1. High prevalence of chlamydia, gonorrhoea, mycoplasma and trichomonas in FSW reached at their working place in Germany
Klaus Jansen, PhD
, IUSTI 2016, Marrakesh

2. Disclosure Diagnostic tests were funded by Hologic |Gen-Probe®.
IUSTI 2016, Marrakesh, Morocco

3. Background & rationale: STIs
Bacterial STIs often asymptomatic
Can lead to cervititis, urethritis, pelvic infammatory disease and partly female infertility, increase risk of getting HIV
Mostly easy to treat with antibiotics
 partly increasing resistance
No mandatory or sentinel reporting of these STIs in Germany
Epidemiological data on STI in female sex workers (FSW) is scarce
In Germany, local public health authorities (LPHA) offer free and anonymous HIV testing and counselling
< 30% of LPHA offer screening for chlamydia and gonorrhoeae
IUSTI 2016, Marrakesh, Morocco

4. Background and rationale: sex work in Germany
Number of FSW in Germany unknown
 probably high
Sex work legalised in Germany since 2002
 in reality: very different working conditions
FSW might be at higher risk for STI, depending on living and working conditions
Higher risk for STI in FSW without regular contact to local public health authorities (LPHA)*
Very few data on STI in „hard to reach“ FSW
* KABP-Surv STI (2011)
IUSTI 2016, Marrakesh, Morocco

5. Study aim To measure prevalence of
Chlamydia trachomatis
Neisseria gonorrhoeae
Mycoplasma genitalium
Trichomonas vaginalis
in „hard to reach“ FSW in Berlin, Hamburg, North Rhine-Westphalia
to describe demographic characteristics
to identify potential risk factors for acquiring a STI
to measure proportion of SW reached by existing offers of LPHA
IUSTI 2016, Marrakesh, Morocco

6. Population Who is „hard to reach“? lacking language skills
 Persons having no/rare contact to health care and prevention
lacking language skills
lacking residence permit
lacking health insurance
IUSTI 2016, Marrakesh, Morocco

7. Collection of data
Recruitment only via outreach at working places of FSW
 voluntary and anonymous participation
Patient information in 11 languages
Oral informed consent  anonymity!
Short questionnaire for FSW
Sex, country of birth, language skills, health insurance, duration SW, last gyn. exam, ever visited LPHA?
Institutional questionnaire on work places
City, type and size of sex work institution, distribution of origin of SW
 Constant use of cultural and language mediators
IUSTI 2016, Marrakesh, Morocco

8. Clinical diagnostics Vaginal swabs Taken directly at work place
Easy self collection by FSW
(explicit picture-based manual)
TMA based diagnostics
MG: Aptima® Mycoplasma genitalium Assay (RUO, tested after end of study)
Chlamydia (CT) and gonorrhoea (NG) : Aptima® Combo 2
Trichomonas (TV): Aptima® Trichomonas vaginalis Assay
IUSTI 2016, Marrakesh, Morocco

9. Statistical methods Descriptive statistics
Comparisons between groups: chi-square-test, Mann-Whitney test
Multivariate logistic regression model to identify risk factors for acquiring at least one STI
IUSTI 2016, Marrakesh, Morocco

10. Sociodemographics Participants: 1,445 FSW
Enrolled by 20 LPHA at 292 working places
87.6% born outside of Germany
IUSTI 2016, Marrakesh, Morocco

11. Sociodemographics German FSW Non-German FSW p-value
Age (median; n=1,439)
30 years
28 years
<.001
Duration sex work (median; n=1,335)
4 years
3 years
< 0.01
No German language skills (n=1,261)
---
41.4%
Valid health insurance (n=1,363)
89.3%
21.2%
Ever visited LPHA (n=1,439)
69.5%
43.0%
IUSTI 2016, Marrakesh, Morocco

12. Prevalences Diagnosis of at least one STI: 32.9% 11.5.2016
IUSTI 2016, Marrakesh, Morocco

13. Multivariate analysis for acquiring at least one STI*
Odds Ratio
95%-CI
Age (per year increasing)
0.98
Country of birth (reference: Germany)
Bulgaria
3.95
2.10 – 7.42
Romania
3.64
1.95 – 6.79
Other Central Europe
3.04
1.44 – 6.41
Other countries
2.01
1.11 – 3.65
Type of working place (reference: street-based sex work)
Brothel
0.75
0.46 – 1.22
Club/bar
0.66
0.40 – 1.09
Sauna-club
0.91
0.51 – 1.65
Rooms for rent in brothel
0.61
0.35 – 1.05
Appartment
0.41
0.23 – 0.73
Other
1.17
0.57 – 2.40
* Model adjusted for German language skills, health insurance status, prior contact to LPHA, type of working place, size of working place
Number of observations: 1,259
IUSTI 2016, Marrakesh, Morocco

14. Limitations Recruiting bias probable  not all FSW populations reached
 prevalence probably higher than in general FSW population,
due to outreach approach
IUSTI 2016, Marrakesh, Morocco

15. Conclusions Extensive outreach approach worked
High prevalences of STIs
Study population largely characterised by
Lacking German language skills
No health insurance
Rare contact to LPHA
Origin outside Germany
Representing important barriers for accessing health services
Mostly mediated by migration
IUSTI 2016, Marrakesh, Morocco

16. Recommendations
LPHA should consider offering tests for all tested STIs for foreign-born FSW having lacking language skills
Testing and treatment anonymously and free of cost at LPHA
Cultural and language mediators needed
Constant outreach work required
Comprehensive sexual health approach important
IUSTI 2016, Marrakesh, Morocco

17. Acknowledgements Participating sex workers Staff of LPHA
Cultural and language mediators
Lab Staff
Co-authors
Labor Krone: Andreas Lucht, Dieter Münstermann, Carsten Tiemann
Hologic |Gen-Probe®: Sven Schaffer
RKI: Viviane Bremer, Stine Nielsen, Navina Sarma, Gyde Steffen
IUSTI 2016, Marrakesh, Morocco

18.
IUSTI 2016, Marrakesh, Morocco

19. Treatment
Personal communication of test results for chlamydia and gonorrhoea
No communication on trichomonas due to missing approval of assay for self collection
No communication on mycoplasma as tested after end of study
Therapy free of cost for chlamydia and gonorrhoea
IUSTI 2016, Marrakesh, Morocco

21. Study cycle Training Outreach-workers
Oral informed consent following counselling
Questionnaire filled in by Outreach-workers
Self collection of samples
Communication of test results as established by LPHA
Therapy (LPHA or via networking)
IUSTI 2016, Marrakesh, Morocco

22. Test quality Sensitivity Specificity Aptima Combo 2®
Vaginal swab self collected % %
Vaginal swab collected by physician % %
Urine sample % %
Aptima® Trichomonas vaginalis Assay
w/o CE
100%
99.0%
95.2%
98.9%
IUSTI 2016, Marrakesh, Morocco