High prevalence of chlamydia, gonorrhoea, mycoplasma and trichomonas in FSW reached at their working place in Germany Klaus Jansen, PhD 11.5.2016, IUSTI 2016, Marrakesh

Disclosure Diagnostic tests were funded by Hologic |Gen-Probe®. 11.5.2016 IUSTI 2016, Marrakesh, Morocco

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 11.5.2016 IUSTI 2016, Marrakesh, Morocco

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) 11.5.2016 IUSTI 2016, Marrakesh, Morocco

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 11.5.2016 IUSTI 2016, Marrakesh, Morocco

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 11.5.2016 IUSTI 2016, Marrakesh, Morocco

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 11.5.2016 IUSTI 2016, Marrakesh, Morocco

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 11.5.2016 IUSTI 2016, Marrakesh, Morocco

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 11.5.2016 IUSTI 2016, Marrakesh, Morocco

Sociodemographics Participants: 1,445 FSW Enrolled by 20 LPHA at 292 working places 87.6% born outside of Germany 11.5.2016 IUSTI 2016, Marrakesh, Morocco

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% 11.5.2016 IUSTI 2016, Marrakesh, Morocco

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

Multivariate analysis for acquiring at least one STI* Odds Ratio 95%-CI Age (per year increasing) 0.98 0.96 - 0.99 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 11.5.2016 IUSTI 2016, Marrakesh, Morocco

Limitations Recruiting bias probable  not all FSW populations reached  prevalence probably higher than in general FSW population, due to outreach approach 11.5.2016 IUSTI 2016, Marrakesh, Morocco

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 11.5.2016 IUSTI 2016, Marrakesh, Morocco

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 11.5.2016 IUSTI 2016, Marrakesh, Morocco

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 11.5.2016 IUSTI 2016, Marrakesh, Morocco

11.5.2016 IUSTI 2016, Marrakesh, Morocco

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 11.5.2016 IUSTI 2016, Marrakesh, Morocco

11.5.2016

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) 11.5.2016 IUSTI 2016, Marrakesh, Morocco

Test quality Sensitivity Specificity Aptima Combo 2® Vaginal swab self collected 98.4 - 100% 96.8 - 99.5% Vaginal swab collected by physician 96.0 - 96.6% 96.8 - 99.2% Urine sample 91.3 - 94.7% 98.8 - 99.3% Aptima® Trichomonas vaginalis Assay w/o CE 100% 99.0% 95.2% 98.9% 11.5.2016 IUSTI 2016, Marrakesh, Morocco