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Master Thesis in Public Health

A case-control study to investigate risk factors for syphilis among MSM presenting for STI testing in Stockholm, Sweden

Lara Payne

Supervisor: Prof. Johan Giesecke

Umeå International School of Public Health, Epidemiology and Public Health Sciences, dept of Public Health and clinical Medicine, Umeå University, 2007

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Table of contents
ACKNOWLEDGEMENTS ..................................................................................... 3 ABBREVIATIONS ................................................................................................. 5 1. ABSTRACT ....................................................................................................... 6 2. GENERAL BACKGROUND .............................................................................. 7 3. OBJECTIVE AND HYPOTHESES OF STUDY ............................................... 10 4. METHODS ...................................................................................................... 11 4.1 Ethical considerations ............................................................................ 11 4.2 Study design .......................................................................................... 11 4.3 Study population .................................................................................... 11 4.4 Sample size calculation ......................................................................... 15 4.5 Data required ......................................................................................... 15 4.6 Data processing ..................................................................................... 17 4.7 Data validation, recoding and analyses ................................................. 17 4.8 Pilot study .............................................................................................. 18 5. STUDY PLANNING ........................................................................................ 19 6. RESULTS ....................................................................................................... 20 6.1 Study population .................................................................................... 20 6.2 Sexual partners in last 12 months .......................................................... 23 6.3 Partnerships in Sweden and when abroad ............................................ 27 6.4 Use of drugs and alcohol ....................................................................... 30 6.5 Reported behaviour on most recent sexual encounter .......................... 30 6.6 Multivariate logistic regression model .................................................... 31 7. DISCUSSION.................................................................................................. 32 7.1 Study findings ........................................................................................ 33 7.2 Possible limitations and bias in this study .............................................. 37 7.3 Final conclusions on findings ................................................................. 39 8. REFERENCES ............................................................................................... 40 9. APPENDICES ................................................................................................. 43 Appendix 1: Result tables and figures – numbers of partners ..................... 43 Appendix 2: Result tables and figures – sexual behaviour .......................... 45 Appendix 3: Clinic information sheet............................................................ 49 Appendix 4: Questionnaire used for cases and controls .............................. 50 Appendix 5: Information sheet for study participants ................................... 66

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ACKNOWLEDGEMENTS

This project would not have been possible without the contribution both directly and indirectly of many people.

Firstly, I would like to thank all the anonymous men who completed questionnaires and contributed to this research study.

I would like to thank my supervisor Professor Johan Giesecke for his encouragement in developing this research project in the first instance, for learned discussions in epidemiology, for his continued support and above all for keeping project aims in focus!

My gratitude goes to colleagues at Venhälsan clinic, Södersjukhus, Stockholm, Sweden: Professor Eric Sandström for his encouragement, Dr. Anders Karlsson and Dr. Göran Bratt, Nurse Lena Persson and Nurse Stefan Ekroth for their endless advice and friendly support in implementing the study.

My sincere thanks go to my colleague Torsten Berglund (SMI) for his valuable scientific advice in this project, his endless time and support at all stages, for listening and encouraging, and not least for good friendship and a warm welcome to Sweden.

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Data on syphilis trends in Sweden were provided by Torsten Berglund and Inga Velicko from the national surveillance database at SMI. John Imrie (London) for his scientific encouragement and sharing the questionnaire and experiences of the Brighton Syphilis study. Thank you to colleagues at SMI.Analyses of the results would not have been finally completed without the assistance and dexterity of Sharon Kühlmann-Berenzon. for support and encouragement. yet very enjoyable hours of statistical analyses together. I would also like to acknowledge and thank Dr. Thank you for your excellence in R software and meticulous approach to keep this large dataset in check! But above all thank you for the many. long. especially Yvonne Andersson. 4 . and my thanks are given for their assistance. This study was partly financed by a grant from The Swedish National Institute for Public Health. statistician at SMI.

ABBREVIATIONS ART CI IDU HIV MSM MSW OR mOR SMI STI UAI Anti-Retroviral Therapy Confidence Interval Injecting Drug Use Human Immunodeficiency Virus Men having Sex with Men Men having Sex with Women Odds Ratio Matched Odds ratio Swedish Institute for Infectious Disease Control Sexually Transmitted Infections Unprotected Anal Intercourse 5 .

1. and increasing travel abroad. to investigate possible risk factors for Syphilis among Men having Sex with Men (MSM) presenting for STI testing in Stockholm. having more than 10 anonymous partners in the last year. and being under the influence of drugs under sexual intercourse with a casual or anonymous partner. With reported outbreaks of syphilis within European cities around the same time. Stockholm. the question remained were the behavioural risk factors among MSM acquiring syphilis in Sweden. A prospective case-control study was carried out at Venhälsan clinic. and borderline significance with 10 or more casual/anonymous partners. A decrease in the number of cases of syphilis resulted in a total of 24 cases and 82 controls being included in the study. These tentative results agree with findings by Imrie et al from a case-control study of syphilis cases in Brighton. ABSTRACT In the 5 years between 1999 and 2004. 6 . Sweden. being short of the optimum power and sample size but providing an indication of possible risk factors among MSM. Results of the study suggest the following factors as being more likely to be associated with being a case than a control: previously having an STI infection in the last 5 years (particularly syphilis or chlamydia infection). the annual number of reported cases of syphilis increased sharply in Sweden. which found a significant association of syphilis with previous STI infection history and recent recreational drug use. UK. between 1st October 2004 and 31st August 2005.

Effective treatment with antibiotics is available. with a large increase of cases particularly among MSM (Figure2). In the late 1990s an increase in reported syphilis cases was observed across Europe [2]. The annual number of reported cases of syphilis in Sweden also increased sharply in the 5 years between 1999 to 2004 (Figure 1). thus prompt diagnosis is important. the vast majority of MSM individuals were reported as acquiring infection within Sweden. to 42 cases in 2000 and doubling to 97 cases in 2003. Manchester and Brighton [3]. Of the cases reported in 2003. If infection is acquired and untreated. Norway and Sweden [9] also increased. including numerous focalized outbreaks amongst Men who have Sex with Men (MSM) in several European cities.2. from 8 cases in 1999. 25% were reported acquiring infection abroad. Trends observed in some European cities were also observed in Sweden. Annual reported cases of syphilis among MSM in the Scandinavian countries of Denmark [8]. 7 . Of the 258 MSM cases in Sweden reported in 2000-03. it can develop from ulcers and sores to a tertiary stage clinical presentation that may include neurological symptoms [1]. However. GENERAL BACKGROUND Syphilis is a sexually transmitted bacterial infection that can be easily prevented through appropriate use of protective measures such as condoms. 70% were reported from Stockholm County. Oslo [4] and Rotterdam [5] experienced outbreaks in 1999. Paris and Berlin and Dublin [6] in 2000 and London in 2001[7].

the question remained whether syphilis was becoming endemic again among the population of Sweden. Figure 1: Number of Syphilis cases reported in Sweden (1960-2003) Figure 2: Infection route of syphilis cases in Sweden (1990-2003) 200 180 160 140 120 100 80 60 40 20 0 19 90 19 91 19 92 19 93 19 94 19 95 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03 Men MSM Men MSW Women 8 .With reported outbreaks of syphilis across Europe. and increasing travel abroad. and whether directly or indirectly resulting from acquisition abroad.

identified no significant association between being a syphilis case and having unprotected oral sex. among MSM seeking testing for Sexually Transmitted Infections (STI) in Stockholm. 9 . Preliminary findings from a syphilis case-control study by Imrie et al [12]. following a large syphilis outbreak in Brighton. A study carried out in Manchester [11] implicated unprotected oral sex as a likely risk factor for syphilis and possibly HIV infection. Studies show that infection with syphilis facilitates transmission of HIV in unprotected sex [10].Syphilis is deemed a marker of risky sexual behaviour and the increase of reported cases in Sweden was of concern. Therefore if ongoing syphilis transmission amongst MSM and outbreaks were occurring. This study sought to identify possible behavioural and demographic risk factors for acquiring syphilis. There are few published case-control studies on syphilis in MSM in Europe in the last 5 years: all from the United Kingdom. but found number of oral sex partners and receptive anal sex as risk factors. to assist with targeting of prevention measures and public health messages. individuals with undiagnosed syphilis engaging in unprotected sex would be likely furthermore at increased risk of acquiring or transmitting HIV infection.

That MSM presenting at a clinic in Stockholm for STI testing and testing recently positive for syphilis. have a greater median age than those testing negative for syphilis. in MSM presenting for STI testing in Stockholm Hypotheses examples 1. 2. 3. OBJECTIVE AND HYPOTHESES OF STUDY Principal objective: To understand possible factors associated with recently acquired syphilis infection. That MSM presenting at a clinic in Stockholm for STI testing and testing recently positive for syphilis. That MSM presenting at a clinic in Stockholm for STI testing and testing recently positive for syphilis. are more likely to have engaged in unprotected oral sex in the 12 months prior to diagnosis than those testing negative for syphilis. 10 . are more likely to have had greater than 10 partners in the 12 months prior to diagnosis than those testing negative for syphilis.3.

located in a main hospital of central Stockholm.3 Study population 3. 4.2 Study design A prospective case-control study was implemented. how information would be processed. All patients were made aware that participation in the study was voluntary. The study population consisted of MSM attending a gay and bisexual men’s health clinic. METHODS 4.1 Population Stockholm city has the largest community of MSM in Sweden.4.3. Diarienummer 04-569/3). A contact at the clinic and at SMI was also provided for any questions that could arise about the study. Venhälsan. This clinic was selected for the study as the centre has reported an average of 68% (123/180) of all MSM syphilis notifications from Stockholm. Thus the findings of the study were considered to be fairly representative of the MSM population in Stockholm seeking STI testing. and that non-participation did not affect the healthcare received in any way. stored and used.1 Ethical considerations Ethical approval for this study was given by Stockholm Region Ethical Committee (Regionala Etikprövningsnämnden i Stockholm. between 2000-2003. anonymous and confidential. An information sheet was provided to respondents concerning the purpose of the study (Appendix 5). 11 . 4.

within the study period of 1st October 2004 .2 Definition of cases and controls Eligibility for the study A gay or bisexual man aged ≥15 years old. between the dates of 1st October 2004. A case was defined as: A gay or bisexual man having a positive laboratory serology result for primary. 4.5 Selection of cases All gay or bisexual men on their return visit to clinic for syphilis test results.31st August 2005.3. 4. secondary or early latent syphilis.31st August 2005. secondary or early latent syphilis.3. A control was defined as: A gay or bisexual man having a negative laboratory serology result for syphilis.4 Mechanism of recruitment Individuals presenting for syphilis testing at the clinic were considered part of the population to be sampled. 12 . presenting at Venhälsan clinic in Stockholm. having a test result for syphilis within the last 60 days.3. found to be positive for primary.3.

to ensure that controls arise from the same population as cases with an equal chance of experiencing similar temporal exposure factors such as annual organized events. and specifically for HIV infected individuals. HIV status: .6 Selection of controls A gay or bisexual man presenting for a negative syphilis test result at the clinic within two weeks after the matching case. sero-concordant). controls will also be matched to cases according to time of year. Controls were matched to cases according to known HIV status before testing. Reasons for matching on time and HIV status: Time: . Thus HIV positive individuals may respond to questions in a different way then individuals with HIV status not known or negative.3.4. HIV positive individuals should not have unprotected sex [14]. Swedish Communicable Disease law states that an individual with a diagnosed communicable disease infection has a duty to minimise the risk for spread of infection to any sexual contact [13]. or behaviour due to seasonality.HIV positive individuals are likely to mix with other HIV positive individuals (ie. By recruitment mechanism. 13 .

4. Eligible controls however needed to have returned to the clinic for their test result within 2 weeks to be matched by time. Figure 3: Diagram illustrating patient recruitment pathway for case-control study on syphilis among MSM attending an STI clinic in Stockholm.3. and a day clinic for HIV-positive patient care. On a weekly basis. Data collection Patients Return to clinic for syphilis result Ask whether want to participate in study ? All meeting eligibility criteria are asked Patient completes questionnaire at clinic and hands over in sealed envelope at clinic Q + All . two nurses at the clinic identified syphilis cases to be recruited using the list of laboratory results returned to the clinic.cases 1:4 controls Clinic completes test result sheet + Tally sheet monitor Result sheet SMI 14 . Controls were then selected as the four consecutive eligible syphilis negative patients presenting in clinic after the case. Controls could be recruited in the following evening clinic if there were not enough eligible controls presenting after the case recruited in an evening clinic.7 Sampling frame Venhälsan has an evening clinic for HIV and STI testing and advice.

HIV/STI laboratory results.0 Odds ratio. Questions consisted principally of multiple choice closed-question tick boxes (Appendix 4).5 Data required Paper questionnaires in Swedish or English were given by the doctor to cases and controls being recruited. The approximate number of patient visits to the clinic in a year was 1500. 15 . a ratio of 1:4 cases and controls and an expected frequency of exposure in control group of 25%. ART and CD4 count if HIV positive. The anonymous questionnaires were self-completed in a private room in the clinic and once completed. A one-page test results sheet was completed by the nurse for every patient (case or control) asked to participate in the study (Appendix 3). syphilis disease stage. The 25% exposure in control group was based on results of a sexual behaviour study undertaken in Venhälsan between 2001-2002 that showed 75% of study participants (n=203) reported unprotected oral –genital sex with a casual partner in the last month [15]. The sample size required 156 controls and 39 cases. 80% power. The observed number of syphilis cases among MSM at Venhälsan in 2003 was 55.4. asked to be handed in a sealed envelope to reception at the clinic. to be able to detect a 3. 4. The sheet recorded basic information such as age.4 Sample size calculation Sample size was calculated for an unmatched case-control study with 95% confidence interval. thus it was necessary to recruit at least 70% of anticipated annual cases. after the consultation of their test result.

). on maybe one or two occasions.an ANONYMOUS partner is defined as a man who you don’t know anything about apart from the sex you had with them. .For the purposes of the research. You know a lot about these men other than the sex you had with them. other than their name and you may have had sex with them. or other partners such as lovers or ‘fuck-buddies’. This may include steady partners (‘husbands’ or boyfriends etc. This includes men you may have had sex with in a dark room or cruising ground. definitions for sexual partnerships were given in the questionnaire as: regular. This may include ‘one-night stands.a CASUAL partner is defined as a man who you don’t know much about. . casual or anonymous.a REGULAR partner is defined as a man who you have or had an ongoing sexual relationship with. and you don’t have their name or number. 16 . These definitions were: .

2 Data Recoding Data responses on condom usage were used to define two exposure categories: unprotected and protected sex.6 Data processing Questionnaires were collated monthly to the study co-ordinator. 17 .7. Protected sex was defined as those reporting always using a condom for that sex technique. in which case the latter question was excluded and the questionnaire assessed overall as being still valid if less than 2 contradictory statements were made. Data was entered using Epidata® (Denmark).1 Data validation Validation of data occurred on entry through a check program on Epidata®.7 Data validation. 4. and unprotected as never. and checks undertaken for consistency. Questionnaires did not contain any personal identifiable information. A total of 26 mistakes among 12 questionnaires with 368 variables each was measured and this error level of 0.7. Twelve randomly-selected questionnaires (10%) were also data-entry checked in the raw dataset as a quality control measure.4. recoding and analyses 4. no follow-up on information provided was possible and thus responses to questions were accepted. 4. As questionnaires were anonymous. unless contradictory to other responses in questionnaire. Data entry was undertaken by the study co-ordinator. sometimes or often using condoms. validity and logic before analysis.5% was deemed acceptable.

18 . Questionnaires and data collection methods were then revised in consultation with the clinic.10. However as an unmatched analysis biases towards the null hypothesis. Mann Whitney U test was used for testing differences in age distribution. 4. Multiple logistic conditional regression analyses were undertaken using R. taken as P<0.7.4. A test result was deemed significant when the confidence interval did not include zero.3 Data analyses These were undertaken in Epi-Info for windows (Version 3.8 Pilot study The questionnaire was reviewed by a few clinic staff and some volunteer patients. Differences in behaviour reported with different partner types (i.2) and R statistics software. As the required sample size was not reached. unmatched odds ratios were calculated in Epi-Info.3.e. taking Fisher Exact test results for significance values. irrespective of syphilis status) were tested using a McNemar test (chi-square test of paired proportions P1-P2) [16]. conditional logistic regression providing matched analyses for odds ratios (mOR) were then undertaken in R for all borderline significant ORs.

2005-Jan.5. 2006 February 2006 February . STUDY PLANNING Planning/ organisation of study Formalisation of questionnaire Application to ethics committee Pilot study undertaken Data collection begins Total weeks: 6 weeks April 2004 June 2004 July 2004 September 2004 1st October 2005 3 weeks 2 weeks 1 week Data cleaning Preliminary analysis Preliminary report of findings to clinic Final analyses Final report Total weeks: 14 weeks October-November 2005 Dec.March 2007 April-May 2007 3 weeks 2 weeks 2 weeks 3 weeks 4 weeks 19 .

05. 24 of 25 eligible cases and 93 of 100 controls chose to participate in the study.1.2 Demography of study population AGE The age distribution of cases and controls did not differ significantly (Mann Whitney U test p=0.6. RESULTS 6. resulting in a 94% response rate. p=0.1 Study population 6.1 Recruitment into study Between September 2004 and October 2005. Age distribution differed between HIV positive and negative individuals (Mann Whitney U test p<0.1. 6. Controls: 34 years Matched OR=1. p=0. Thus a total of 24 cases and 82 controls were included in the analysis. Figure 4: Age group distribution by HIV status of cases and control enrolled in syphilis case-control study Figure 4a: HIV positive individuals enrolled in study cases controls 25 Figure 4b: HIV negative individuals enrolled in study cases controls 25 20 15 10 5 0 15-24 25-34 35-44 45-54 55-64 20 15 10 5 0 15-24 25-34 35-44 45-54 55-64 Median age: Cases: 45 years.92.001) but was not significantly different among cases and controls by HIV status (Figure 4).047 . Controls: 50 years Matched OR=0. Nine controls were then subsequently lost to the study: four due to the nonparticipation of the matching case and five were excluded as they did not meet the criteria of having reported a sexual contact in the last 12 months.131).231 20 Median age: Cases: 38 years.

5 n/N % 14/24 58 18/24 75 24/24 100 22/22 100 Controls 36. Social demography and Sexuality of study population Cases 38.1. Table 1: Age. Sweden. Over 99% of both cases and controls were resident in Stockholm. 21 . All cases reported being homosexual and among both cases and controls over 80% were open about their sexuality.University level Employed Residency in Sweden Residency in Stockholm Sexuality: Homosexual Bisexual Transsexual Not reported Sexuality openness: Very open Sometimes open Sometimes closed Very closed Don't know n/N 24/24 % 100 N/N 76/89 10/89 2/89 1/89 N/N 40/89 35/89 9/89 4/89 1/89 % 85 11 2 1 % 45 39 10 4 1 n/N 10/24 12/24 1/24 0/24 1/24 % 42 50 4 0 4 6. Most individuals presented for testing due to reasons of symptoms or recent unprotected sex.0 n/N % 42/89 40 59/89 66 87/89 98 85/86 99 Median age (years) Demographics Education .3 Sexual health of study population Table 2 lists the reported reason for visit to clinic and eventual testing for syphilis.SOCIAL DEMOGRAPHICS AND SEXUALITY The demographics of the population included in the study are shown in Table 1.

0076 Controls Cases mOR 3. In the last 5 years. significantly more cases (59%) versus controls (30%) (mOR 3.051 40 60 80 100 % Syphilis cases were more likely to have been previously diagnosed with syphilis or Chlamydia infection in the last 5 years prior to this visit. 22 .Table 2: Reason for visit to clinic and testing for syphilis: Own/ partners' symptoms Change of relationship Unprotected sex/routine testing Contact tracing Read about syphilis Other /not reported Cases (N= 24) n % 12 50 0 0 9 38 1 4 1 4 1 4 Controls (N=84) n % 17 20 10 12 41 49 9 11 0 0 7 8 60% of cases and 48% of controls also reported taking a test for an STI prior to their latest to the clinic. had been diagnosed with an STI (Figure 5).008).02 p=0.75 p=0. than controls. under the last 12 months (non significant difference). p=0.74. Figure 5: Percentage of cases and controls with an STI in the last 5 years prior to this visit to the clinic Syphilis Hepatitis C Hepatitis B Hepatitis A Gonorrhea Chlamydia 0 20 mOR 7.

102 Over 80% of both cases and controls reported having a regular partner in the last year.58 0.44 p-value 0. 9 (8%) reported having male and female partners in the last 12 months. whereas 79% and 61% of cases and controls respectively reported having an anonymous partner.502 0. Table 3: Types of relationship in last 12 months Partner type Regular Casual Anonymous Cases Controls 16/20 20/24 19/24 70/84 72/80 50/82 mOR 1.542 0. None reported having female partners only in the last 12 months and thus no respondents were excluded by this criterion.1 Gender of partner Of 107 men responding. 23 .2.52 1.6.2 Sexual partners in last 12 months 6. Casual partners were reported for 83% of cases and 90% of controls. 6.2.2 Relationship and number of partners and sexual practices Cases and controls were as likely to have different partner relationships in the last 12 months (Table 3).

Only half of HIV positive men had regular partners compared to HIV negative men (76/88) (data not shown in table). Seventy-two of 84 HIV negative individuals and 7 of 20 HIV positive individuals, reported having both a regular and a casual or anonymous partner in the last 12 months.

Numbers of partners Reported total number of male partners (for N=75 respondents) in the last 12 months ranged from 1-101 with a median of 10 and a mean of 16 partners (Appendix 1 Figure 1). The number of partners reported by cases and controls significantly differed only for anonymous partners (See Appendix 1 Figures 2-4), where cases were 3.77 times more likely to have had more than 10 partners in the last 12 months (OR=3.77, p =0.041).

6.2.3 Sexual practices in different relationships

No significant differences were observed between cases and controls in the sexual practices reported for regular partners (See Appendix 2a, Table 1). However, in the matched analyses cases were borderline significantly more likely to have given unprotected anal sex with casual partners in the last 12 months (mOR=2.97, p=0.08), and more likely to have fisted their partners (mOR=3.63, p=0.08). No differences in behaviour were significantly different in the matched analyses for anonymous partners. However response rates to these set of

questions dropped in comparison to casual and regular partners. Response rates

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on questions regarding sexual techniques varied from 75-92% for questions about regular partners, to 69-88% for casual and 54-66% for anonymous.

Of those having sex with a casual partner in the last 12 months (92), most (66%) had met their partner through the Internet and had sex with them at home (88%, 83/92) (see Appendix 2 Appendix Table 3b and 3c). Anonymous partners (N=69) were contacted more through video places (38) and Internet (29) followed by bars (26) and saunas (25), with sex occurring most in video places (38), at home (31) and in saunas (26).

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6.2.4 Differences in behaviour with casual and anonymous partners

In order to test whether there were differences in behaviour reported with causal and anonymous partners regardless of syphilis status, and thus whether a distinction between casual or anonymous partners was made, difference tests were undertaken for sexual techniques reported.

A total of 59 people responded to all questions on sexual technique with casual and anonymous partners. Table 4 shows the responses for oral sex and anal sex, where 0=No and 1=Yes. Thus in Table 4a, 5 individuals reported giving oral sex to casual partners but not with anonymous partners, and in Table 4c, 7 people reported receiving anal sex with casual but not anonymous partners.

Table 4: Differences in sexual behaviour reported with a casual or an anonymous partner

Table 4a: Oral sex give
Anon Casual 0 1 0 2 1 1 5 48

Table 4b: Oral sex receive
Casual 0 1 Anon 0 1 2 0 4 50

P1- P2 = -0.07 CI= -0.15 to +0.01

P1- P2 = -0.07 CI= -0.14 to –0.004

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0.3 Partnerships in Sweden and when abroad Meeting partners in Sweden 23/24 cases and 69/81 controls reported meeting a casual or anonymous partner in Sweden in the last 12 months (OR=4. Appendix table 4 (in Appendix 2b) shows the response regarding places where men reported meeting 27 . 6.2.15).17 CI= -0.04 P1-P2= -0.Table 4c: Anal sex receive A non 0 1 17 0 7 27 Table 4d: Anal sex give A non 0 1 8 1 10 33 Cas ual 0 1 Cas ual 0 1 P1-P2 = -0.3). unprotected sex.14 CI= -0. p=0. but significantly different between partner types for anal sex practices. No significant differences of behaviour or risk factors between syphilis cases and controls were identified in this dataset (Data not shown here). analyses were undertaken on aggregated data for responses on anonymous and casual partners. As anal sex with casual partners had appeared as a borderline significant value in the matched OR analyses (shown in 5. No differences were observed for all other sexual practices. it was considered best to continue to differentiate casual and anonymous partnership types for all OR analyses.29 to –0. number of oral or anal partners reported (Wilcoxon rank sum test).23 to –0.06 Differences in behaviour were thus borderline significant for receiving oral sex. Furthermore. as a check. but not giving oral sex.

p=0. Meeting at bars. p=0. p=0. South Africa. France (4). England.0298). Countries where saunas were visited included: Denmark (10). Australia. Hungary.184. 59% (34/58) controls. and other countries (Switzerland. Canada. Bars. Cases were not more significantly likely than controls to meet a casual/anonymous partner abroad (74% (14/19) cases vs. OR=1. and 97% (33/34) of video places. Estonia. Thailand (3) and Norway (3).477.97. Japan). Germany (6). 57% of cases (13/23) and 72% (60/83) of controls reported meeting a male partner in Sweden through the Internet in the last 12 months (Matched OR=0. 28 .11. Meeting partners abroad Cases and controls were equally likely to have travelled abroad in the last 12 months (83% (19/23) of cases versus 73% (60/82) of controls). No places were significantly different on matched analyses.16). Spain (7). Cases were much less likely than controls to have had sex with these partners: 69% (9/13) of cases and 95% (56/59) of controls (mOR=0. video places and discos were the most frequently reported meeting places. saunas and discos were the most common venue (see Appendix 2b Appendix table 5).a casual/anonymous partner in Sweden in the last 12months. Austria. However differences in meeting places for cases and controls were insignificant in matched analyses. Ireland. Stockholm was named as the location for 95% (42/44) of those meeting in bars. USA. Brazil.

1 Differences in behaviour when abroad and when in Sweden Testing for differences in meeting places preferences when in Sweden or abroad revealed that MSM were more likely to meet a casual/anonymous partner in a sauna abroad than in Sweden.65 CI= 0. MSM were more likely to meet casual/anonymous partners at a video place or a park in Sweden. However.21 29 . Particularly high numbers of MSM met partners through the Internet in Sweden (Table 5 d).3. Table 5a: Sauna SE Abroad 0 1 0 7 20 1 1 1 Table 5b: Video place SE Abroad 0 1 0 6 1 1 13 9 P1-P2 = 0.41 CI= -0. few cases or controls travelling abroad used the Internet to meet partners abroad (2/19 cases and 7/60 controls FE p=0.63).45 to 0. On the contrary.85 P1-P2= -0.61 to –0. nearly all (8) reported also having sex with these partners. of those meeting partner abroad through the Internet (9). 6. but only 8 met both partners in Sweden and abroad through the Internet. Table 5: Differences in meeting places for casual/anonymous partners when in Sweden or abroad. casual and an anonymous partner in the last 12months. These 8 men reported having a regular.Contrary to the reported behaviour in Sweden.

39%) to have used drugs when having sex with a casual or anonymous partner (mOR 2.17 CI= -0. the descriptive data indicate that the most widely-used drugs were poppers (38/52) and viagra (13/51). casual or anonymous partner.5 Reported behaviour on most recent sexual encounter Exactly one third of cases reported having sex on the most recent occasion with either a regular. p=0. However cases and controls were equally likely to have been under the influence of alcohol (55% 12/22 cases and 59% 49/83 controls).32 to -0. No other drugs were reported.55 CI= -0. 63%) were twice as likely than controls (33/84. Any significant differences in type of drugs used between cases and controls could not be calculated due to too little response for each drug type. whereas two-thirds of controls reported having sex last with a regular partner.4 Use of drugs and alcohol Cases (15/24. 6. cannabis. Between 5-8 respondents reported using amphetamines.034 P1-P2= -0.057).43 6.38.Table 5c: Park (N=30) SE Abroad 0 1 0 17 0 1 5 6 Table 5d: Internet (N=78) SE Abroad 0 1 0 25 1 1 44 8 P1-P2= -0. cocaine or ecstasy.66 to –0. though viagra was often used simultaneously with other drugs. However. No significant differences 30 .

001). drug use.300 0.027 0. except receptive anal intercourse (OR=2. Several variables were not included in the model due to missing data preventing convergence of the model. Age was included in the model as a potential The best-fit model that resulted was: = Age + PrevSTI<5yrs + anon partners 10+ The model was based on 87 questionnaire replies.between sexual techniques at last sex was reported for cases and controls. p=0.03-19. total number partners>10.04 4.196-19. Fit to model p=0. previous STI positive. Most men reported having sex at their or their partner’s home (n=77/103).969-1.6 Multivariate logistic regression model The following variables were used in a stepwise model of factors contributing to the likelihood of being a case: age.045 31 . confounding factor.45 1.066) and receptive fisting (OR=undefined. total number of anonymous partners >10.00523 Age Previous STI in last 5 years Anonymous partners 10+ OR 1.53 95% CI 0.11 1.82 4. 3/15 cases and 0/55 controls.77 p-value 0. 6. followed by video places (9/103).70. p<0.

and borderline significance with 10 or more casual/anonymous partners. 32 .7. The results from the study in Stockholm should be interpreted with caution as the study lacked statistical power to be able to disentangle the effect of variables other than these above and control for possible confounders other than age. Too few syphilis cases presented at the clinic under the study period. which found a significant association of syphilis with previous STI infection history and recent recreational drug use. These tentative results agree with findings by Imrie et al [17] from a case-control study of syphilis cases in Brighton. the number of syphilis cases in the wider MSM population of Stockholm decreased during 2004-06 (see Appendix 2c Appendix Figure 5). DISCUSSION This study sought to investigate the risk factors associated with being a syphilis case among MSM attending an STI clinic in Stockholm. and being under the influence of drugs under sexual intercourse with a casual or anonymous partner. thus the target sample size could not be reached. Results of the study suggest the following factors as being more likely to be associated with being a case than a control: previously having an STI infection in the last 5 years (particularly syphilis or chlamydia infection). having more than 10 anonymous partners in the last year. Despite good recruitment levels into the study. UK. Sweden.

indicating several types of relationship and partner change. Though age overall did not appear significantly different between cases and controls. 7. Numbers of partners reported differed according to partner 33 . History of previous STI infections Cases were more likely to have been diagnosed with an STI in the last 5 years than controls. with a majority being open about their sexuality.1 Study findings Homogenous population but median age differs by HIV status The study population recruited appeared to be fairly homogenous. All types of relationship in the last 12 months The majority of both cases and controls reported having a regular. casual and anonymous partner in the last 12 months. similar to findings in the studies of Bellis et al and Imrie et al [11.Considering this limitation. there are nonetheless some interesting results in this study.16]. including descriptive results of the MSM population attending the clinic and differences in behaviour with different partner types. when stratified by HIV status there was an age difference between HIV negative and positive individuals. being homosexual men living in Stockholm. Age was considered a confounder and not a direct risk factor for acquiring syphilis.

This trend was also apparent in the reporting of last sexual encounter where receptive anal intercourse and receptive fisting with casual/anonymous partners were borderline 34 . All MSM have oral sex with different partners Between 88-100% of both cases and controls had oral sex with all types of partners. but not oral sex itself. usually unprotected. The high frequency of oral sex practice among cases and controls implied that no association with syphilis infection could be tested. where cases were more likely to have had more than 10 partners in the last 12 months. Chlamydia. indicating a high use of this sexual technique and consequent risk for STIs such as syphilis. Relatively high numbers of partners is a cause for concern for its contribution to increasing STI incidences among MSM and has been identified as a cause in other European countries such as Germany [18]. who identified an association between syphilis and higher numbers of oral sex partners.type. However. than controls. But this differentiated significantly between cases and controls only on the number of anonymous partners reported. a strong association of syphilis with oral sex and number of oral sex partners was identified by Bellis et al [11]. The high level of reported oral sex practice is similar to findings by Imrie et al [16]. Syphilis cases more likely to have risky non-oral sex with casual partners Results suggest that cases were both more likely to engage in giving unprotected anal sex with casual partners and to fist their partners. and possibly HIV or hepatitis B.

No difference was observed between cases and controls in Internet use. Many MSM find partners through the Internet in Sweden Sixty-nine percent of MSM in this study reported meeting a partner in Sweden through the Internet and over 80% of these reported having sex with these partners. No behaviours appeared as risk factors for anonymous partners but this may be due to wide confidence intervals and too smaller numbers for analysis. but cases were much less likely to have had sex with a partner met through the Internet than controls. However of those meeting partners abroad this way nearly all also had 35 . Differences in behaviour reported between casual and anonymous partners also indicated that although anal sex occurred with both casual and anonymous partners. indicating the Internet as being widely used to meet partners. These results are similar to Imrie et al [16] who identified a higher odds ratio for receptive anal intercourse with casual/anonymous partners among syphilis cases. Analyses of behavioural differences with partner types are not reported in the literature and thus cannot be compared. In comparison few MSM reported meeting partners abroad through using the Internet.significantly different between cases and controls. significantly more men were likely to have anal sex with casual partners but not with anonymous partners than vice versa.

thus have not generally been accessible. However there were no significant differences between cases and controls on travel behaviour and likely meeting venues abroad. is that MSM in the study population in general met casual/anonymous partners more frequently in video places in Sweden and in saunas when abroad. Gay sauna clubs were banned in Sweden between 1987 and April 2004 [21]. Travelling abroad common but meeting places differ to being in Sweden Over three-quarters of MSM in the study population reported travelling abroad in the last 12 months. and this may explain the difference in reported use of saunas abroad noted here. Of note. Some studies have linked syphilis outbreaks to meeting partners through the Internet [19-20]. However as a high rate of Internet use is reported in this study. but bars were also reported as often the location for meeting MSM both in Sweden and abroad. In particular ‘poppers’ were the most frequently 36 . it would indicate that any risk for syphilis in Sweden would be indirectly linked to online-meeting. Relatively high use of recreational drugs Over 40% of MSM reported using recreational drugs when having sex with a casual or anonymous partner and syphilis cases were borderline significantly more likely to have used drugs.met a partner in Sweden through the Internet and had sex with partners from abroad and in Sweden.

This is unlikely to have occurred however as study participants were made fully-aware that questionnaires would be self-completed. through day of recruitment and thus differences in individuals and their lifestyles. However to minimise this effect the selection criteria for controls was consecutively presenting eligible patients. information bias.2 Possible limitations and bias in this study Possible limitations that may affect the results of this study and should be considered here include: selection bias. Selection bias may have been introduced on selecting controls. if the partner attended the clinic within the same evening. Information bias could have been possible in two different ways.reported drugs used by the study population. 7. The Swedish Communicable Disease Act requires that an individual with a diagnosed current STI/HIV infection protect their sexual partners from potentially acquiring infection. anonymous and not accessible by the clinic staff. UK [11]. A further selection bias possibility was that the partner of the case was recruited as a control. corresponding to findings by Bellis et al in the population of MSM with syphilis in Manchester. systematic error and the role of chance. 37 . Thus. bias in the information on condom use may have been introduced in apprehension of this.

However. If this study was to be repeated I would consider shortening the questionnaire as the response rate to individual questions decreased as the questionnaire progressed. However I believe that it was important to differentiate in the questionnaire between types of partner (regular. 38 . The findings of the study may also be an underestimate as the control population are men presenting for testing rather than the MSM community in general.Systematic error could have been introduced if a study participant misunderstood the definition of different partner types. significant results may have occurred by random chance. indicating response fatigue. This limitation was handled by having a clear analysis plan for the results where less than 20 key variables were listed as of interest in the questionnaire. due to the numerous questions and consequent possible variables of interest in this study. this larger population sample frame was deemed unfeasible to access for this study and the population of STI clinic attendees chosen as the best option. and also investigate the different behaviour of MSM when in Sweden and when abroad. The clear definitions given in the questionnaire aimed to minimise this error. casual and anonymous) partners in Sweden. Finally. This likely also introduced information bias.

This study had provided experience in reaching the MSM population under epidemic disease investigations and assisted in identifying current sexual behaviour among MSM attending an STI clinic. Of consideration in this study is that due to the population size in Sweden.3 Final conclusions on findings This study was unable to tease out the exact contributions of possible risk factors for acquiring syphilis among MSM attending an STI clinic in Stockholm. Such findings can assist in 39 . With higher connectivity it is possible that the risk for syphilis changes temporally and spatially. A much larger study sample size would be required. Descriptive data of the study population nonetheless provides some indications of the behaviours and demography of the MSM populations and is in accordance with findings of several published studies in recent years. The descriptive data shows that MSM in Stockholm are more likely to meet other men in Sweden and in Stockholm. and thus be harder to identify in such a study.7. MSM social networks may be more inter-connected than in other European cities. Thus the risk of syphilis in such a population could be micro-foci according to place and time and not in general behaviour. Other studies have shown that at-risk groups can be variable and change in terms of potential risk behaviour [22]. or more cases presenting in a shorter period of time in a rapid outbreak in the population. Furthermore variation in behaviour reported could be too subtle to distinguish risks and as measured in a generalised question of 12 months behaviour.

Goh BT. The Netherlands’. Hopkins S. Fenton K. Eurosurveillance Monthly. O’Flanagan D. Wallace L. ‘Syphilis in adults’. Sexually Transmitted Infections. Eurosurveillance Monthly. REFERENCES 1.eurosurveillance.targeting prevention activities. Cronin M. ‘Outbreak of syphilis in Rotterdam. Domegan L. ‘The epidemiology of infectious syphilis in the Republic of Ireland’. ‘Syphilis surveillance and epidemiology in the United Kingdom’. 8. and decrease the potential for HIV infection to spread in the population. http://www. Lowndes C.org/ew/2002/020328.asp accessed 27th may 2004 6. 9 (12) 40 . 2002.asp 4. Solomou A. ‘An outbreak of syphilis in Oslo’. 6 (13) http://www. Sexually Transmitted Infections Aug 2004 : 80(4) :255-63 3. O’Lorcain P. International Journal of STD and AIDS. Dec 2004 : 9 (12) 7. 2005 : 81 (448452) 2. Fitzgerald M. Thornton L. educating on the risks for syphilis infection and other STIs. 13: 370-372 5.eurosurveillance. optimising sexual health. 2004. Nilsen Ø. Righarts A. Blystad H.org/ew/2002/020725. Eurosurveillance weekly ‘Rates of syphilis in England are rising’. Fenton K. Simms I. 2002. Eurosurveillance Weekly 2002. Creamer E. Aavitsland P. ‘Recent trends in the epidemiology of sexually transmitted infections in the European Union’.

8.dk/sw10793. Chapman and Hall 41 . Smittskyddslag (2004:168) http://www. 13. Fakta om Smittskyddslagen http://www. Perry N. sexual partnerships and sexual behaviours associated with recent syphilis diagnosis among men who have sex with men (MSM) on England’s South coast’. 56: 235-236. Blaxhult A. Flemming DT. 2002. 1991.se/rnp/sls/lag/20040168. Hoskins A.htm 14. Epi-aktuellt. Lambert NL. 9.asp accessed 27th may 2004.ssi. Blystad H. Bath 19-21st May 2004. Table 2 in Thesis for doctoral degree: Recent trends in the epidemiology of gonorrhoea in Sweden. Mercer C. Cook P. Altman DG.notisum. Epi-News 2003 http://www. Axelson N. Berglund T. Fisher M. Andersen P. Wasserheit JN ‘From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection’ Sexually Transmitted Infections. 75(1): 3-17 11. 2006. 1999. RFSL website. Berglund T. Dean G. ‘Demographic. Watson R. ’Syphilis 2003 Denmark’ .rfsl. ‘Re-emerging syphilis in gay men: a case-control study of behavioural risk factors and HIV status’ Journal of Epidemiology and Community Health. Syed Q. Bellis M A. 12. ‘Practical statistics for medical research’. 2004. Mazick A.smittskyddsinstitutet.se/upload/EPI-Aktuellt/EA-0322.se/?p=1363 15. Poster presentation at spring meeting of British Association for Sexual Health and HIV (BASHH).pdf 10. Absolutely positive. Copas A. 16. ‘Utbrott av syfilis in Sverige och Norge bland män som har sex med män’. Clark P. Imrie J. Philips A. 2 (22) http://www.

Jessen H. ‘ Re-emerging syphilis: a detrended correspondence analysis of the behaviour of HIV positive and negative gay men’ BMC Public Health. Clark P. Mercer CH. 33 (1) 11-17 19. Lag om upphävande av lagen (1987:375) om förbud mot s. Zimmer Y.bastuklubbar och andra liknadde verksamhete. Imrie J. Schmidt A.17. http://62. 82: 80-83 18. 20. Nieri G. Hamouda O. Klausner J. Copas A. Philips A. Syed Q.69. Rothaar A. Bellis M. Bremer V. Fisher-Ponce L. Lambert N. Svensk Författningssamling 2004:177.PDF 22. Wolf W. 7 April 2004. 2000. ‘ Understanding recent increases in the incidence of sexually transmitted infections in men having sex with men : changes in risk behavior from risk avoidance to risk reduction’ Sexually Transmitted Diseases. ‘ Tracing a syphilis epidemic through cyperspace’ Journal of the American Medical Association.3/SFSDOC/04/040177. Wheater C P. Reinhardt B.95. 284:485-487 21. ‘Refocusing health promotion for syphilis prevention: results of a casecontrol study of men who have sex with men on England’s South coast’.k. Dean G. Cook PA. Fisher M. 2006. San Francisco. Watson R. Katz M. Wong W. MMWR Weekly. Zolt I. Dec 19 2003. 2006. Sexually Transmitted Infections. Kramer M. Wolf W. Marcus U. Freiwald M. Klausner J. 2003: 3:34 42 . ‘Internet use and early syphilis infection among men who have sex with men. Rausch M. Kent C. California 19992003’. 52 (50) 1229-232.

4 40 30 20 10 0 0-1 2-4 5-9 10+ Number of partners 43 . APPENDICES Appendix 1: Result tables and figures – numbers of partners Appendix 1a: Reported total numbers of partners in last 12 months Appendix Figure 1: Total number of Male partners 60 50 Frequency 40 30 20 10 0 0-4 5-9 Number of partners 10+ Cases Controls N=75 Range of numbers=1-101 Median=10 Mean=16 Appendix Figure 2: Total number of Male Regular partners 60 50 Frequency Cases Controls N=98 Range of numbers=0-10 Median=2 Mean=2.9.

1 Frequency 5-9 10+ Number of partners Appendix Figure 4: Total number of Male Anonymous partners 60 50 Frequency 40 30 20 10 0 0-1 2-4 5-9 10+ Number of partners OR=3.Appendix Figure 3: Total number of Male Casual partners 60 50 40 30 20 10 0 0-1 2-4 Cases Controls N=91 Range of numbers=0-45 Median=3 Mean=7. 44 .0 Ref.13.041 Cases Controls N=90 Range of numbers=0-100 Median=2 Mean=7.77 (1.43) p=0.057 .

08 0.60 3.08 3.8) p=0.6) p=0.33 0.63 95%CI (0.Appendix 2: Result tables and figures – sexual behaviour Appendix 2a: Reported sexual behaviour with different partners in last 12 months Appendix Table 1: Reported sexual behaviour with regular partners cases controls n/N % n/N % OR Oral sex give 16/16 100 66/68 97 N/A Oral sex receive 15/16 94 65/67 97 0.73 0.30 95%CI (0.08 2.82 95%CI (0.32 0.39 1.30 pvalue FE 0.07 0.46 Anal sex receive 12/16 75 40/62 65 1.52 0.84-10.76 Appendix Table 2: Reported sexual behaviour with casual partners cases % n/N 19/19 100 18/19 95 18/19 95 17/18 94 15/18 10/15 15/18 11/15 10/18 16/18 11/18 10/19 11/17 3/15 5/15 83 67 83 73 56 89 61 53 65 20 33 controls n/N % 60/68 88 52/57 91 67/68 99 59/64 92 39/63 15/37 50/66 21/50 27/58 47/62 33/57 25/55 47/60 3/52 6/53 62 41 76 42 47 76 58 46 78 6 11 unmatched OR pvalue FE N/A 0.05 0.58 0.06 # ## ### Oral sex give Unprotected oral sex give Oral sex receive Unprotected oral sex receive Anal sex receive Unprotected anal sex receive Anal sex give Unprotected anal sex give Group sex Masturbate Rimming receive Rimming give Fingersex Fisting receive Fisting give #### # matched OR=2.97 95%CI (0.13 1.65 Anal sex give 13/15 87 55/66 83 1.72 1.35 0.20 0.57 0.44 0.20 0.08 45 #### matched OR=3.8) p=0.35 0.22 ### matched OR=2.17 0.66 1.83-15.51 4.13 0.14 1.90 0.60 3.53 0.39 0.60-8.19 0.03 0.10 0.84) p=0.37 0.68 1.12 0.43 2.47 3.11 ## matched OR=2.65 0.08 .31 Group sex Masturbate Rimming receive Rimming give Fingersex Fisting receive Fisting give 9/15 13/16 10/15 9/16 10/15 3/13 4/14 60 81 67 56 67 23 29 23/55 53/64 46/61 32/58 47/58 4/53 10/54 42 83 75 55 81 8 19 2.92 0.93 1.74-10.55 0.55 1.48 0.27 0.

20 Appendix Table 3b and 3c: Meeting and sex locations with casual and anonymous partners Table 3b: N=92 N=69 Meeting location Casual Anonymous Through friends 24 N/A Bar 51 26 Video place 27 38 Park 10 10 Bath house 6 6 Telephone chat line 5 4 Leather club 8 8 Work place 1 1 Other 3 3 Through internet 61 29 Restaurant 6 4 Sauna 14 25 Toilet 1 1 Gym 6 8 Through newspaper 0 0 Pride festival 9 5 Private Club 5 4 Abroad 23 20 NB.45 0.07 0.29 0.36 1.61 0.56 0.57 2. More than one category possible Table 3c: Sex location Home Bar Video place Park Bath house Hotel Other At friends place Restaurant Sauna Toilet Gym Private club Leather club N=92 Casual 83 17 23 14 1 16 1 13 3 14 3 4 2 5 N=69 Anonymous 31 17 38 13 6 11 3 N/A 3 26 4 7 3 8 46 .02 1.16 0.11 0.35 95%CI (0.74 1.72 0.45 0.84 0.83 N/A 1.20 2.47 0.99 0.1) p=0.61 0.76 2.24 0.Appendix Table 3: Reported sexual behaviour with anonymous partners cases % n/N 15/17 88 21/22 96 15/17 88 20/21 95 11/16 11/18 12/16 11/17 8/15 14/18 9/16 7/16 9/15 0/14 3/14 69 61 75 65 53 78 56 44 60 0 21 controls n/N % 42/48 88 57/62 92 44/48 92 64/69 93 22/44 16/40 29/46 23/55 22/41 38/46 24/43 15/39 27/42 1/36 6/38 50 40 63 42 54 83 56 39 64 3 16 unmatched OR pvalue FE 1.65 1.50 1.50 0.68 0.61-9.08 0.46 Oral sex give Unprotected oral sex give Oral sex receive Unprotected oral sex receive Anal sex receive Unprotected anal sex receive Anal sex give Unprotected anal sex give Group sex Masturbate Rimming receive Rimming give Fingersex Fisting receive Fisting give # # matched OR=2.50 0.55 0.

40 0.29 1.63 1.20 0.01 0.80) p=0.50 0.22 0.30 1.21 0.93 95%CI (0.85 0.81 0.15 – 5.55 N/A N/A 0.59 1.00 N/A 2.64 0.12 # N/A N/A N/A 0.85 0.24 N/A N/A Party Bar Toilet Gym Bath place Leather club Private club Park Disco Pride Restaurant Sauna Video Work Appendix Table 5: Reported meeting casual or anonymous partner abroad cases Party Bar Toilet Gym Bath place Leather club Private club Park Disco Pride Restaurant Sauna Video Work n/N 2/10 8/11 0/10 0/10 0/10 3/10 0/10 2/10 6/11 0/10 0/10 9/13 2/10 0/10 % 20 73 0 0 0 30 0 20 55 0 0 69 20 0 controls n/N % 5/22 22 20/28 71 3/20 15 2/20 10 3/21 14 5/20 25 0/19 0 5/22 23 5/19 26 0/19 0 1/19 5 21/27 68 8/21 38 0/19 0 unmatched OR pvalue FE 0.43 1.41 0.36 0.89 0.57 3.93 0.52 0.25 2.46 0.Appendix 2b: Partners within Sweden in last 12 months Appendix Table 4: Reported meeting casual or anonymous partner in Sweden cases n/N % 4/12 33 14/16 88 0/11 0 4/14 29 2/14 14 4/12 33 1/12 8 5/14 36 7/12 58 5/13 39 1/12 8 2/12 17 13/16 81 0 0 controls n/N % 19/48 40 37/50 74 2/37 5 6/39 15 6/38 16 12/41 29 6/40 15 15/40 38 21/42 50 10/39 26 2/38 5 2/37 5 29/43 67 0 0 unmatched OR pvalue FE 0.62 3.52 0.28 N/A N/A *N varies according to item due to non-response # matched OR=0.48 0.938 47 .09 0.48 2.64 0.24 0.76 0.29 0.65 0.28 N/A 0.62 1.41 0.44 N/A 0.63 N/A 0.

reported in Stockholm county. statutory notifications database Number of cases 48 .Appendix 2c: Reported syphilis cases among MSM in Stockholm Appendix Figure 5: Number of cases of syphilis infected through sex between men. Sweden 1998-2006 80 70 60 50 40 30 20 10 0 1998 1999 2000 2001 2002 2003 2004 2005 2006 Year of report Data source: Swedish Institute for Infectious Disease Control.

Appendix 3: Clinic information sheet Study number:__________ Syphilis Case Control Study Clinical data ------------------------------------------------------------------------------------------------------Date of recruitment : _ _ /_ _/ _ _ Birth year: _ _ _ _ ------------------------------------------------------------------------------------------------------Laboratory results Negative Syphilis HIV Gonorrhea Chlamydia Other: _________ [ ] [ ] [ ] [ ] [ ] Positive [ ] [ ] [ ] [ ] [ ] Date result _ _/_ _/_ _ _ _/_ _/_ _ _ _/_ _/_ _ _ _/_ _/_ _ _ _/_ _/_ _ not tested [ ] [ ] [ ] [ ] [ ] If syphilis positive Stage of infection: [ ] Primary [ ] Early latent (<2yrs) [ ] Secondary [ ] Tertiary [ ] Late latent (>2yrs) [ ] Other If HIV positive: Previously known HIV positive patient to clinic: [ ] Yes [ ] No Patient on ART in last 12 months? [ ] No [ ] Yes [ ] Not known Most recent CD4 count: ________ Most recent viral load count: ________ Date: _ _ /_ _/ _ _ Date: _ _ /_ _/ _ _ 49 .

Tel: 08. Please note that some questions may appear to be repeated throughout the questionnaire but they are asked with reference to different situations or partners. The receptionist will give you a Trisslott (lottery scratch card) as a thank-you for completing this questionnaire. you are welcome to contact the project co-ordinator Lara Payne at SMI. The individual responses you provide will not be seen by the clinic staff.616 25 00. Please write in the space provided or place a cross next to the relevant answer for you. If you have any questions or queries about the study.Appendix 4: Questionnaire used for cases and controls Study number: ___________ Consent: Yes [ ] No [ ] Questionnaire for a case-control study on Syphilis in men Instructions: The questionnaire should takes around 20-25 minutes to complete.457 2378. please seal it in the envelope provided and return the questionnaire to reception. you are welcome to contact Stefan Ekroth (counsellor) or Lena Persson (nurse) at Venhälsan Tel: 08. If after completing the questionnaire you have any concerns or would like to speak to someone at the clinic. Remember : this is an anonymous questionnaire. Only the project leaders at SMI who will handle the completed questionnaires will see the individual answers and they do not know your identity. On completion of the questionnaire. THANK YOU FOR COMPLETING THIS QUESTIONNAIRE! 50 . The questions are divided into several sections.

How do you describe your sexual orientation? : [ ] Homosexual [ ] Bisexual [ ] Transsexual [ ] Heterosexual [ ] Don’t know [ ] None of the above – please state: ______________________ Q7. Have you lived mainly in Sweden in the last 12 months? [ ] Yes [ ] No If no: Please name the main other country you have been resident in? :_________________________ Q5. If you consider yourself homosexual or bisexual. work colleagues) [ ] Completely open [ ] Open to most people [ ] Open to some people [ ] Not open [ ] Don’t know 51 . family. How old are you? _ _ years Q2. Are you currently? [ ] Unemployed [ ] Employed / Self-employed [ ] Student [ ] On sick leave [ ] Medically retired [ ] Retired [ ] Other – please specify ________________________ Q4.g. What is the highest educational qualification that you have? [ ] I have no educational qualifications [ ] School to age 16 [ ] School to age 19 [ ] Degree or higher [ ] Other – please specify ________________________ Q3. friends. how open are you about your sexual identity with others in everyday life: (e. In which county within Sweden have you mainly lived in the last 12 months? Example: Stockholm county _______________________ Q6.Study Number: ___________ Some basic questions about you Q1.

B. Before this visit to the clinic. What was the main reason that led you to be tested for syphilis (and possibly other sexually transmitted infections) at your most recent visit to Venhälsan? Select only one answer [ ] Symptoms [ ] Partner has/had symptoms [ ] New sexual relationship [ ] Ended a sexual relationship [ ] Unsafe sex (anal.11) . Q9. C . what was the most recent test result? [ ] Negative [ ] Don’t know [ ] Don’t wish to say [ ] Positive If positive.Some questions about your sexual health Q8. have you in the last 5 years been diagnosed positive with any of the following sexually transmitted infections. oral or vaginal) with a partner [ ] Routine health check up [ ] Requested to be tested following contact tracing [ ] Response to information/campaign on syphilis [ ] Other :_____________________________ Questions 9 to 12 relate to your sexual health before this most recent visit and testing at the clinic.13 Go to Q. and in which year? Chlamydia Gonorrhoea Hepatitis A Hepatitis B Hepatitis C Syphilis Other STI (not HIV): No [ ] [ ] [ ] [ ] [ ] [ ] [ ] Don’t know [ ] [ ] [ ] [ ] [ ] [ ] [ ] Yes [ ] [ ] [ ] [ ] [ ] [ ] [ ] Year positive test ____ ____ ____ ____ ____ ____ ____ Please specify:_______________ Q11. or Syphilis? [ ] No [ ] Don’t know [ ] Yes Q10. in what year were you diagnosed? Year: _ _ _ _ 52 . Have you ever had a test for HIV? [ ] No [ ] Don’t know [ ] Yes Go to Q. year of most recent HIV test: _ _ _ _ Q12. Hepatitis A. If you have been tested for HIV (Q.13 If yes. Before this visit to the clinic. have you in the last 12 months had a test for any of the following sexually transmitted infections: Chlamydia. Gonorrhea.

53 . If you have had sexual contacts with women in the last 12 months please now go to Q. In the last 12 months have you had sexual contacts with: [ ] Men only [ ] Men and women [ ] Women only [ ] I have had no sexual contacts Q14. Q13. In the last 12 months. how many men or women did you have sexual contacts with? (please write 0 in the relevant space if none) Number of men : ______ Number of women : ______ The next 3 sections (Questions 15-43) are about your male: A) Regular partners B) Casual partners C) Anonymous partners Please read and answer each section.44. following jumps to question numbers where relevant. anal or vaginal intercourse. rimming or fisting.Some questions about your sexual lifestyle A sexual contact is defined as having physical interaction with another man or woman’s genital area and may include masturbation. oral sex.

I had no regular partner(s) If none. In the last 12 months how many regular partner(s) did you have sexual contact with? a) Number of regular partners: _________ [ ] Don’t know (Go to Q. or other partners such as lovers or ‘fuck-buddies’. You know a lot about these men other than the sex you had with them. This may include steady partners (‘husbands’ or boyfriends etc. with another regular partner(s) and another sexual contact(s) Yes. For the purpose of this questionnaire a regular partner is defined as a man who you have or had an ongoing sexual relationship with. not a regular partner(s) No. Q15. In the last 12 months. but with another regular partner(s) only Yes. how often did you have sexual contact with your regular partner(s)? [ [ [ [ [ ] ] ] ] ] Every day 2-3 times per week Once a week 2-3 times a month Once a month [ [ [ [ [ ] ] ] ] ] 6-10 times in the year 3-5 times in the year Once or twice Not once Don’t know 54 . but only with another sexual contact(s).19 [ ] Never had a regular partner [ ] Don’t remember b) How many of your regular partners were: Steady partners : ____ Lovers/Fuck-buddies: ____ Q16.Some questions about regular partners The following 5 questions are about REGULAR partners. while in a relationship with your regular partner(s) did you have sex with another man? [ [ [ [ ] ] ] ] Yes.19) [ ] None . In the last 12 months.). how long ago did you have a regular partner? [ ] Between 1 to 5 years ago [ ] More than 5 years ago Go to Q. I had no other sexual contacts Q17.

how often did you have sexual contact with your casual partner(s)? [ ] Every day [ ] 6-10 times in the year [ ] 2-3 times per week [ ] 3-5 times in the year [ ] Once a week [ ] Once or twice [ ] 2-3 times a month [ ] Not once [ ] Once a month [ ] Don’t know 55 . other than their name and you may have had sex with them. This may include ‘one-night stands’. Do you ask a new regular partner their HIV status before any sexual contact? [ ] Never [ ] Sometimes [ ] Often [ ] Always Some questions about casual partners (excluding anonymous) Questions 20 to 27 are about CASUAL partners. Q20. Do you ask a new casual partner their HIV status before any sexual contact? [ ] Never [ ] Sometimes [ ] Often [ ] Always Q21.28) Number of casual partners : ______________ [ ] Don’t know Q22. Note that ANONYMOUS partners are excluded in the answers to this section.If you had this type of sex with your regular partner(s) and . with how many casual partner(s) did you have sexual contact with? (Please write 0 if none and go to Q.Q18. how often you used condoms? Condom use: No Yes Type of sex: Always Often Sometimes Never [ ] [ ] Oral sex: sucking [ ] [ ] [ ] [ ] [ ] [ ] Oral sex: being sucked [ ] [ ] [ ] [ ] [ ] [ ] Anal sex: receptive [ ] [ ] [ ] [ ] [ ] [ ] Anal sex: insertive [ ] [ ] [ ] [ ] [ ] [ ] Group sex: sex with more than one man [ ] [ ] Mutual masturbation [ ] [ ] Being rimmed [ ] [ ] Rimming [ ] [ ] Finger sex (finger in anus) [ ] [ ] Being fisted [ ] [ ] Fisting [ ] [ ] Other: ____________ Q19. on maybe one or two occasions. For the purpose of this questionnaire a CASUAL partner is defined as a man who you don’t know much about. In the last 12 months. In the last 12 months. please indicate below for each type of sex technique: . In the last 12 months.If yes for oral or anal sex.

Pride Private members club On travels abroad 56 . In the last 12 months. 2= next most often.) [ [ [ [ [ [ [ [ [ ] ] ] ] ] ] ] ] ] __ __ __ __ __ __ __ __ __ Through friends Bar /pub/club Gay videoclub Park/outside venue/ cruising ground Swimming pool / Spa Telephone chat line or call line Work / college Leather men’s club Other (please state)_________ [ [ [ [ [ [ [ [ [ ] ] ] ] ] ] ] ] ] __ __ __ __ __ __ __ __ __ Internet (chat or contact site) Restaurant/ café Gay sauna Public toilets ‘cottage’ Gym Personal column newspaper Gayfestival. etc. In the last 12 months.g. how many casual partners did you have oral sex (sucking or being sucked) with? (Please write 0 if you didn’t have oral sex) Number of partners : ________ [ ] Don’t know Q25. In the last 12 months.If yes for oral or anal sex.If you had this type of sex with your casual partner(s) and . how many casual partners did you have anal sex (receptive or insertive) with? (Please write 0 if you didn’t have anal sex) Number of partners : ________ [ ] Don’t know Q26. e.Q23. In the last 12 months. how often you used condoms? Condom use: No Yes Type of sex: Always Often Sometimes Never [ ] [ ] Oral sex: sucking [ ] [ ] [ ] [ ] [ ] [ ] Oral sex: being sucked [ ] [ ] [ ] [ ] [ ] [ ] Anal sex: receptive [ ] [ ] [ ] [ ] [ ] [ ] Anal sex: insertive [ ] [ ] [ ] [ ] [ ] [ ] Group sex: sex with more than one man [ ] [ ] Mutual masturbation [ ] [ ] Being rimmed [ ] [ ] Rimming [ ] [ ] Finger sex (finger in anus) [ ] [ ] Being fisted [ ] [ ] Fisting [ ] [ ] Other: ____________ Q24. please indicate below for each type of sex technique: . where did you meet or make contact with your casual partners? Select as many as apply and then please number up to the 3 most often (start with 1=most often.

toilets etc.) [ ] Restaurant/ café (toilets etc. In the last 12 months where did you have sex with casual partners? Tick as many as apply [ ] Your/his home/ place [ ] Friend’s home [ ] Bar /pub/ danceclub (dark room.Q27.) [ ] Gay videoclub [ ] Gay sauna [ ] Park/outside venue/ cruising ground [ ] Public toilet/ ‘cottage’ [ ] Swimming pool / Spa [ ] Gym [ ] Hotel /hostel room [ ] Private members club [ ] Other (please state)________ [ ] Leather men’s club please turn over page……… 57 .

how often did you have sexual contact with an anonymous partner(s)? [ [ [ [ [ ] ] ] ] ] Every day 2-3 times per week Once a week 2-3 times a month Once a month [ [ [ [ [ ] ] ] ] ] 6-10 times in the year 3-5 times in the year Once or twice Not once Don’t know Q30. please indicate below for each type of sex technique: . how many anonymous partners did you have oral sex (sucking or being sucked) with? (Please write 0 if you didn’t have oral sex) 58 .If yes for oral or anal sex. For the purpose of this questionnaire an anonymous partner is defined as a man who you don’t know anything about apart from the sex you had with them. with how many anonymous partner(s) did you have sexual contact with? (Please write 0 if none and go to Q35) [ ] Number of anonymous partners : ______________ [ ] Don’t know Q29. and you don’t have their name or number. In the last 12 months. how often you used condoms? Condom use: No Yes Type of sex: Always Often Sometimes Never [ ] [ ] Oral sex: sucking [ ] [ ] [ ] [ ] [ ] [ ] Oral sex: being sucked [ ] [ ] [ ] [ ] [ ] [ ] Anal sex: receptive [ ] [ ] [ ] [ ] [ ] [ ] Anal sex: insertive [ ] [ ] [ ] [ ] [ ] [ ] Group sex: sex with more than one man [ ] [ ] Mutual masturbation [ ] [ ] Being rimmed [ ] [ ] Rimming [ ] [ ] Finger sex (finger in anus) [ ] [ ] Being fisted [ ] [ ] Fisting [ ] [ ] Other: ____________ Q31.Some questions about anonymous partners Questions 28 to 34 are about ANONYMOUS partners.If you had this type of sex with your anonymous partner(s) and . In the last 12 months. In the last 12 months. This includes men you may have had sex with in a dark room or cruising ground. In the last 12 months. Q28.

In the last 12 months where did you have sex with anonymous partners? Tick as many as apply [ [ [ [ [ [ ] ] ] ] ] ] Bar /pub/ danceclub (dark room. 2= next most often.Number of partners : ________ [ ] Don’t know Q32.) Gay sauna Public toilet/ ‘cottage’ Gym Private members club Your/his home/ place [ ] Other (please state)________ please turn over page……… 59 . e. etc. how many anonymous partners did you have anal sex (receptive or insertive) with? (Please write 0 if you didn’t have anal sex) Number of partners : ________ [ ] Don’t know Q33. Pride Private members club Internet (chat or contact site) Q34. where did you meet or make contact with your anonymous partners? Select as many as apply and then please number up to the 3 most often often (start with 1=most often. toilets etc. In the last 12 months.) [ Gay videoclub [ Park/outside venue/ cruising ground [ Swimming pool / Spa [ Leather men’s club [ Hotel /hostel room [ ] ] ] ] ] ] Restaurant/ café (toilets etc. In the last 12 months.g.) [ [ [ [ [ [ [ [ [ ] ] ] ] ] ] ] ] ] __ __ __ __ __ __ __ __ __ Bar /pub/club Gay videoclub Park/outside venue/ cruising ground Swimming pool / Spa Telephone chat line or call line Work / college Leather men’s club On travels abroad Other (please state):______ [ [ [ [ [ [ [ [ ] ] ] ] ] ] ] ] __ __ __ __ __ __ __ __ Restaurant/ café Gay sauna Public toilet ‘cottage’ Gym Personal column newspaper Gayfestival.

did you meet a casual/anonymous partner in any of the following places and in which city/town? If you didn’t meet a casual/anonymous partner in the last 12 months.QX qruiser.g. Q35.g. In the last 12 months. The following questions relate to contacts you had with men in Sweden. please name the internet sites you used (e. gaypride Restaurant/ café Gay sauna Videoclub Work/ study place Other (please state): No [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] Yes [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] City/town(s) in Sweden _________ __________ _________ __________ _________ __________ _________ __________ _________ __________ _________ __________ _________ __________ _________ __________ _________ __________ _________ __________ _________ __________ _________ __________ _________ __________ _________ __________ _________ __________ _____________ Q36.36 Place Private party Gay bar/pub Cottage (public toilets) Gym Swimming pool/Spa Leather mens’ club Private members club Park/ cruising ground Public disco or dance club Gayfestival e. In the last 12 months. have you used the internet to meet other men in Sweden (they may live in Sweden or be visiting from abroad)? [ ] No [ ] Don’t know [ ] Yes If yes. Go to Q. RFSL chat): ____________________________________________ 60 .Some questions about your sexual contacts in Sweden Questions about your possible sexual contacts abroad are included in the next section.

In the last 12 months. In the last 12 months.40 Place Private party Gay bar/pub Cottage (public toilets) Gym Swimming pool/Spa Leather mens’ club Private members club Park/ cruising ground Public disco or dance club Gayfestival e. gaypride Restaurant/ café Gay sauna No [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] Yes [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] Country City/town(s) _________ __________ _________ __________ _________ __________ _________ __________ _________ __________ _________ __________ _________ __________ _________ __________ _________ __________ _________ __________ _________ __________ _________ __________ 61 . have you met a man through the internet who you then had sex with in Sweden? [ ] No [ ] Don’t know [ ] Yes If yes. Have you travelled outside Sweden for any length of time in the last 12 months? [ ] No Go to Q.) [ ] Restaurant/ café (toilets etc.) [ ] Gay videoclub [ ] Gay sauna [ ] Park/outside venue/ cruising ground [ ] Public toilet/ ‘cottage’ [ ] Swimming pool / Spa [ ] Gym [ ] Leather mens’ club [ ] Private members club [ ] Other (please state)________ Some questions about travel and sexual contacts abroad Q38.Q37. go to Q. where did you meet to have sex? ( mark a cross in all that apply) [ ] Your/his home/ place [ ] Hotel /hostel room [ ] Bar /pub/ danceclub (dark room. how many trips outside Sweden did you make? _____ Q39.42 [ ] Yes If yes. did you meet a casual/anonymous partner abroad in any of the following places and in which country and city/town(s)? If you didn’t meet a casual/anonymous partner in the last 12 months. how many men did you have sex with ? : __________ If yes.g. toilets etc.

have you met a man through the internet who you then had sex with abroad? [ ] No [ ] Don’t know [ ] Yes If yes. I used the following drugs: No Amphetamines [ ] Anobolic steroids [ ] Cannabis [ ] Cocaine [ ] Crack [ ] GHB [ ] Ecstasy [ ] Heroin [ ] LSD [ ] Poppers [ ] Viagra (or similar) [ ] Other :________ [ ] Yes [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] Don’t know [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] Decline to answer [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] Q43. In the last 12 months.Videoclub Work/ study place Other (please state): [ ] [ ] [ ] [ ] _________ __________ _________ __________ _________ __________ _____________ Q40. have you used the internet to meet other men abroad (they may live in Sweden or be visiting from abroad)? [ ] No [ ] Don’t know [ ] Yes If yes. Have you in the last 12 months had sex with a casual or anonymous male partner while you considered yourself drunk (as determined then or now)? [ ] No [ ] Yes [ ] Don’t know 62 . Have you in the last 12 months used any of the following drugs when you had sex with a casual/ anonymous male partner? [ ] I did not use any drugs [ ] Don’t know [ ] Yes. please name the internet sites you used: ____________________________________________ Q41. how many men did you have sex with ? : __________ And please name the countries where you met to have sex? : __________________________________________________ Some questions about drugs and alcohol Q42. In the last 12 months.

Some questions about the last time you had sex Q44. In which city and country did you (first) meet? [ ] Sweden City: _________________ [ ] Abroad Country and city:___________ Q48. [ ] a casual partner [ ] an anonymous partner [ ] don’t remember Q46.g. How long have they been a sexual partner? [ ] anonymous partner [ ] one night stand [ ] < 1 week [ ] 1-3 weeks [ ] 1-3 months [ ] 3-6 months [ ] 7-12 months [ ] >1 year [ ] don’t remember Q47. If you last had sex with a casual or anonymous partner. What approximate time of day did you meet your casual/anonymous partner the last time you had sex? Time _ _ : _ _ e. Which partner was it with? [ ] a regular partner . Pride Private members club On travels abroad Q49. 19:30 63 . did you have sex with: [ ] a man [ ] a woman Q45. The last time you had sex.50 [ [ [ [ [ [ [ [ [ ] ] ] ] ] ] ] ] ] Through friends Bar /pub /club Gay videoclub Park/ cruising ground Swimming pool / Spa Telephone chat line or call line Work / college Leather mens club Other (please state)_________ [ [ [ [ [ [ [ [ [ ] ] ] ] ] ] ] ] ] Internet (chat or contact site) Restaurant/ café Gay sauna Public toilet ‘cottage’ Gym Personal column newspaper Gay festival e. where/how did you (first) meet? If it was a regular partner.g. please go to Q.

how often you used condoms? Condom use: No Yes Type of sex: Yes No Don’t remember [ ] [ ] Oral sex: sucking [ ] [ ] [ ] [ ] [ ] Oral sex: being sucked [ ] [ ] [ ] [ ] [ ] Anal sex: receptive [ ] [ ] [ ] [ ] [ ] Anal sex: insertive [ ] [ ] [ ] [ ] [ ] Group sex: sex with more than one man [ ] [ ] Mutual masturbation [ ] [ ] Being rimmed [ ] [ ] Rimming [ ] [ ] Finger Sex [ ] [ ] Being fisted [ ] [ ] Fisting [ ] [ ] Other: ____________ Q51.) Gay sauna Public toilet/ ‘cottage’ Gym Q52.What did you think was the HIV status of your partner? [ ] I assumed he was HIV negative [ ] I assumed he was HIV positive [ ] He told me he was HIV negative [ ] I knew he was HIV negative [ ] He told me he was HIV positive [ ] I knew he was HIV positive [ ] I did not think about his HIV status 64 .If yes for oral or anal sex. What kind of sex did you have? Please indicate below for each type of sex technique: . toilets etc.Q50.If you had this type of sex with your partner(s) and . Where did you have sex? [ ] Your/his home/ place [ [ ] Bar /pub/ danceclub (dark room.) [ [ ] Gay videoclub [ [ ] Park/outside venue/ cruising ground [ [ ] Swimming pool / Spa [ [ ] Other (please state)________ ] ] ] ] ] Hotel /hostel room Restaurant/ café (toilets etc.

Please hand in the closed envelope to the receptionist at Venhälsan. Venhälsan tel 08-616 25 00. SMI Tel : 08-457 23 78 65 . If this questionnaire has raised any queries or concerns. RFSL) [ ] Friends [ ] Other organization : ________________ [ ] Gay magazines [ ] Internet [ ] Partner [ ] Other: ________________________ Q54. or Lara Payne . Where do you usually seek information on health issues related to sex? Select as many as apply [ ] Doctor / health clinic [ ] Gay/ GBT organizations (e. You will be given a Trisslott (lottery card) as a thank-you. Are there any comments or points you would like to share with us? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ _______________________________________________________________ Thank you for completing this questionnaire ! Please seal the questionnaire in the envelope provided.g.Some general questions Q53. you are welcome to contact: Stefan Ekroth or Lena Persson.

The results will provide better sexual health information for MSM and allow targeting of prevention activities to prevent syphilis spreading further in the population. or anyone else signed below. Aims of the study This study focuses on sexual behaviour and factors that may contribute to the transmission of syphilis amongst MSM. it is important that you return the questionnaire in the sealed envelope to reception. Lara Payne Project leader. but no link will be made to your identity after completion of the questionnaire. Among men who have sex with men (MSM) only a few cases were reported annually. The aim of the study is to compare the responses to these questions to identify possible differences and assess possible risk factors for acquiring syphilis. Clinical data from your most recent visit to Venhälsan will also be included in the analysis. but some were acquired abroad in other European cities. Your participation and time As someone who has recently tested for syphilis (positive or negative). The study is being done through Venhälsan working with the epidemiology department at the Swedish Institute for Infectious Disease Control (Smittskyddsinstitutet. you are welcome to contact Stefan Ekroth or Lena Persson. Data handling Answers to the questionnaire will not be read by any staff at Venhälsan. It is important though that you complete all sections of the questionnaire as fully as possible. The study comprises of a questionnaire through which 54 questions are asked equally to both MSM who are infected with syphilis and those testing negative. please complete the questionnaire after your appointment and return it sealed in the envelope provided to reception. Even if you only complete some of the questions. over 100 cases of syphilis were reported in MSM in Sweden. In 2003. Some of the questions and language used may appear sensitive or shocking. For administrative and analysis purposes every questionnaire has a study number. and we hope that you do not take offence for their use in this context. Since 2000. Consultant Venhälsan tel 08-616 25 71 66 . tel: 08-616 25 00. To thank you for your participation. Epi/SMI tel 08-457 23 78 Anders Karlsson Doctor Venhälsan tel 08-616 25 00 Göran Bratt Doctor Venhälsan tel 08-616 25 00 Eric Sandström Professor. only by the project leader at SMI who will analyse the data collectively from all questionnaires and produce a scientific report. The majority of infections were acquired in Stockholm. Further information If you have any concerns or queries following completion of the questionnaire. Confidentiality Remember that participation in this study does not involve providing a name or a ‘personnummer’. a Trisslott (lottery scratch card) will be given to you at reception on return of the questionnaire. the situation has changed. we are asking you whether you would be willing to consent to participate in this study and give 20-25 minutes of your time to answer the questionnaire. SMI). If you do wish to take part in the study.Appendix 5: Information sheet for study participants Patient Information: Study on syphilis in men who have sex with men Background Syphilis was a rare infection in the 1990s in Sweden. and you are guaranteed full anonymity for your answers. If there is anything you do not wish to answer then that question can be skipped. If you do not wish to participate this will not affect your present or future care at the clinic in anyway. Remember that participation in the study is completely voluntary.