Quantifying heterogeneity in sexual behaviour and distribution of STIs before and after pre-exposure prophylaxis among men who have sex with men

Daphne Amanda van Wees, Sophie Diexer, Ganna Rozhnova, Amy Matser, Chantal den Daas, Janneke Heijne, Mirjam Kretzschmar

Research output: Contribution to journalArticlepeer-review

2 Citations (Scopus)


Objectives: Pre-exposure prophylaxis (PrEP) use may influence sexual behaviour and transmission of STIs among men who have sex with men (MSM). We aimed to quantify the distribution of STI diagnoses among MSM in the Netherlands based on their sexual behaviour before and after the introduction of PrEP.

Methods: HIV-negative MSM participating in a prospective cohort study (Amsterdam Cohort Studies) completed questionnaires about sexual behaviour and were tested for STI/HIV during biannual visits (2009-2019). We developed a sexual behaviour risk score predictive of STI diagnosis and used it to calculate Gini coefficients for gonorrhoea, chlamydia and syphilis diagnoses in the period before (2009 to mid-2015) and after PrEP (mid-2015 to 2019). Gini coefficients close to zero indicate that STI diagnoses are homogeneously distributed over the population, and close to one indicate that STI diagnoses are concentrated in individuals with a higher risk score. 

Results: The sexual behaviour risk score (n=630, n visits=10 677) ranged between 0.00 (low risk) and 3.61 (high risk), and the mean risk score increased from 0.70 (SD=0.66) before to 0.93 (SD=0.80) after PrEP. Positivity rates for chlamydia (4%) and syphilis (1%) remained relatively stable, but the positivity rate for gonorrhoea increased from 4% before to 6% after PrEP. Gini coefficients increased from 0.37 (95% CI 0.30 to 0.43) to 0.43 (95% CI 0.36 to 0.49) for chlamydia, and from 0.37 (95% CI 0.19 to 0.52) to 0.50 (95% CI 0.32 to 0.66) for syphilis comparing before to after PrEP. The Gini coefficient for gonorrhoea remained stable at 0.46 (95% CI 0.40 to 0.52) before and after PrEP.

 Conclusions: MSM engaged in more high-risk sexual behaviour and gonorrhoea diagnoses increased after PrEP was introduced. Chlamydia and syphilis diagnoses have become more concentrated in a high-risk subgroup. Monitoring the impact of increasing PrEP coverage on sexual behaviour and STI incidence is important. Improved STI prevention is needed, especially for high-risk MSM.

Original languageEnglish
Pages (from-to)395-400
Number of pages6
JournalSexually Transmitted Infections
Issue number6
Early online date22 Aug 2022
Publication statusPublished - 1 Sept 2022

Bibliographical note

Acknowledgements The Amsterdam Cohort Studies on HIV infection, a
collaboration between the Public Health Service of Amsterdam, the Amsterdam
University Medical Centres location AMC, Sanquin Blood Supply Foundation, MC
Jan van Goyen and DC Clinics Lairesse, are part of the Netherlands HIV Monitoring
Foundation and financially supported by the Netherlands National Institute for
Public Health and the Environment. The ACS gratefully acknowledge all the study
participants for their cooperation and participation and research nurses for collecting the data (Samantha de Graaf and Leeann Storey). The authors would also like to thank Dominique Loomans, Ertan Ersan, Maartje Dijkstra, Liza Coyer and Ward van Bilsen for data management, and Maartje Basten for acquiring funding for the current project
Funding This project was funded by the Netherlands Organisation for Health
Research and Development ZonMw grant 522 008 010.

Data Availability Statement

All data relevant to the study are included in the article or uploaded as supplemental information. Not applicable.


  • chlamydia infections
  • gonorrhoea
  • pre-exposure prophylaxis
  • sexual behaviour
  • syphilis


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