutch
Turkish/Moroccan
Surinamese/Antillean
European, excluding Dutch
Sub-Sahara African
Asian
Latin American
Other and unknown
Age
�19 yr
20–24 yr
25–29 yr
30–39 yr
�40 yr
Unknown
STD Monodiagnosis*
%
264,937
N
%
29,634
11
35,740
99,141
128,771
106
1,177
13
37
49
0.04
0.4
5907
10,530
13,137
8
52
20
35
44
0.03
0.2
206,117
5757
16,538
9713
4914
4240
4267
13,391
78
2
6
4
2
2
2
5
21,726
814
2986
1063
517
527
469
1532
73
3
10
4
2
2
2
5
9
31
22
22
17
0.05
3425
10,553
5916
5708
4020
12
12
35
20
20
14
0.04
23,235
82,686
57,030
58,014
43,849
123
STD Coinfection*
N
%
2120
0.8
923
535
659
0
3
44
25
31
0.0
0.1
1315
46
410
82
31
50
46
142
341
528
378
486
389
0
62
2
19
4
1
2
2
7
16
25
18
23
18
0.0
P†
�0.0001
�0.0001
�0.0001
*Chlamydia, gonorrhea, infectious syphilis, hepatitis B, HIV.
† 2
� test for monodiagnosis versus STD coinfection.
T3– 4,AQ:2
ever, Figure 1B shows that diagnoses and consultations were
decreasing with age (P � 0.0001 �2 trend). Heterosexuals
aged 19 years or younger accounted for 27% of all coinfections, while having only 14% of monodiagnoses and 10% of
consultations. These different associations by age groups for
MSM and heterosexuals were confirmed in multivariate logistic regression analyses when it was stratified by sexual
preference (Tables 3, 4). In heterosexuals, the highest risk
was in the young (19 years of age or younger, OR � 6.8) and
afterwards declined; in MSM, the older age groups (25–39
years of age) were at highest risk.
Stratified by sexual preference, STD clinic attendees of
Surinamese/Antillean origin were found at increased risk for
coinfections, in both sexual strata. However, this association
was stronger in heterosexual attendees (OR � 6.5) than in
MSM attendees of Surinamese/Antillean origin (OR � 1.5).
No clear trend in time was observed for associations
with STD coinfections. The associations of ethnicity, age,
TABLE 2.
Incident Bacterial STD Coinfections
2 STD coinfections
Chlamydia � gonorrhea
Chlamydia � syphilis
Gonorrhea � syphilis
3 STD coinfections
Chlamydia � gonorrhea � syphilis
Total
Sexually Transmitted Diseases ●
N
%
1756
212
104
83
10
5
50
2122
2
gender, and sexual preference with STD coinfections were
much stronger than the associations of these factors with
STD mono diagnoses. Again, stratified analyses of coinfections, including diagnoses of new HIV-infections, acute
hepatitis B infections, genital warts, genital herpes, and
trichomonas in women, showed comparable associations
(data not shown).
DISCUSSION
Bacterial STD coinfections were diagnosed in 7% of
all incident STD diagnoses. The majority were coexisting
chlamydia and gonorrhea infections. MSM were at highest
risk for STD coinfections, in particular MSM aged 25 to 39
years. In heterosexuals, those 19 years of age or younger
were at highest risk. Independent of sexual preference, clinic
attendees of Surinamese/Antillean origin were more often
diagnosed with multiple bacterial STD compared to other
ethnic groups.
MSM are widely recognized as a core group in STD
acquisition and transmission. Many studies have reported on
STD infections in MSM, and some focus on STD coinfections in HIV-positive MSM.5,10 A recent WHO publication
observed that the incidence of HIV in older individuals is
surprisingly high and the risk factors are as yet unexplored.11
We found in this study that coinfections are common among
MSM who are HIV-negative or not aware of their HIV status
when they visit the clinic. In the Netherlands, STD and HIV
prevention is targeted at specific high-risk groups, including
MSM. Continuous efforts must be made in primary prevention, as well as in secondary prevention, by actively offering
full STD screening to MSM. Additionally, it is advisable to
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van Veen et al.
Figure 1. Consultations, monodiagnoses, and coinfections by sexual
preference: (A) MSM and (B) heterosexual clinic attendees.
explore the role of general practitioners (GPs) in opportunistic screening for STD (co)infections. Since coinfections
are more common in MSM clinic attendees than non-MSM
clinic attendees, MSM should be tested for all prevalent STI,
in particular when they are older.
Regardless of sexual preference, young people are
vulnerable for STD acquisition and transmission for a combination of reasons involving biology, psychology, ambient
culture, and changing mores.12 In general, when rates are
corrected for those who are sexually active, the youngest
adolescents have the highest STD rates of any age group.
Some immunity may develop following an initial or serial
infection with a specific STD. On the other hand, emergence
4
108
of protective immunity induced by chlamydial infection is
not well understood.13 Young people are another STD risk
group that is targeted specifically by prevention organizations in the Netherlands. For example in 2008, a chlamydia
screening initiative has started in 3 geographical regions in
the country, targeted at young people aged 16 to 29 years.14
Our study shows that screening of young people diagnosed
with chlamydia at STD clinics should include testing for
other bacterial STD as well, particularly those aged 19 years
or younger. This is confirmed by an English study on coinfections found in opportunistic chlamydia screening. Of the
women screened at GUM clinics, 28% had a coexisting
STD.15 Before our study, community-based research in the
Sexually Transmitted Diseases ●
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STD Coinfections in The Netherlands
TABLE 3.
Multivariate Associations With Monodiagnosis and STD Coinfections Among MSM STD Clinic Attendees
Number Consultations
N (%)
Year of consultation
2004
2005
2006
2007
Ethnicity
Dutch
Turkish/Moroccan
Surinamese/Antillean
European, excluding Dutch
Sub-Sahara African
Asian
Latin American
Other and unknown
Age
�19 yr
20–24 yr
25–29 yr
30–39 yr
�40 yr
Unknown
STD history
No
Yes
Unknown
Commercial sex contact
No
Yes
Unknown
Monodiagnosis*
OR (95% CI)
8354 (23)
8768 (24)
8954 (25)
9664 (27)
ns
ns
ns
ns
28,343 (79)
474 (1)
985 (3)
1056 (3)
227 (1)
710 (2)
950 (1)
2995 (8)
1.0
1.1 (0.8–1.3)
1.5 (1.3–1.8)
1.2 (1.0–1.4)
1.3 (1.0–1.9)
1.1 (0.9–1.3)
1.0 (0.8–1.1)
1.1 (1.0–1.2)
867 (2)
3821 (11)
5349 (15)
11,510 (32)
14,179 (40)
14 (0.0)
1.0
1.3 (1.0–1.6)
1.5 (1.2–1.9)
1.6 (1.3–1.9)
1.3 (1.1–1.7)
NA
12,824 (36)
5466 (15)
17,450 (49)
1.0
1.8 (1.7–2.0)
1.4 (1.3–1.5)
25,826 (72)
1130 (3)
8783 (25)
1.0
0.8 (0.6–0.9)
1.2 (1.2–1.3)
Overall P
0.054
�0.0001
�0.0001
�0.0001
�0.0001
STD Coinfection*
OR (95% CI)
1.0 (0.8–1.2)
0.9 (0.7–1.1)
1.3 (1.0–1.5)
1.0
1.0
1.1 (0.6–1.8)
1.5 (1.1–2.1)
0.8 (0.5–1.3)
1.3 (0.6–2.7)
1.7 (1.2–2.4)
1.0 (0.7–1.4)
0.8 (0.6–1.1)
1.0
1.3 (0.8–2.3)
1.7 (1.0–2.8)
1.6 (0.9–2.6)
1.1 (0.6–1.8)
NA
1.0
1.8 (1.4–2.2)
1.3 (1.0–1.5)
1.0
1.1 (0.7–1.6)
1.8 (1.4–2.3)
Overall P
0.0095
0.011
�0.0001
�0.0001
�0.0001
*Chlamydia, gonorrhea, infectious syphilis.
ns indicates not significant.
Netherlands on chlamydia prevalence and coexisting gonorrhea showed a very low prevalence of coinfections. Nevertheless, the authors advised that all persons positive for
chlamydia should also be tested for gonorrhea.16
Our study may be the first to report on STD coinfections specifically among ethnic groups. However, associations between African and Caribbean ethnicity and
infections with bacterial STDs have been shown before.17 In
England, people of black ethnic backgrounds are disproportionately affected by STDs.18 In the Netherlands, ethnic
groups from Surinamese and the Netherlands Antilles account for 26% of the non-Western migrant population living
in the Netherlands of whom 50% congregates in one of the
four main cities in our country.19 Positivity rates among
STD clinic attendees of Surinamese/Antillean background
are higher than among attendees from other ethnic groups.2
In addition, first results of the chlamydia screening initiative
show that Surinamese and Antillean migrants were less
likely than Dutch natives to participate in the screening
program whereas they were more likely to be tested positive
for chlamydia (Op de Coul EL et al, unpublished data,
2009). Such differences in positivity rates might be due to
sexual mixing patterns within ethnic groups.20 Because cultural values are shared within ethnic groups, individuals are
more likely to have relationships with members of their own
group than with others. The majority (59%) of Surinamese
and Antillean migrants in the Netherlands reported partners
of their own ethnic group.21 This assortative mixing fuels the
spread of STD within subpopulations22,23 and thus may lead
Sexually Transmitted Diseases ●
to higher positivity ratios and a higher chance of acquiring
multiple STD within those groups. In addition, we see higher
rates of concurrent sexual partners among Surinamese and
Antillean migrants, compared to the general population.24
Moreover, STD clinic attendees of Surinamese/Antillean
origin are often young and might be more vulnerable for
multiple infections because of their age and corresponding
behaviors. Since 2006, HIV and STD primary prevention in
the Netherlands is culturally tailored to reach specific ethnic
groups. These results show that despite tailored prevention
measures, more efforts should be made to reach these
groups. Other prevention measures such as secondary
prevention (STD testing and partner notification) should
become more easily available for ethnic minority populations. In addition, further studies are needed to disentangle
(biologic) risk factors for STD acquisition in different ethnic groups.
Our study had several limitations. First, the results
from a study among STD clinic attendees should be extrapolated to the wider population with caution. Although clinic
consultations increase each year, most people in the Netherlands consult their GP for STD testing.16 GPs should
therefore be alert of the risk of STD coinfections, and
multiple testing is indicated in specific risk groups, such as
young people diagnosed with chlamydia, MSM, and ethnic
groups from Surinam/Antilles. On the other hand, a comparative study of data from STD clinics and GP surveillance
shows that STD clinics attract relatively more high-risk
persons than GPs, and that chlamydia, gonorrhea, and syph-
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TABLE 4.
Multivariate Associations With Monodiagnosis and STD Coinfections Among Heterosexual STD Clinic Attendees
Number Consultations
N (%)
Year of consultation
2004
2005
2006
2007
Gender
Female
Male
Ethnicity
Dutch
Turkish/Moroccan
Surinamese/Antillean
European, excluding Dutch
Sub-Sahara African
Asian
Latin American
Other and unknown
Age
�19 y
20–24 yr
25–29 yr
30–39 yr
�40 yr
Unknown
STD history
No
Yes
Unknown
Commercial sex contact
No
Yes
Unknown
Monodiagnosis*
OR (95% CI)
48,819 (21)
53,297 (23)
58,979 (26)
66,817 (29)
0.9 (0.8–0.9)
0.9 (0.9–1.0)
1.0 (1.0–1.1)
1.0
128,771 (57)
99,141 (44)
1.0
1.2 (1.2–1.2)
177,093 (78)
5259 (2)
15,526 (7)
8629 (4)
4671 (2)
3491 (2)
3284 (1)
9959 (4)
1.0
1.5 (1.4–1.7)
2.0 (1.9–2.1)
1.2 (1.1–1.3)
1.1 (1.0–1.2)
1.3 (1.1–1.4)
1.2 (1.0–1.3)
1.1 (1.0–1.2)
22,302 (10)
78,665 (35)
51,541 (23)
46,089 (20)
29,300 (13)
105 (0.1)
3.0 (2.8–3.2)
2.4 (2.3–2.5)
1.7 (1.6–1.8)
1.3 (1.3–1.4)
1.0
2.1 (1.1–3.9)
126,270 (55)
20,810 (9)
80,832 (35)
1.0
1.4 (1.3–1.4)
1.0 (0.9–1.0)
173,332 (76)
18,851 (8)
35,728 (16)
1.0
0.9 (0.8–0.9)
1.1 (1.1–1.2)
Overall P
�0.0001
�0.0001
�0.0001
�0.0001
�0.0001
�0.0001
STD Coinfection*
OR (95% CI)
ns
ns
ns
ns
1.0
1.3 (1.2–1.5)
1.0
1.7 (1.2–2.4)
6.5 (5.7–7.4)
2.0 (1.6–2.7)
1.4 (0.9–2.1)
1.5 (0.9–2.3)
1.7 (1.0–2.7)
1.6 (1.2–2.1)
6.8 (5.3–8.7)
2.5 (2.0–3.2)
1.7 (1.3–2.2)
1.1 (0.8–1.4)
1.0
NA
1.0
1.8 (1.5–2.1)
1.2 (1.1–1.4)
1.0
1.6 (1.2–1.9)
1.6 (1.4–1.9)
Overall P
0.28
�0.0001
�0.0001
�0.0001
�0.0001
�0.0001
*Chlamydia, gonorrhea, infectious syphilis.
ns indicates not significant.
ilis are more frequently diagnosed at STD clinics (van den
Broek IV, et al, unpublished data, 2009). Second, we could
not differentiate recidivism in our study since a unique
personal identifier was lacking in our data. Some individuals
may have had more than one STD consultation for a new
STD episode; therefore risk factors cannot be totally attributable to individual reports. Furthermore, our results show
that coinfections are more prevalent in networks like young
heterosexuals, specific ethnic groups and older MSM suggesting heterogeneity of risk behavior within these populations or bridging of these sexual networks. However,
because of the nature of our data we could not conduct
network analyses. Further research on sexual networks is
needed to elucidate the contribution of coinfected individuals to the spread of STD.
In conclusion, this study shows that specific sexual
networks such as MSM, ethnic groups, and young heterosexuals are at highest risk for bacterial STD coinfections.
The different age-related trend in MSM versus heterosexuals
suggests that these high-risk networks may have different
determinants that put members at higher risk, such as agerelated sexual risk-taking, biologic susceptibility, and insufficient knowledge or compliance with prevention measures.
Despite screening and treatment efforts, these sexual networks may disproportionately fuel the ongoing STD epidemic. Prevention and treatment efforts involving general
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practitioners and STD clinics, combined with research to
unravel transmission drivers and to improve interventions,
should therefore be targeted differently towards these specific high-risk sexual networks, in particular those networks
identified with concurrent STDs.
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