# Factors associated with bacterial sexually transmitted infection screening uptake and diagnosis among men who have sex with men in France

Cheick Haïballa Kounta, Emilie Chazelle, Youssoufa M Ousseine, Florence

Lot, Annie Velter

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Cheick Haïballa Kounta, Emilie Chazelle, Youssoufa M Ousseine, Florence Lot, Annie Velter. Factors associated with bacterial sexually transmitted infection screening uptake and diagnosis among men who have sex with men in France. BMC Infectious Diseases, 2024, 24 (1), pp.1431. 10.1186/s12879-024-10310-6. inserm-05031113

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# Factors associated with bacterial sexually transmitted infection screening uptake and diagnosis among men who have sex with men in France

Cheick Haïballa Kounta¹*, Emilie Chazelle¹, Youssoufa M. Ousseine¹, Florence Lot¹ and Annie Velter¹,²

**Abstract**

**Background** The prevalence of syphilis, *Chlamydia trachomatis* (CT), and *Neisseria gonorrhoeae* (NG) in men who have sex with men (MSM) is very high. As these bacterial sexually transmitted infections (bSTIs) are frequently asymptomatic, they are often undiagnosed and therefore untreated. We aimed to characterize the profile of MSM who reported bSTI screening and diagnosis in the previous 12 months, and to identify the factors associated with a diagnosis of a bSTI among MSM in France.

**Methods** We used data from *Enquête Rapport au Sexe* (ERAS), a large French national anonymous cross-sectional online survey among MSM conducted from 26 February to 11 April 2021. After comparing MSM screened and diagnosed in the previous year with those who were not, a binary logistic regression model was used to compare MSM diagnosed with at least one bSTI with those who were not.

**Results** Of the 13 300 survey respondents, 6 263 (47.1%) MSM reported screening for at least one bSTI in the previous 12 months. Of these, 1 060 (16.9%) were diagnosed for at least one bSTI during their most recent screening. Specifically, 446 (7.1%) MSM were diagnosed with NG, 427 (6.8%) with CT, and 402 (6.4%) for syphilis. The following self-reported factors were associated with a greater likelihood of bSTI diagnosis: younger age, a lower educational level, frequenting MSM meeting places, not currently using pre-exposure prophylaxis (PrEP) but willing to take preventive treatment against bSTIs (reference group: not using PrEP and not willing to take preventive treatment against bSTIs), low health literacy, more than one sexual male partner, practicing chemsex, and condomless anal intercourse with casual male partners (the latter three factors concerning the previous six months).

**Conclusions** A large proportion of MSM were diagnosed for at least one bSTI. This result provides an insight into bSTI screening uptake and diagnosis among MSM in France, and could inform future decisions about how to plan effective bSTI screening and diagnosis programs for this population.

**Keywords** MSM, Bacterial sexually transmitted infections (Syphilis, CT, NG), HIV, PrEP, Associated factors

<footnote>*Correspondence:
Cheick Haïballa Kounta
cheick.kounta@santepubliquefrance.fr
Full list of author information is available at the end of the article</footnote>
## Background

The World Health Organization (WHO) estimated that approximately 82.4 million new gonorrhea infections and 7.1 million new syphilis infections occurred worldwide in 2020 [1]. In France, the reported numbers of *Chlamydia trachomatis* (CT), *Neisseria gonorrhoeae* (NG), syphilis and rectal lymphogranuloma venereum (LGV) infections have been on the rise ever since their resurgence in the late 1990s [2–5]. Specifically, in 2016, the country had an estimated 267 097 cases and 49 628 cases of diagnosed CT and NG infections, respectively [6]. Furthermore, the largest increases in reported bacterial sexually transmitted infections (bSTIs) were observed among men who have sex with men (MSM) [7].

Screening for bSTIs is a key element in the holistic prevention model to reduce the risk of transmission. Early screening enables early diagnosis and therefore early treatment, which reduces the likelihood of complications [8, 9]. In September 2018, systematic screening in France for CT in all types of health facilities (general medicine, gynecology and midwifery practices) was recommended for all sexually active women aged 15 to 25 years old, pregnant women, and women and men with risk factors irrespective of their age [10]. Syphilis screening is recommended for more vulnerable populations such as MSM, sex workers and their clients, people living with HIV (PLHIV), migrants from endemic countries, and people with multiple sex partners [11]. Screening for NG infections is targeted at MSM, PLHIV and/or with a history of STIs, as well as persons practicing unprotected sex [12]. STI screening in dedicated STI clinics (*CeGIDD* in French) is free of charge, while screening in all other contexts (private clinics, public hospitals, general or specialist practitioners, etc.) is partially reimbursed by the national health insurance system, which covers 95% of the population [7].

Globally, the prevalence of STIs—and in particular syphilis, NG, and CT—is high in MSM [6, 8]. These three bSTIs are frequently asymptomatic and consequently remaining often undiagnosed and therefore untreated [13–15]. bSTIs can increase the risk of human immunodeficiency virus (HIV) transmission and acquisition among MSM through various mechanisms, including inflammatory genital ulcers and lesions caused by ulcerative STIs (e.g., syphilis and LGV), as well as inflammation and mucosal disruption associated with non-ulcerative STIs such as NG and Ct. They can also complicate the clinical course of HIV [8, 16–19]. Previous studies showed a higher incidence of bSTIs in HIV-positive MSM than in their HIV-negative counterparts [20–24].

Repeated cross-sectional online surveys of MSM showed that their level of HIV protection—including

treatment as prevention (TasP), Pre-exposure prophylaxis (PrEP), post-exposure prophylaxis (PEP), and condoms—has evolved in recent years in France [25]. Despite the fact that condoms are still the most frequently used method of protection, there has been a continuous decline in their use among MSM and this could lead to an increased incidence of STIs in this population and their partners [26]. Having said that, this decline is partially offset by a significant rise in PrEP use among MSM in France [25]. PrEP has been available in France since 2016 and is fully reimbursed by the French health insurance system [27]. According to the consolidated guidelines of WHO, PrEP is indicated for ‘high-risk individuals’, which include MSM and other key populations [28]. Although it is highly effective in preventing HIV infection in MSM [27], it does not protect against bSTIs [29]. However, clinical trials have shown that Doxycycline post-exposure prophylaxis (Doxy-PEP) is highly effective at reducing CT and syphilis in key populations, particularly among MSM [30]. Its effectiveness against NG is limited due to increasing bacterial resistance [30]. While Doxy-PEP holds promise as a biomedical tool for reducing bSTIs, concerns about drug resistance continue to hinder its widespread adoption. Although some countries have already recommended its use, long-term studies are essential to evaluate its broader impacts before it can be fully integrated into international health guidelines. Vaccination against bacterial STIs offers a promising opportunity to strengthen prevention strategies among MSM. However, the meningococcal group B vaccine (4CMenB) has not shown efficacy in reducing the incidence of NG in this population in France [31].

In addition, disruptions to healthcare services and the overburdening of health professionals caused by the coronavirus disease 2019 (COVID-19) health crisis, exacerbated bSTI vulnerability in MSM, a population already experiencing inequities in access to healthcare [32]. The consequences of these disruptions included the interruption of access to screening for bSTIs, to PrEP and to condoms. The decline in bSTIs screening activities may have fostered risky sexual behaviors among MSM [33].

A better understanding of the bSTIs diagnosed in MSM and their associated factors may provide important information on how healthcare providers can provide better support and care to MSM. The objectives of the present analysis were: (i) to characterize the profiles of MSM living in France who self-reported screening for one of more bSTIs in the previous 12 months and those diagnosed with a bSTI at their most recent screening, and (ii) to identify the factors associated with bSTIs in the MSM
population, using data from the *Enquête Rapport au Sexe* (ERAS) survey.

# Methods

## Study population

ERAS is a large, French, national, repeated, anonymous, self-administered, voluntary, cross-sectional online survey of MSM conducted in mainland France from 26 February to 11 April 2021. Its main aim was to assess trends in HIV prevention strategies among MSM living in France since the introduction of PrEP in the country in 2016 [34]. Secondary aims included an assessment of bSTI screening and diagnosis. Participants were recruited through various digital media. More specifically, banners were posted directly on gay dating websites, gay geolocation dating apps (e.g., Grindr, Scruff, Hornet), gay affinity news sites, and social media networks (e.g., Facebook). Clicking on these banners redirected the user to the survey website, where information about the survey's objectives, the conditions for participation, and data confidentiality were presented. In order to access the online survey questionnaire, participants had to provide informed consent by checking the relevant box. The only inclusion criteria for participation in ERAS were being male and being at least 18 years old.

In order to assess bSTI screening and diagnosis in the previous 12 months, our present analysis only focused on ERAS participants who self-identified as homosexual or bisexual or who self-reported they had sex with a man in their lifetime (all three categories considered as MSM for the present analysis), had been sexually active in the previous 12 months, and were living in France.

## Data collection

### Outcomes

The present study's outcomes were factors associated with bSTIs screening uptake and diagnosis. They were measured using the data collected for the included participants from the following questions regarding STIs in the ERAS questionnaire: 'In the past 12 months, have you had been tested at least once for the following? a. Hepatitis C, b. Hepatitis B, c. Syphilis, d. Chlamydia infections, e. Gonococcal disease, f. Condyloma, venereal vegetations, genital warts (HPV)'. Participants who answered 'yes' were then asked the following question: "What was the result of your most recent test for each STI you were screened for in the past 12 months?". Participants who answered they have been tested for at least one bSTI (i.e., c. Syphilis, d. Chlamydia infections, e. Gonococcal disease) were categorized as "screened" for at least one bSTI in the 12 previous months. Those who declared that they are not tested for at least one bSTI or answered 'I do not know' about the testing question were categorized

as "not screened" for at least one bSTI in the 12 previous months. Participants among those who were screened for at least one bSTI, who answered they tested positive for at least one bSTI (i.e., c. Syphilis, d. Chlamydia infections, e. Gonococcal disease) were categorized as having a bSTI in the previous 12 months. Those who declared that they tested negative or answered 'I do not know' about the result were categorized as not having a diagnosed bSTI in the previous 12 months.

## Explanatory variables

A) *Sociodemographic and socioeconomic characteristics:* Sociodemographic characteristics included in the analysis were: age (continuous variable), birthplace, education level, size of city of residence, relationship status with a man (i.e., married, living with a partner vs. single, separated/divorced, widowed), self-declared HIV status combined with PrEP use status. Socioeconomic characteristics included employment status and self-perceived financial situation.

b) *Behavioral characteristics:* Behavioral characteristics included self-defined sexual identity, frequenting MSM meeting places, using dating websites and applications, not having screened for bSTIs during the second COVID-19 lockdown (October-December 2020 in France), willing to take preventive treatment against bSTIs, and health literacy level. The latter was evaluated using the Health Literacy Questionnaire (HLQ) scale 'Appraisal of health information' [35, 36] which contains five items, each scored on a 4-point Likert scale. The total score is calculated as the average of the five item scores, and ranges from 1 to 4. Participants were categorized into two groups: lower (score ≤ 2.8 1st quartile) and higher (score > 2.8) health literacy. A lower score means that respondents may find it more difficult to understand health information and might get confused when there is conflicting information. Sexual behaviors included: i) the number of sexual male partners; ii) practicing chemsex in the previous six months (cocaine, GHB/GBL, amphetamines, MDPV, 3-MMC, 4-MMC, etc.); iii) having sex with stable male partners and casual male partners in the previous six months; iv) condom use during anal sex with stable male partners and casual male partners in the previous six months.

## Data analysis

Outcomes were compared first between MSM who had been screened for at least one bSTI in the 12 previous months and MSM who had not. They were then compared between MSM in the screened group who had tested positive for at least one bSTI at their most recent screening and those who did not. Pearson's χ2 test or Fisher's exact test were used for dichotomous and
categorical variables as appropriate, while the Wilcoxon-
Mann-Whitney test was used for continuous variables.
The number and proportion of positive syphilis, Ct and
NG infections at the most recent screenings were calcu-
lated according to HIV status and to PrEP use status.

Binary logistic regression models were used to identify
factors associated with bSTI diagnosis in the previous 12
months. Variables with a *p*-value < 0.20 in the univariate
analyses were considered eligible to enter the multivariate
model. A forward selection procedure was used to select
significant variables for the multivariate model (*p* < 0.05).
Interactions were tested between all variables likely to
influence each other in the multivariate model. Only vari-
ables and interactions with a *p* < 0.05 were retained in the
final multivariate model. Stata version 16.0 software was
used for all statistical analyses.

Results

Overall sample description

From February 26 to April 11, 2021, 18 474 respondents fully completed and validated the ERAS study questionnaire (see Fig. 1). Of these, 15 506 (83.9%) respondents were MSM living in France, and among the latter, 13 300 (85.8%) reported having sex with men in the previous 12 months preceding ERAS study. Among them, 6 263 (47.1%) MSM reported being screened at least once for a bSTI in the previous 12 months. Of these, 1 060 (16.9%) declared they were diagnosed positive for at least one bSTI (see Fig. 1).

Diagnoses of syphilis, CT and NG infections

With respect to the bSTIs studied, 446 (7.1%) of
screened (i.e., previous 12 months) MSM were diag-
nosed with NG, 427 (6.8%) *CT*, and 402 (6.4%) syphilis
(see Table 1). One hundred and ninety-one (3.1%) were
diagnosed with more than one STI. Syphilis was more

<figure><img src="image_4.png" /><figcaption>**Fig. 1** Study population flow chart. *ERAS (Enquête Rapport au Sexe); *MSM, Respondents who self-identified as homosexual or bisexual or who self-reported they had sex with a man in their lifetime</figcaption></figure>
<table><caption>**Table 1** Diagnoses of syphilis, *Chlamydia trachomatis* and *Neisseria gonorrhoeae* infections, according to HIV/PrEP status in MSM screened for at least one bacterial STI in the previous 12 months (n = 6 263)</caption><thead><tr><th>Diagnosis</th><th>All<br>n=6 263 (100%)<br>n (%)</th><th>HIV+<br>n=777 (12.4%)<br>n (%)</th><th>Unknown HIV status<br>n=168 (2.7%)<br>n (%)</th><th>HIV-/PrEP+<br>n=1 460 (23.3%)<br>n (%)</th><th>HIV-/PrEP-<br>n=3 858 (61.6%)<br>n (%)</th><th>P-value<sup>a</sup></th></tr></thead><tbody><tr><td><strong>Tested positive for at least 1 bacterial STI</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No or don't know result</td><td>5 203 (83.1)</td><td>609 (78.4)</td><td>146 (86.9)</td><td>1 122 (76.9)</td><td>3 326 (86.2)</td><td>&lt;0.001</td></tr><tr><td>Yes</td><td>1 060 (16.9)</td><td>168 (21.6)</td><td>22 (13.1)</td><td>338 (23.1)</td><td>532 (13.8)</td><td></td></tr><tr><td><strong>Syphilis</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No or don't know result</td><td>5 861 (93.6)</td><td>677 (87.1)</td><td>159 (94.6)</td><td>1 365 (93.5)</td><td>3 660 (94.9)</td><td>&lt;0.001</td></tr><tr><td>Yes</td><td>402 (6.4)</td><td>100 (12.9)</td><td>9 (5.4)</td><td>95 (6.5)</td><td>198 (5.1)</td><td></td></tr><tr><td><strong>Chlamydia trachomatis infection</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No or don't know result</td><td>5 836 (93.2)</td><td>715 (92.0)</td><td>157 (93.4)</td><td>1 298 (88.9)</td><td>3 666 (95.0)</td><td>&lt;0.001</td></tr><tr><td>Yes</td><td>427 (6.8)</td><td>62 (8.0)</td><td>11 (6.6)</td><td>162 (11.1)</td><td>192 (5.0)</td><td></td></tr><tr><td><strong>Neisseria gonorrhoeae infection</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No or don't know result</td><td>5 817 (92.9)</td><td>726 (93.4)</td><td>162 (96.4)</td><td>1 284 (88.0)</td><td>3 645 (94.5)</td><td>&lt;0.001</td></tr><tr><td>Yes</td><td>446 (7.1)</td><td>51 (6.6)</td><td>6 (3.6)</td><td>176 (12.0)</td><td>213 (5.5)</td><td></td></tr><tr><td><strong>Association with bacterial STI co-infection</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>0 bSTI</td><td>5 203 (83.1)</td><td>609 (78.4)</td><td>146 (86.9)</td><td>1 122 (76.9)</td><td>3 326 (86.2)</td><td>&lt;0.001</td></tr><tr><td>1 bSTI</td><td>869 (13.9)</td><td>132 (17.0)</td><td>19 (11.3)</td><td>252 (17.3)</td><td>466 (12.1)</td><td></td></tr><tr><td>2 bSTIs</td><td>167 (2.7)</td><td>27 (3.5)</td><td>2 (1.2)</td><td>77 (5.3)</td><td>61 (1.6)</td><td></td></tr><tr><td>3 bSTIs</td><td>24 (0.4)</td><td>9 (1.2)</td><td>1 (0.6)</td><td>9 (0.6)</td><td>5 (0.1)</td><td></td></tr></tbody></table>

frequent among HIV-positive MSM (12.9%), while NG and CT infections were more frequent among HIV-negative PrEP users (12.0% and 11.1%, respectively). HIV-negative PrEP users and HIV-positive MSM were the groups most often diagnosed with at least one bSTI (23.1% and 21.6%, respectively) and with more than one bSTI (5.9% and 4.7%, respectively).

## Characteristics of the study population

1. Factors associated with screening in the previous 12 months

Compared to unscreened MSM, screened MSM were significantly more likely to (Table 2):

### a) Demographics and living situation

* Be older (median age 34 [IQR=26–45] years vs. 32 [IQR=24–43] years, *p* < 0.001).

* Have a tertiary education level (73.6% vs. 66.2%, *p* < 0.001).

* Reside in a large city of over 100 000 people (46.9% vs. 31.3%, *p* < 0.001).

* Be in a stable relationship with a man (51.9% vs. 42.5%, *p* < 0.001).

* Self-identifying as homosexual (84.0% vs. 75.0%, *p* < 0.001).

* Report a difficult financial situation (14.0% vs. 12.7%, *p* = 0.023).

### b) Social behaviors

* Frequent MSM meeting places (69.4% vs. 49.6%, *p* < 0.001).

* Use dating websites or applications (88.5% vs. 69.6%, *p* < 0.001).

### c) Sexual behaviors

* Be HIV-negative PrEP users (23.3% vs. 0.7%, *p* < 0.001).

* Be HIV-positive MSM (12.4% vs. 2.4%, *p* < 0.001).

* Express willingness to take preventive treatment against bSTIs (69.6% vs. 43.0%, *p* < 0.001).

* Report multiple male sexual partners in the past six months (70.8% vs. 39.4%, *p* < 0.001).

* Engage in sex with at least one casual male partner in the past six months (73.1% vs. 44.9%, *p* < 0.001).

* Practice chemsex (18.3% vs. 5.1%, *p* < 0.001).

* Report consistent condom use with casual male partners in the past six months (20.0% vs. 16.8%, *p* < 0.001).

<footnote><sup>a</sup> p Calculated with χ2 test or Fisher's exact test for qualitative variables, Student's t-test for quantitative variables</footnote>
<table><caption>**Table 2** Description and comparison of sociodemographic and behavioral characteristics of the study population, according to self-reported screening or not for bacterial STIs in the previous 12 months (n = 13 300)</caption><thead><tr><th>Background characteristics</th><th>MSM not screened for any bacterial STI<br>n = 7 037<br>(52.9%)<br>n (%)</th><th>MSM screened for at least one bacterial STI<br>n = 6 263<br>(47.1%)<br>n (%)</th><th>All<br>n = 13 300<br>(100%)<br>n (%)</th><th>P-value<sup>a</sup></th></tr></thead><tbody><tr><td>Age, (years) median [IQR] (per one-year increase)</td><td>32 [24–43]</td><td>34 [26–45]</td><td>33 [25–44]</td><td>&lt;0.001</td></tr><tr><td>Place of birth</td><td></td><td></td><td></td><td></td></tr><tr><td>Outside of France</td><td>335 (4.8)</td><td>399 (6.4)</td><td>734 (5.5)</td><td>&lt;0.001</td></tr><tr><td>France</td><td>6 702 (95.2)</td><td>5 864 (93.6)</td><td>12 566 (94.5)</td><td></td></tr><tr><td>Education level</td><td></td><td></td><td></td><td></td></tr><tr><td>High-school diploma or lower</td><td>2 377 (33.8)</td><td>1 655 (26.4)</td><td>4 032 (30.3)</td><td>&lt;0.001</td></tr><tr><td>Tertiary</td><td>4 660 (66.2)</td><td>4 608 (73.6)</td><td>9 268 (69.7)</td><td></td></tr><tr><td>City of residence size greater than 100 000 inhabitants</td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>4 836 (68.7)</td><td>3 328 (53.1)</td><td>8 164 (61.4)</td><td>&lt;0.001</td></tr><tr><td>Yes</td><td>2 201 (31.3)</td><td>2 935 (46.9)</td><td>5 136 (38.6)</td><td></td></tr><tr><td>Stable relationship with a man</td><td></td><td></td><td></td><td></td></tr><tr><td>No (single, widowed, divorced)</td><td>4 045 (57.5)</td><td>3 010 (48.1)</td><td>7 055 (53.1)</td><td>&lt;0.001</td></tr><tr><td>Yes (married, in a couple)</td><td>2 992 (42.5)</td><td>3 253 (51.9)</td><td>6 245 (46.9)</td><td></td></tr><tr><td>Self-defined sexual identity</td><td></td><td></td><td></td><td></td></tr><tr><td>Homosexual</td><td>5 275 (75.0)</td><td>5 259 (84.0)</td><td>10 534 (79.2)</td><td>&lt;0.001</td></tr><tr><td>Bisexual</td><td>1 221 (17.3)</td><td>701 (11.2)</td><td>1 922 (14.5)</td><td></td></tr><tr><td>Other</td><td>541 (7.7)</td><td>303 (4.8)</td><td>844 (6.3)</td><td></td></tr><tr><td>Gainful employment</td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>2 296 (32.6)</td><td>1 957 (31.3)</td><td>4 253 (32.0)</td><td>0.088</td></tr><tr><td>Yes</td><td>4 741 (67.4)</td><td>4 306 (68.7)</td><td>9 047 (68.0)</td><td></td></tr><tr><td>Self-perceived financial situation</td><td></td><td></td><td></td><td></td></tr><tr><td>Comfortable</td><td>6 145 (87.3)</td><td>5 385 (86.0)</td><td>11 530 (86.7)</td><td>0.023</td></tr><tr><td>Difficult</td><td>892 (12.7)</td><td>878 (14.0)</td><td>1 770 (13.3)</td><td></td></tr><tr><td>Frequented MSM meeting places</td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>3 545 (50.4)</td><td>1 918 (30.6)</td><td>5 463 (41.1)</td><td>&lt;0.001</td></tr><tr><td>Yes</td><td>3 492 (49.6)</td><td>4 345 (69.4)</td><td>7 837 (58.9)</td><td></td></tr><tr><td>Used dating websites and applications</td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>2 139 (30.4)</td><td>718 (11.5)</td><td>2 857 (21.5)</td><td>&lt;0.001</td></tr><tr><td>Yes</td><td>4 898 (69.6)</td><td>5 545 (88.5)</td><td>10 443 (78.5)</td><td></td></tr><tr><td>HIV status/PrEP use</td><td></td><td></td><td></td><td></td></tr><tr><td>HIV- PrEP non-user</td><td>5 023 (71.4)</td><td>3 858 (61.6)</td><td>8 881 (66.8)</td><td>&lt;0.001</td></tr><tr><td>HIV- PrEP user</td><td>48 (0.7)</td><td>1 460 (23.3)</td><td>1 508 (11.3)</td><td></td></tr><tr><td>HIV + MSM</td><td>172 (2.4)</td><td>777 (12.4)</td><td>949 (7.1)</td><td></td></tr><tr><td>Unknown HIV status</td><td>1 794 (25.5)</td><td>168 (2.7)</td><td>1 962 (14.8)</td><td></td></tr><tr><td>Forewent bacterial STI screening during France's second COVID-19 lockdown (October-December 2020)</td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>7 003 (99.5)</td><td>5 765 (92.0)</td><td>12 768 (96.0)</td><td>&lt;0.001</td></tr><tr><td>Yes</td><td>34 (0.5)</td><td>498 (8.0)</td><td>532 (4.0)</td><td></td></tr><tr><td>Willing to take preventive treatment against bacterial STIs</td><td></td><td></td><td></td><td></td></tr><tr><td>No or don't know</td><td>4 012 (57.0)</td><td>1 907 (30.4)</td><td>5 919 (44.5)</td><td>&lt;0.001</td></tr><tr><td>Yes</td><td>3 025 (43.0)</td><td>4 356 (69.6)</td><td>7 381 (55.5)</td><td></td></tr><tr><td>Health literacy level</td><td></td><td></td><td></td><td></td></tr><tr><td>Higher</td><td>4 603 (65.4)</td><td>4 603 (73.5)</td><td>9 206 (69.2)</td><td>&lt;0.001</td></tr><tr><td>Lower</td><td>2 434 (34.6)</td><td>1 660 (26.5)</td><td>4 094 (30.8)</td><td></td></tr></tbody></table>
<table><caption>**Table 2** (continued)</caption><thead><tr><th rowspan="2">Background characteristics</th><th>MSM not screened for any bacterial STI</th><th>MSM screened for at least one bacterial STI</th><th>All</th><th rowspan="2">P-value<sup>a</sup></th></tr><tr><th>n = 7 037<br>(52.9%)<br>n (%)</th><th>n = 6 263<br>(47.1%)<br>n (%)</th><th>n = 13 300<br>(100%)<br>n (%)</th></tr></thead><tbody><tr><td><strong>Number of male sexual partners in the previous 6 months</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>0–1</td><td>4 263 (60.6)</td><td>1 826 (29.2)</td><td>6 089 (45.8)</td><td>&lt;0.001</td></tr><tr><td>&gt; 1</td><td>2 774 (39.4)</td><td>4 437 (70.8)</td><td>7 211 (54.2)</td><td></td></tr><tr><td><strong>Chemsex in the previous 6 months</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>No or don't know</td><td>6 096 (86.6)</td><td>4 866 (77.7)</td><td>10 962 (82.4)</td><td>&lt;0.001</td></tr><tr><td>Yes</td><td>362 (5.1)</td><td>1 144 (18.3)</td><td>1 506 (11.3)</td><td></td></tr><tr><td>Not concerned (no sexual partner)</td><td>579 (8.2)</td><td>253 (4.0)</td><td>832 (6.3)</td><td></td></tr><tr><td><strong>Had a stable male sexual partner in the previous 6 months</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>2 269 (32.2)</td><td>2 374 (37.9)</td><td>4 643 (34.9)</td><td>&lt;0.001</td></tr><tr><td>Yes</td><td>4 768 (67.8)</td><td>3 889 (62.1)</td><td>8 657 (65.1)</td><td></td></tr><tr><td><strong>Used condoms during anal intercourse with stable sexual male partner in the previous 6 months</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Unsystematically</td><td>3 504 (49.8)</td><td>2 908 (46.4)</td><td>6 412 (48.2)</td><td>&lt;0.001</td></tr><tr><td>Systematically</td><td>563 (8.0)</td><td>475 (7.6)</td><td>1 038 (7.8)</td><td></td></tr><tr><td>Not concerned (no anal intercourse or no stable partner)</td><td>2 970 (42.2)</td><td>2 880 (46.0)</td><td>5 850 (44.0)</td><td></td></tr><tr><td><strong>Had sex with a casual male partner in the previous 6 months</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>3 298 (46.9)</td><td>1 431 (22.9)</td><td>4 729 (35.6)</td><td>&lt;0.001</td></tr><tr><td>Yes</td><td>3 160 (44.9)</td><td>4 579 (73.1)</td><td>7 739 (58.2)</td><td></td></tr><tr><td>Not concerned (no sexual partner)</td><td>579 (8.2)</td><td>253 (4.0)</td><td>832 (6.3)</td><td></td></tr><tr><td><strong>Used condoms during anal intercourse with casual male partner in the previous 6 months</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Unsystematically</td><td>1 327 (18.9)</td><td>2 915 (46.5)</td><td>4 242 (31.9)</td><td>&lt;0.001</td></tr><tr><td>Systematically</td><td>1 182 (16.8)</td><td>1 251 (20.0)</td><td>2 433 (18.3)</td><td></td></tr><tr><td>Not concerned (no anal sex or no casual partner)</td><td>4 528 (64.3)</td><td>2 097 (33.5)</td><td>6 625 (49.8)</td><td></td></tr></tbody></table>

### d) Health literacy

* Have a higher level of health literacy (73.5% vs. 65.4%, *p* < 0.001).

### e) COVID-19-related behavior

* Not have been screened for bSTIs during the second COVID-19 lockdown in France (8.0% vs. 0.5%, *p* < 0.001).

Screened MSM (vs. unscreened) were significantly less likely to:

* Have been born in France (93.6% vs. 95.2%, *p* < 0.001).

* Have had a stable sexual male partner in the previous 6 months (62.1% vs. 67.8%, *p* < 0.001).

* Report consistent condom use with stable male partners (7.6% vs. 8.0%, *p* < 0.001).

2. Factors associated with a positive test at the most recent screening

Compared to screened MSM testing negative for a bSTI, those testing positive were significantly more likely to (Table 3):

#### a) Demographics and living situation:

* Reside in a large city of over 100 000 people (50.9% vs. 46.0%, *p* = 0.003).

* Report a difficult financial situation (15.7% vs. 13.7%, *p* = 0.091, not significant).

#### b) Social behaviors:

* Frequent MSM meeting places (78.6% vs. 67.5%, *p* < 0.001).

* Use dating websites or applications (93.2% vs. 87.6%, *p* < 0.001).

#### c) Sexual behaviors:

<footnote><sup>a</sup> p Calculated with χ2 test or Fisher's exact test for qualitative variables, Student's t-test for quantitative variables</footnote>
<table><caption>**Table 3** Description and comparison of sociodemographic and behavioral characteristics of MSM screened for at least one bacterial STI in the previous 12 months, according to diagnosis of a bacterial STI or not (n = 6 263)</caption><thead><tr><th>Sociodemographic and behavioral characteristics</th><th>Screened MSM not diagnosed with a bacterial STI<br>n = 5 203<br>(83.1%)<br>n (%)</th><th>Screened MSM diagnosed with at least 1 bacterial STI<br>n = 1 060<br>(16.9%)<br>n (%)</th><th>All<br>n = 6 263<br>(100%)<br>n (%)</th><th>P-value<sup>a</sup></th></tr></thead><tbody><tr><td>Age, (years) median [IQR] (per one-year increase)</td><td>33 [26-46]</td><td>35 [27-45]</td><td>34 [26-45]</td><td>0.102</td></tr><tr><td>Place of birth</td><td></td><td></td><td></td><td></td></tr><tr><td>Outside of France</td><td>326 (6.3)</td><td>73 (6.9)</td><td>399 (6.4)</td><td>0.450</td></tr><tr><td>France</td><td>4 877 (93.7)</td><td>987 (93.1)</td><td>5 864 (93.6)</td><td></td></tr><tr><td>Education level</td><td></td><td></td><td></td><td></td></tr><tr><td>High school diploma or lower</td><td>1 356 (26.1)</td><td>299 (28.2)</td><td>1 655 (26.4)</td><td>0.149</td></tr><tr><td>Tertiary</td><td>3 847 (73.9)</td><td>761 (71.8)</td><td>4 608 (73.6)</td><td></td></tr><tr><td>City of residence size greater than 100 000 inhabitants</td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>2 808 (54.0)</td><td>520 (49.1)</td><td>3 328 (53.1)</td><td>0.003</td></tr><tr><td>Yes</td><td>2 395 (46.0)</td><td>540 (50.9)</td><td>2 935 (46.9)</td><td></td></tr><tr><td>Stable relationship with a man</td><td></td><td></td><td></td><td></td></tr><tr><td>No (single, widowed, divorced)</td><td>2 520 (48.4)</td><td>490 (46.2)</td><td>3 010 (48.1)</td><td>0.190</td></tr><tr><td>Yes (married, living with a partner)</td><td>2 683 (51.6)</td><td>570 (53.8)</td><td>3 253 (51.9)</td><td></td></tr><tr><td>Self-defined sexual identity</td><td></td><td></td><td></td><td></td></tr><tr><td>Homosexual</td><td>4 352 (83.6)</td><td>907 (85.6)</td><td>5 259 (84.0)</td><td>0.190</td></tr><tr><td>Bisexual</td><td>589 (11.3)</td><td>112 (10.6)</td><td>701 (11.2)</td><td></td></tr><tr><td>Other</td><td>262 (5.1)</td><td>41 (3.8)</td><td>303 (4.8)</td><td></td></tr><tr><td>Gainful employment</td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>1 650 (31.7)</td><td>307 (29.0)</td><td>1 957 (31.3)</td><td>0.078</td></tr><tr><td>Yes</td><td>3 553 (68.3)</td><td>753 (71.0)</td><td>4 306 (68.7)</td><td></td></tr><tr><td>Self-perceived financial situation</td><td></td><td></td><td></td><td></td></tr><tr><td>Comfortable</td><td>4 491 (86.3)</td><td>894 (84.3)</td><td>5 385 (86.0)</td><td>0.091</td></tr><tr><td>Difficult</td><td>712 (13.7)</td><td>166 (15.7)</td><td>878 (14.0)</td><td></td></tr><tr><td>Frequented MSM meeting places</td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>1 691 (32.5)</td><td>227 (21.4)</td><td>1 918 (30.6)</td><td>&lt;0.001</td></tr><tr><td>Yes</td><td>3 512 (67.5)</td><td>833 (78.6)</td><td>4 345 (69.4)</td><td></td></tr><tr><td>Used dating websites and applications</td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>646 (12.4)</td><td>72 (6.8)</td><td>718 (11.5)</td><td>&lt;0.001</td></tr><tr><td>Yes</td><td>4 557 (87.6)</td><td>988 (93.2)</td><td>5 545 (88.5)</td><td></td></tr><tr><td>HIV status/PrEP use</td><td></td><td></td><td></td><td></td></tr><tr><td>HIV- PrEP non-user</td><td>3 326 (63.9)</td><td>532 (50.2)</td><td>3 858 (61.6)</td><td>&lt;0.001</td></tr><tr><td>HIV- PrEP user</td><td>1 122 (21.6)</td><td>338 (31.9)</td><td>1 460 (23.3)</td><td></td></tr><tr><td>HIV + MSM</td><td>609 (11.7)</td><td>168 (15.8)</td><td>777 (12.4)</td><td></td></tr><tr><td>Unknown HIV status</td><td>146 (2.8)</td><td>22 (2.1)</td><td>168 (2.7)</td><td></td></tr><tr><td>Forewent bacterial STI screening during France's second COVID-19 lockdown (October-December 2020)</td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>4 787 (92.0)</td><td>978 (92.3)</td><td>5 765 (92.1)</td><td>0.776</td></tr><tr><td>Yes</td><td>416 (8.0)</td><td>82 (7.7)</td><td>498 (7.9)</td><td></td></tr><tr><td>Willing to take preventive treatment against bacterial STIs</td><td></td><td></td><td></td><td></td></tr><tr><td>No or don't know</td><td>1 742 (33.5)</td><td>165 (15.6)</td><td>1 907 (30.4)</td><td>&lt;0.001</td></tr><tr><td>Yes</td><td>3 461 (66.5)</td><td>895 (84.4)</td><td>4 356 (69.6)</td><td></td></tr><tr><td>Health literacy level</td><td></td><td></td><td></td><td></td></tr><tr><td>Higher</td><td>3 853 (74.0)</td><td>750 (70.7)</td><td>4 603 (73.5)</td><td>0.027</td></tr><tr><td>Lower</td><td>1 350 (26.0)</td><td>310 (29.3)</td><td>1 660 (26.5)</td><td></td></tr></tbody></table>
<table><caption>**Table 3** (continued)</caption><thead><tr><th rowspan="2">Sociodemographic and behavioral characteristics</th><th>Screened MSM not diagnosed with a bacterial STI</th><th>Screened MSM diagnosed with at least 1 bacterial STI</th><th>All</th><th rowspan="2">P-value<sup>a</sup></th></tr><tr><th>n = 5 203<br>(83.1%)<br>n (%)</th><th>n = 1 060<br>(16.9%)<br>n (%)</th><th>n = 6 263<br>(100%)<br>n (%)</th></tr></thead><tbody><tr><td><strong>Number of sexual male partners in the previous 6 months</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>0-1</td><td>1 649 (31.7)</td><td>177 (16.7)</td><td>1 826 (29.2)</td><td>&lt;0.001</td></tr><tr><td>&gt; 1</td><td>3 554 (68.3)</td><td>883 (83.3)</td><td>4 437 (70.8)</td><td></td></tr><tr><td><strong>Chemsex in the previous 6 months</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>No or don't know</td><td>4 177 (80.3)</td><td>689 (65.0)</td><td>4 866 (77.7)</td><td>&lt;0.001</td></tr><tr><td>Yes</td><td>798 (15.3)</td><td>346 (32.6)</td><td>1 144 (18.3)</td><td></td></tr><tr><td>Not concerned (no sexual partner)</td><td>228 (4.4)</td><td>25 (2.4)</td><td>253 (4.0)</td><td></td></tr><tr><td><strong>Had a stable male sexual partner in the previous 6 months</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>1 962 (37.7)</td><td>412 (38.9)</td><td>2 374 (37.9)</td><td>0.478</td></tr><tr><td>Yes</td><td>3 241 (62.3)</td><td>648 (61.1)</td><td>3 889 (62.1)</td><td></td></tr><tr><td><strong>Used condoms during anal intercourse with stable sexual male partner in the previous 6 months</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Unsystematically</td><td>2 409 (46.3)</td><td>499 (47.1)</td><td>2 908 (46.4)</td><td>0.033</td></tr><tr><td>Systematically</td><td>415 (8.0)</td><td>60 (5.7)</td><td>475 (7.6)</td><td></td></tr><tr><td>Not concerned (no anal sex or no stable partner)</td><td>2 379 (45.7)</td><td>501 (47.3)</td><td>2 880 (46.0)</td><td></td></tr><tr><td><strong>Had sex with a casual male partner in the previous 6 months</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>1 291 (24.8)</td><td>140 (13.2)</td><td>1 431 (22.9)</td><td>&lt;0.001</td></tr><tr><td>Yes</td><td>3 684 (70.8)</td><td>895 (84.4)</td><td>4 579 (73.1)</td><td></td></tr><tr><td>Not concerned (no sexual partner)</td><td>228 (4.4)</td><td>25 (2.4)</td><td>253 (4.0)</td><td></td></tr><tr><td><strong>Used condoms during anal intercourse with a casual male partner in the previous 6 months</strong></td><td></td><td></td><td></td><td></td></tr><tr><td>Unsystematically</td><td>2 205 (42.4)</td><td>710 (67.0)</td><td>2 915 (46.5)</td><td>&lt;0.001</td></tr><tr><td>Systematically</td><td>1 107 (21.3)</td><td>144 (13.6)</td><td>1 251 (20.0)</td><td></td></tr><tr><td>Not concerned (no anal sex or no casual partner)</td><td>1 891 (36.3)</td><td>206 (19.4)</td><td>2 097 (33.5)</td><td></td></tr></tbody></table>

o Be HIV-negative PrEP users (31.9% vs. 21.6%, p < 0.001).

o Be HIV-positive MSM (15.8% vs. 11.7%, p < 0.001).

o Express willingness to take preventive treatment against bSTIs (84.4% vs. 66.5%, p < 0.001).

o Report multiple male sexual partners in the past six months (83.3% vs. 68.3%, p < 0.001).

o Engage in sex with at least one casual male partner in the past six months (84.4% vs. 70.8%, p < 0.001).

o Practice chemsex (32.6% vs. 15.3%, p < 0.001).

d) **Health literacy:**

o Have a lower level of health literacy (70.7% vs. 74.0%, p = 0.027).

Screened MSM testing positive (vs. screened MSM who tested negative) were significantly less likely to:

* Report consistent condom use with casual male partners (13.6% vs. 21.3%, p < 0.001).

* Report consistent condom use with stable male partners (5.7% vs. 8.0%, p = 0.033).

**Results from the multivariate analyses on factors associated with bSTI diagnosis**

In the final multivariable regression model (Table 4), the self-reported factors associated with a greater likelihood of bSTI diagnosis were as follows: i) younger age (adjusted OR (aOR)[95%CI]:0.99[0.98–0.99]) per one-year increase, ii) lower educational level (defined here as a high-school diploma or less) (aOR:1.18[1.01–1.38]), iii) frequenting MSM meeting places (aOR:1.34[1.13–1.60]),

<footnote><sup>a</sup> p Calculated with χ2 test or Fisher's exact test for qualitative variables, Student's t-test for quantitative variables</footnote>
<table><caption>**Table 4** Factors associating screened MSM with diagnosed bacterial STIs: univariate and multivariate analyses with binary logistic regression (n = 6 263)</caption><thead><tr><th rowspan="2">Characteristics</th><th colspan="3">Univariate analysis<sup>a</sup></th><th colspan="3">Multivariate analysis<sup>b</sup></th></tr><tr><th>OR<sup>c</sup></th><th>[IC95%]</th><th>P-value<sup>e</sup></th><th>aOR<sup>d</sup></th><th>[IC95%]</th><th>P-value<sup>e</sup></th></tr></thead><tbody><tr><td>Age (years), median (per one-year increase)</td><td>0.99</td><td>[0.99–1.01]</td><td>0.103</td><td>0.99</td><td>[0.98–0.99]</td><td>0.001</td></tr><tr><td><strong>Place of birth</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Outside of France</td><td>Ref</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>France</td><td>0.90</td><td>[0.69–1.18]</td><td>0.451</td><td></td><td></td><td></td></tr><tr><td><strong>Education level</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Tertiary</td><td>Ref</td><td></td><td></td><td>Ref</td><td></td><td></td></tr><tr><td>High school diploma or lower</td><td>1.11</td><td>[0.96–1.29]</td><td>0.149</td><td>1.18</td><td>[1.01–1.38]</td><td>0.037</td></tr><tr><td><strong>City of residence size greater than 100 000 inhabitants</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>Ref</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Yes</td><td>1.22</td><td>[1.07–1.39]</td><td>0.004</td><td></td><td></td><td></td></tr><tr><td><strong>In a stable relationship with a man</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No (single, widowed, divorced)</td><td>Ref</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Yes (married, living with a partner)</td><td>1.09</td><td>[0.96–1.25]</td><td>0.190</td><td></td><td></td><td></td></tr><tr><td><strong>Self-defined sexual identity</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Homosexual</td><td>Ref</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Bisexual</td><td>0.91</td><td>[0.74–1.13]</td><td>0.402</td><td></td><td></td><td></td></tr><tr><td>Other</td><td>0.75</td><td>[0.54–1.05]</td><td>0.095</td><td></td><td></td><td></td></tr><tr><td><strong>Gainful employment</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>Ref</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Yes</td><td>1.14</td><td>[0.99–1.32]</td><td>0.078</td><td></td><td></td><td></td></tr><tr><td><strong>Self-perceived financial situation</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Comfortable</td><td>Ref</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Difficult</td><td>1.17</td><td>[0.97–1.41]</td><td>0.091</td><td></td><td></td><td></td></tr><tr><td><strong>Frequented MSM meeting places</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>Ref</td><td></td><td></td><td>Ref</td><td></td><td></td></tr><tr><td>Yes</td><td>1.77</td><td>[1.51–2.07]</td><td>&lt;0.001</td><td>1.34</td><td>[1.13–1.60]</td><td>0.001</td></tr><tr><td><strong>Used dating websites and applications</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>Ref</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Yes</td><td>1.95</td><td>[1.51–2.51]</td><td>&lt;0.001</td><td></td><td></td><td></td></tr><tr><td><strong>Forewent bacterial STI screening during France's second COVID-19 lockdown (October-December 2020)</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>Ref</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Yes</td><td>0.96</td><td>[0.75–1.23]</td><td>0.776</td><td></td><td></td><td></td></tr><tr><td><strong>HIV status/PrEP use</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>HIV- PrEP non-user</td><td>Ref</td><td></td><td></td><td>Ref</td><td></td><td></td></tr><tr><td>HIV- PrEP user</td><td>1.88</td><td>[1.62–2.19]</td><td>&lt;0.001</td><td>0.69</td><td>[0.39–1.21]</td><td>0.193</td></tr><tr><td>HIV + MSM</td><td>1.72</td><td>[1.42–2.09]</td><td>&lt;0.001</td><td>1.61</td><td>[0.95–2.73]</td><td>0.078</td></tr><tr><td>Unknown HIV status</td><td>0.94</td><td>[0.60–1.49]</td><td>0.798</td><td>1.39</td><td>[0.61–3.19]</td><td>0.434</td></tr><tr><td><strong>Willing to take preventive treatment against bacterial STIs</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No or don't know</td><td>Ref</td><td></td><td></td><td>Ref</td><td></td><td></td></tr><tr><td>Yes</td><td>2.73</td><td>[2.29–3.25]</td><td>&lt;0.001</td><td>2.32</td><td>[1.86–2.88]</td><td>&lt;0.001</td></tr><tr><td><strong>Interaction between HIV status/PrEP use and Willing to take preventive treatment against bacterial STIs</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>HIV- PrEP non-user # No or don't know</td><td>Ref</td><td></td><td></td><td>Ref</td><td></td><td></td></tr><tr><td>HIV- PrEP user # Yes</td><td>1.39</td><td>[0.78–2.47]</td><td></td><td>0.59</td><td>[0.34–1.04]</td><td>0.070</td></tr><tr><td>HIV + # Yes</td><td>0.59</td><td>[0.34–1.04]</td><td></td><td>0.40</td><td>[0.15–1.10]</td><td>0.076</td></tr><tr><td><strong>Health literacy level</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Higher</td><td>Ref</td><td></td><td></td><td>Ref</td><td></td><td></td></tr></tbody></table>
<table><caption>**Table 4** (continued)</caption><thead><tr><th rowspan="2">Characteristics</th><th colspan="3">Univariate analysis<sup>a</sup></th><th colspan="3">Multivariate analysis<sup>b</sup></th></tr><tr><th>OR<sup>c</sup></th><th>[IC95%]</th><th>P-value<sup>e</sup></th><th>aOR<sup>d</sup></th><th>[IC95%]</th><th>P-value<sup>e</sup></th></tr></thead><tbody><tr><td>Lower</td><td>1.18</td><td>[1.02–1.37]</td><td>0.027</td><td>1.28</td><td>[1.10–1.49]</td><td>0.002</td></tr><tr><td><strong>Number of sexual male partners in the previous 6 months</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>0–1</td><td>Ref</td><td></td><td></td><td>Ref</td><td></td><td></td></tr><tr><td>> 1</td><td>2.31</td><td>[1.95–2.75]</td><td>&lt;0.001</td><td>1.31</td><td>[1.03–1.66]</td><td>0.029</td></tr><tr><td><strong>Chemsex in the previous 6 months</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No or don't know</td><td>Ref</td><td></td><td></td><td>Ref</td><td></td><td></td></tr><tr><td>Yes</td><td>2.63</td><td>[2.26–3.05]</td><td>&lt;0.001</td><td>1.88</td><td>[1.59–2.21]</td><td>&lt;0.001</td></tr><tr><td>Not concerned (no sexual partner)</td><td>0.66</td><td>[0.44–1.01]</td><td>0.057</td><td>1.12</td><td>[0.72–1.76]</td><td>0.613</td></tr><tr><td><strong>Had a stable male sexual partner in the previous 6 months</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>Ref</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Yes</td><td>0.95</td><td>[0.83–1.09]</td><td>0.478</td><td></td><td></td><td></td></tr><tr><td><strong>Used condoms during anal intercourse with stable sexual male partner in the previous 6 months</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Systematically</td><td>Ref</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Unsystematically</td><td>1.43</td><td>[1.07–1.91]</td><td>0.014</td><td></td><td></td><td></td></tr><tr><td>Not concerned (no anal sex or no stable partner)</td><td>1.46</td><td>[1.09–1.94]</td><td>0.010</td><td></td><td></td><td></td></tr><tr><td><strong>Had sex with a casual male partner in the previous 6 months</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No</td><td>Ref</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Yes</td><td>2.24</td><td>[1.85–2.71]</td><td>&lt;0.001</td><td></td><td></td><td></td></tr><tr><td>Not concerned (no sexual partner)</td><td>1.01</td><td>[0.65–1.58]</td><td>0.961</td><td></td><td></td><td></td></tr><tr><td><strong>Used condoms during anal intercourse with a casual male partner in the previous 6 months</strong></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Systematically</td><td>Ref</td><td></td><td></td><td>Ref</td><td></td><td></td></tr><tr><td>Unsystematically</td><td>2.48</td><td>[2.04–3.00]</td><td>&lt;0.001</td><td>1.96</td><td>[1.59–2.42]</td><td>&lt;0.001</td></tr><tr><td>Not concerned (no anal sex or no casual partner)</td><td>0.84</td><td>[0.67–1.05]</td><td>0.123</td><td>1.04</td><td>[0.79–1.36]</td><td>0.785</td></tr></tbody></table>

iv) not using PrEP but willing to take preventive treatment against bSTIs (reference group: not using PrEP and not willing to take preventive treatment against bSTIs) (aOR:2.32[1.86–2.88]), v) lower health literacy (aOR:1.28[1.10–1.49]), and in the previous 6 months, vi) more than one male sexual partner (aOR:1.29[1.02–1.65]), vii) practicing chemsex (aOR:1.86[1.58–2.19]), and finally, viii) practicing condomless anal intercourse with a casual male partner (aOR:1.96[1.59–2.42]).

Discussion

This study of bSTI screening uptake and diagnosis among a large sample of MSM in France provides a greater understanding of bSTI epidemiology and factors associated with bSTIs in the time of COVID-19. Its results could be used to adapt prevention strategies.

Overall, nearly half of the participants reported having been screened for at least one bSTI (NG, CT, or

syphilis) in the previous 12 months. Of these, more than a tenth reported testing positive for one or more bSTI at their most recent screening for each bSTI. The proportions of NG (12.0%) and CT (11.1%) infections were significantly higher in HIV-negative PrEP users while the proportion of syphilis (12.9%) was significantly higher in HIV-positive MSM. These proportions are consistent with French surveillance data collected on MSM in free STI clinics in France in 2020 [37] and with European surveillance data on MSM collected in 2017 [38–41].

With regard to the French data, a decline of approximately 6% and 30% was observed in screening availability in France in 2020 for these three bSTIs in private and CeGIDD services, respectively. This decline was partly due to the partial or total closure of screening centers during the two national COVID-19 lockdowns that year (March–May and October–December, 2020), and

<footnote><sup>a</sup> Univariate analysis using a binary logistic regression model</footnote>

<footnote><sup>b</sup> Multivariate analysis using a multivariate binary logistic regression model</footnote>

<footnote><sup>c</sup> OR odds ratio, IC confidence interval</footnote>

<footnote><sup>d</sup> aOR adjusted odds ratio, IC confidence interval</footnote>

<footnote><sup>e</sup> p Calculated with Wald's chi2 test</footnote>

<footnote>Not concerned = not documented. Includes missing data and "no response"</footnote>
to a reduction in the number of healthcare profession- als available to screen and diagnose bSTIs due to their mobilisation to tackle the COVID-19 health crisis [42]. This explains why fewer bSTIs were diagnosed between 2019 and 2020 in CeGIDD, especially for CT (-31% vs. -18% for syphilis and -13% for NG) [42]. This decline in screening and in diagnoses is consistent with our result that the proportion of MSM who were not screened for any of the three studied bSTIs during the second lock- down, was higher than in MSM who reported screening for at least one bSTI. Moreover, this decline may have favored the spread of these infections among this high- risk population.

Early bSTI screening facilitates prompt identification and treatment for MSM and their partners. In turn, treat- ment helps to reduce transmission in the sexually-active MSM population. More than half of the MSM in our study were not screened for at least one bSTI. Of these, nearly half reported having sex with a casual male part- ner in the previous six months, and nearly of two-fifths reported condomless anal intercourse with a casual male partner in the same timeframe. These two results high- light the importance of expanding coverage of bSTI screening for MSM and ensuring that screening tests become more accessible (e.g., no need for a prescription), especially for those less frequently screened. In our study, the latter primarily included MSM who did not consist- ently practice prevention behaviors (e.g., systematic con- dom use with a casual partner), younger MSM, those living in a small town (i.e., < 100 000 inhabitants), those not in a stable relationship with a man, those who did not self-identify as homosexual, those who did not have a higher educational level (understood here as tertiary education), and finally, MSM with lower health literacy.

With a view to better targeting most-at-risk MSM subgroups through screening programs, future research should describe the individual characteristics associ- ated with bSTIs in greater detail to better understand the socio-behavioral determinants associated with bSTI occurrence. Our study highlighted that some sociodemo- graphic factors were associated with a greater likelihood of bSTI occurrence among MSM as follows: younger age, lower educational level, and lower health literacy. With respect to younger age, this association is consistent with previous research among MSM in Europe [38, 43]. A lower educational level and lower health literacy, particu- larly regarding STI-related information, could constitute barriers to informed decision-making when having sex [44].

In terms of behavioral characteristics, PrEP non-users willing to take preventive treatment against bSTIs were more likely to have bSTIs than non-users who were not willing to take preventative treatment. One possible

explanation for this is that some of PrEP non-users who engage in risky sexual practices are not reached by the current PrEP offer in France. Therefore, they may have less access to preventive care than PrEP users, a situation which fosters a desire to improve their self-protection by taking medicine to prevent bSTIs as a risk minimisation strategy. This hypothesis is supported by a French study in 2020, which suggested that the country's current PrEP offer is not reaching certain MSM subpopulations with less access to preventive care but who wish to improve their self-efficacy regarding safe sex [45]. Another French study showed that MSM PrEP non-users with a good perception of HIV treatment had similar characteristics to MSM PrEP users in terms of risky sexual practices [46].

Unlike previous studies, we found no association between PrEP use and bSTI diagnosis among MSM in our multivariate model [47, 48]; this was to be expected given that follow-up for PrEP users in France involves early testing and rapid treatment for bSTIs [49]. On the one hand, this follow-up reduces non-diagnosed infec- tions and thus could increase artificially the number of diagnoses. On the other hand, it could decrease the num- ber of lately diagnosed infections and thus explain why we did not find any such association [50, 51].

In addition, we found that MSM who frequented MSM meeting places were more likely to have been diagnosed for at least one bSTI at their most recent screening; this could be explained by the fact that MSM with multiple sexual partners tend to frequent such places. This find- ing is consistent with other studies [52, 53]. MSM meet- ing places are important to take into account when implementing sex education programs and early screen- ing to ensure early treatment of bSTIs. With respect to risky sexual behaviors, we identified several risk fac- tors for bSTI diagnosis including having more than one sexual male partner, practicing chemsex, and practicing condomless anal intercourse with a casual male part- ner (all three factors in the previous six months). These risky sexual practices among MSM have been previously demonstrated as risk factors associated with all STIs, including bSTIs [8, 22]. Given that participation in these risky sexual practices increases the risk of acquiring a bSTI, interventions aimed at empowering MSM to bet- ter understand the risks of bSTI transmission, as well as notifying sexual partners of a bSTI diagnosis, could be extremely beneficial to enhance targeted testing of MSM at high risk of bSTI acquisition, and subsequent linkage to care for those diagnosed positive. Education and pre- vention programs on bSTIs should investigate in greater detail how early screening and regular follow-up—with a view to early diagnosis and rapid treatment in MSM— may influence risk perceptions and risk sexual behaviors.
## Limitations

Our analysis has some limitations. First, the ERAS study was designed to assess trends in HIV prevention strategies among MSM, not specifically to investigate bSTIs. As a result, our analysis lacked certain data that could have provided additional insights, such as information on the frequency of bSTI screening and diagnosis, the time gap between STI symptoms and screening, and data on treatment. Consequently, we used the most recent "positive" screening to classify MSM with bSTI diagnoses. While this approach may not capture the full history of infections, it allowed us to focus on the most current health status and risk behaviors, which are important for understanding the immediate risk of infection, given the rapid changes in STI status. Nevertheless, the data collected in ERAS enabled us to characterize the risk profile of MSM vulnerable to bSTIs. Future research could benefit from including longitudinal data on screening and diagnosis histories to provide a more comprehensive assessment of bSTI diagnoses. Second, the ERAS study sample is not representative of the whole MSM population in France because the online survey did not reach MSM who do not routinely use the web. Nevertheless, studies have shown that internet-based surveys are generally effective in reaching a significant portion of the MSM population, as this group tends to use online platforms frequently for social interaction, dating, and accessing information [54]. Third, given the declarative nature of the data, social desirability, memory and classification biases are possible. Accordingly, sexual risk behaviors and HIV status self-report may have been underreported [55]. However, the fact that information was provided anonymously and voluntarily reduces any such bias. Finally, the questions on sexual behaviors concerned the previous six months while the questions on screening and diagnosis of bSTIs concerned the previous 12 months. Therefore, sexual behaviors might not have fully influenced bSTI screening uptake or diagnosis. However, as the sexual behavior of MSM depends on the HIV seroadaptation strategies they adopt, such as HIV serosorting and strategic positioning, it is possible that their sexual behaviors are habitual.

Despite these limitations, our results provide valuable information for the optimization of bSTI education, screening and diagnosis programs among MSM in France. Biomedical, behavioral, and structural interventions, such as the implementation of both early screening and treatment, as well as interventions to reduce bSTI occurrence, are needed to mitigate the effect of ongoing bSTI transmission in this population.

## Conclusion

We found a high proportion of MSM diagnosed with at least one bSTI in their most recent screening. More specifically, 7.1% were diagnosed for *Neisseria gonorrhoeae* infection, 6.8% for *Chlamydia trachomatis* infection, and 6.4% for syphilis. Several self-reported risky sexual behaviors (e.g., multiple sexual partners, practicing chemsex, and condomless anal intercourse with casual male partners) and socioeconomic characteristics (younger age, lower education level and lower health literacy) were associated with a greater likelihood of bSTI diagnosis.

This study contributes to other work on bSTIs highlighting the relationship between their diagnosis and risky sexual behaviors. Further research is needed to acquire an in-depth understanding of bSTI screening uptake and diagnosis among most-at-risk MSM, with a view to better assessing their needs in terms of prevention.

### Abbreviations

<table><tr><td>bSTIs</td><td>Bacterial sexually transmitted infections</td></tr><tr><td>CAI</td><td>Condomless anal intercourse</td></tr><tr><td>COVID-19</td><td>Coronavirus disease 2019</td></tr><tr><td>CT</td><td>Chlamydia trachomatis</td></tr><tr><td>ERAS</td><td>Enquête Rapport au Sexe</td></tr><tr><td>HIV</td><td>Human immunodeficiency virus</td></tr><tr><td>HLQ</td><td>Health Literacy Questionnaire</td></tr><tr><td>LGV</td><td>Lymphogranuloma venereum</td></tr><tr><td>MSM</td><td>Men who have sex with men</td></tr><tr><td>NG</td><td>Neisseria gonorrhoeae</td></tr><tr><td>PEP</td><td>Post-exposure prophylaxis</td></tr><tr><td>PrEP</td><td>HIV Pre-exposure prophylaxis</td></tr><tr><td>STI</td><td>Sexually transmitted infections</td></tr><tr><td>TasP</td><td>Treatment as prevention</td></tr><tr><td>WHO</td><td>World Health Organization</td></tr></table>

### Acknowledgements

The authors would like to thank Nathalie Lydié, Nicolas Etien (Santé Publique France), Bérangère Gall and Julien Vivant (BVA Institute) for their involvement in the implementation of the ERAS survey, and our partners from various associations for their support and for raising awareness of our survey throughout their networks. Finally, we would like to thank all the ERAS participants for taking the time to complete the ERAS survey questionnaire.

### Authors' contributions

AV designed and supervised the data collection for ERAS study and supervised the analysis. CHK conducted the present analysis and wrote the paper under the supervision and advice of YMO, EC, and FL. AV is responsible for the content. All authors reviewed the manuscript, read the final version of the manuscript and agreed to submitting it for publication. All authors read the final version of the manuscript and agreed to submitting it for publication.

### Funding

The authors declare that they did not receive any specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

### Data availability

The full dataset and statistical code are available from the corresponding author cheick.kounta@santepubliquefrance.fr. All data relevant to the study are included in the article or have been uploaded as supplementary information. French law restricts public sharing of the data of this study. Requests for
access to cohort data, clinical study data, and data from any kind of study on humans must be addressed to the French Data Protection Authority (Commission Nationale de l'Informatique et des Libertés) at https://www.cnil.fr/.

## Declarations

### Ethics approval and consent to participate

The online survey protocol was evaluated and approved by the Inserm Ethics Review Committee (IRB00003888 avis n° 21–771). Participants provided informed consent to participate in the study before taking part.

### Consent for publication

Not applicable.

### Competing interests

The authors declare no competing interests.

### Author details

¹Santé Publique France, the National Public Health Agency, Saint-Maurice 94415, France. ²Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de La Santé &, Traitement de L'Information Médicale, ISSPAM, Marseille, France.

Received: 23 October 2023 Accepted: 4 December 2024

Published online: 18 December 2024

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