By Carol A. Kemper, MD, FACP

Clinical Assistant Professor of Medicine, Stanford University, Division of Infectious Diseases, Santa Clara Valley Medical Center

Online Sex and Sexually Transmitted Diseases

SOURCE: Cabecinha M, Mercer CH, Gravningen K, et al. Finding sexual partners online: Prevalence and associations with sexual behavior, STI diagnoses and other sexual health outcomes in the British population. Sex Transm Infect 2017;93:572-582.

It has been debated whether finding sexual partners via the internet is inherently riskier, or if seeking out relationships online is biased toward those more likely to have sexually transmitted disease (STD). While the use of online dating has been well described in men who have sex with men (MSM), less is known about the modern heterosexual online dating habits and consequences.

From 2010-2012, the British performed a National Survey of Sexual Attitudes and Lifestyles (Natsal-3) involving a cross section of 15,162 individuals aged 16 to 74 years. Using data from participants with at least one lifetime sexual partner, the researchers found that 17.4% of men and 10.1% of women had used the internet to find sexual partners within the previous year. Surprisingly, use of the internet to find sexual partners was more common in individuals aged 35-44 years (on average, 30.6% for men and 17.7% for women) and lowest in younger people aged 16-24 years (on average, 10.1% for men and 4.2% for women).

Following adjustments for age, non-heterosexual persons were significantly more likely to use the internet to locate sexual partners, compared with straight or married persons (odds ratio [OR], 12.75). Women “not in a steady relationship” were also more likely to use the internet for finding partners (OR, 3.14). Men who paid for sex within the previous year also were significantly more likely to find sexual partners online.

Seeking sexual partners online was associated with several higher-risk sexual behaviors, including condomless sex with two or more partners and higher partner numbers. For those who used the internet for sexual hook-ups, compared to those who did not, the odds of hooking up with five or more partners in the previous year was significantly greater (adjusted OR, 5.9 for men and 7.0 for women).

Online sex also was associated with higher rates of non-viral STDs (syphilis, gonorrhea, and chlamydia). In those aged 16-44 years who sought sexual partners online and who had available STD testing, 9.3% of men and 6.2% of women developed one or more non-viral STDs in the previous year. In contrast, for those not seeking partners online, 3.2% of men and 5.7% of women developed one or more non-viral STDs. This suggests an increased risk of STDs in those using the internet for sexual partners or hook-ups. An additional finding was the frequency of HIV testing, which appeared to be higher in men but lower in women who used the internet for locating sexual partners.

Use of the internet to find future partners isn’t limited to the comfort of your own home. Networking mobile smartphone apps, such as Grindr, Tinder, and GROWLr, with GPS capability allow for fast and ready hook-ups. Several of us, sitting in the HIV clinic at the county, tried this technology once and were stunned to locate within seconds an individual interested in sex only 75 feet away in the same building — with particular descriptions of what kind of sex he or she was interested in. I’m seldom accused of prudishness, but this took me aback. I liken this kind of sexual encounter to fast food — feels good while it’s going down but is really bad for you.

The practice of finding sexual partners online has been faulted, in part, for the resurgence of STDs, especially in the United States. Rates of STDs continue to skyrocket in Americans, hitting the greatest number of cases ever recorded in 2016.

Just one small example: Rates of syphilis in California have climbed from a nadir of 2,880 cases in 1999, during the height of the AIDS epidemic, to 17,665 cases in 2016 (along with 207 cases of congenital syphilis).

However, California and New York were only sixth and seventh on the list of states with the highest rates of STDs in 2016. Surprisingly, states with the highest rates of STDs in 2016 were, in descending order, Louisiana, North Carolina, Georgia, Mississippi, and South Carolina. Researchers say the biggest culprit is poverty.

The increase in STDs throughout the United States also may be attributed to the reduction of public health infrastructure support and shuttering of many county-based STD clinics over the past decade. The increased use of methamphetamines and what is euphemistically termed “prevention fatigue” may be additional factors. As one man phrased it, younger people who did not live through the AIDS crisis in the 1980s-1990s lack “healthy fear.”

Swingers Come Out

SOURCE: Spauwen LWL, Niekamp AM, Hoebe CJPA, Dukers-Muijrers NHTM. Do swingers self-identify as swingers when attending STI services for testing? A cross-sectional study. Sex Transm Infect 2018; Jan. 30. doi: 10.1136/sextrans-2017-053321. [Epub ahead of print].

Sexual behaviorists lament that clinicians don’t do enough to identify individuals who “swing” when providing medical care or administering sexual behavior and STD questionnaires. Swingers are an interesting group and, although they can be defined in different ways, the term generally implies someone who freely engages in sex, but the term has become more narrowly defined as those who exchange spouses for sexual activities and/or indulge in group sex at organized meetings.

It is estimated there are more than 1 million swingers in the United States, many of whom are “hidden” or unrecognized, even when they present for medical care. As a group, they may have higher than recognized rates of STDs, and since some may be bisexual, the swinging community may be an important “transmission bridge” to the entire population.

Researchers in the Netherlands have been attempting to track this group and their STD rates since 2007, when it was first recognized that combined rates of gonorrhea and chlamydia were twice as high in swingers than in female prostitutes (10.4% vs. 5%). Further, female swingers often did not self-identify as swingers, and therefore were less likely to seek STD screening. Further research in this group in 2014 found rates of gonorrhea and chlamydia in swingers in the Netherlands had increased to 13%, and recreational drug use was reported by nearly half.

The current study sought to determine whether a group of 289 swingers self-identify as swingers, and to assess their awareness of safe sex and STD testing. The median age was 45 years, and 49% of the group was female. While meeting the definition of a swinger, only 56% of participants self-identified as such. While safe sex was considered important (77%), only 62% reported routine STD testing and 56% routinely used condoms. Of the women, condomless vaginal sex was reported by 57%. Interestingly, those who self-identified as swingers “swinged more often,” had more partners, and more often swinged at home. Thirteen percent were positive for STDs.

The authors maintain that many STD clinics do not identify clients as swingers, which is a missed opportunity for identifying a high-risk group, with focused counseling and more extensive partner notification.

As an aside, the original definition of “swing” was to oscillate or move in a violent circulatory motion, but by 1545 the word more commonly meant “to move freely back and forth.” By 1899, it was used to suggest a shift in public opinion. The origins of our idea of a swinger likely originates from the 1930s-1940s big band period with its swinging rhythms, and the idea that swingers are people who “live in an unrestrained way.” What would Benny Goodman say to this?

HIV-positive Patients Require Hepatitis B Vaccine

SOURCE: Weiser J, Perez A, Bradley H, et al. Low prevalence of hepatitis B vaccination among persons receiving medical care for HIV infection in the United States, 2009-2012. Ann Intern Med 2018;168:245-254.

Hepatitis B vaccination is one of the simplest and most effective interventions we can offer patients with HIV infection. Such individuals are at much higher risk for exposure to hepatitis B virus (HBV), and at higher risk for chronic infection, cirrhosis, hepatic failure, and hepatocellular carcinoma. Studies suggest that 8-9% of patients with HIV are chronically infected with HBV, compared with 0.3% of American adults. HBV vaccination is one of those key baseline interventions listed on every guideline for HIV care.

So, how is it this survey of 18,089 HIV-positive persons in the United States found that 44.2% showed no evidence of immunity to HBV, or a history of vaccination, nor evidence of HBV infection, and were candidates for HBV vaccination? During a one-year surveillance period of observation, only 9.6% of those identified as candidates for HBV vaccination received the vaccine, and another 7.5% had no documentation of vaccination but new evidence of immunity or infection. This left more than one-third (36.7%) of HIV-positive individuals at risk for HBV infection.

Baseline characteristics of this group indicate they are in care and receiving active medical therapy: 91% had received anti-retroviral therapy in the previous year, and 75% had undetectable viral loads (< 200 copies per mL). More than half of the patients attended large HIV specialty clinics providing care for more than 400 patients. Approximately 15.8% had recognized hepatitis C virus infection, and 3.3% had chronic HBV infection.

When examining risk factors for non-vaccination, patients cared for in smaller private offices were less likely to receive vaccine than those in larger, non-private clinics (5.6% vs. 11.8% received vaccine, respectively). And those not receiving funding from Ryan White programs were less likely to receive vaccination than those facilities that did (3.7% vs. 12.5% received vaccine, respectively). Factors associated with a higher prevalence of vaccination included lower income levels, lower educational attainment, black race, younger age, recent homelessness, and a mean CD4 count < 500 cells per mL, probably all factors associated with attendance in a larger non-private clinic supported by Ryan White funding. No relationship was observed between receipt of anti-retroviral therapy and vaccination.

Ironically, HIV-positive individuals with insurance and cared for in the private sector are more likely to not receive HBV vaccination. But many HIV-positive individuals remain at risk for HBV infection, regardless of where they receive their care. The authors speculated that the inconsistent and changing recommendations on timing and administration of HBV vaccine may play a role in healthcare provider confusion or fatigue.