Objectives: We aimed to assess the awareness, willingness to use and use of doxycycline post-exposure prophylaxis (doxyPEP) among men who have sex with men (MSM) and transgender women (TGW) in Belgium. Additionally, we aimed to identify factors associated with doxyPEP use and concerns regarding antimicrobial resistance (AMR).Methods: Cross-sectional online survey among MSM and TGW in Belgium in April 2024. Participants were recruited through sexual networking applications and social media of community-based organisations. Numerical variables were compared with Wilcoxon rank-sum test and categorical variables with χ²or Fisher’s exact tests. Factors associated with doxyPEP use were assessed using logistic regression. Willingness to use doxyPEP and concerns about side effects/AMR were assessed before and after presenting a brief paragraph on the potential effects of doxyPEP on AMR.Results: 875 individuals initiated the survey. Almost all identified as men (860/875, 98.3%) with a median age of 40 years (IQR 32–48), 40.4% (n=352/875) had heard of doxyPEP and 9.4% (n=82/875) had used it, among whom the majority used it within the previous 6 months (70/81, 86.4%). In multivariable logistic regression, doxyPEP use was associated with reporting ≥1 sexually transmitted infection (STI) in the previous 12 months, engagement in chemsex, HIV status and pre-exposure prophylaxis use, and education level.About 80% of the participants initially reported being willing to use doxyPEP, and about 50% reported being concerned about side effects. After reading about the potential effects of doxyPEP on AMR, willingness to use decreased to 60% and concerns of side effects/AMR increased to around 70%.Conclusions: Approximately 1 in 10 MSM in Belgium reported using doxyPEP. A recent history of STIs and STI risk factors were positively associated with doxyPEP use. Importantly, concerns about AMR and side effect influenced willingness to use doxyPEP. If doxyPEP is introduced, informing patients about doxyPEP benefits and risks is crucial to enable informed decision-making.

It remains unclear why patients discontinue HIV pre-exposure prophylaxis (PrEP) care and to what extent they remain at risk for HIV when they do. We reviewed routinely collected medical records and patient questionnaires and performed an e-mail/telephone survey to assess reasons for discontinuing PrEP care, ongoing risks for HIV infection, and associated factors. Patients with more than two registered PrEP visits from a PrEP clinic in Antwerp, Belgium between June 2017 and February 2020 were included in this study. Patients who did not return for a visit after October 30, 2019 and who were not transferred out were considered as having discontinued PrEP care. A total of 143/1073 patients were considered as having discontinued PrEP care. Patients who discontinued PrEP care were more likely to be younger than those who remained in care (35 vs. 38 years old, p < 0.01). The most common reasons for discontinuation were having stopped using PrEP (62/101, 61.4%) and “COVID-19” ( n = 35, 34.7%). The most common reasons for stopping PrEP use was a decreased sexual activity due to coronavirus disease 2019 (COVID-19; 21/62, 33.9%) or not COVID-19 related (10/62, 16.1%), a monogamous relationship (20/62, 32.3%) and consistent condom use (7/62, 11.3%). Among respondents who reported about current HIV risk the majority reported being at low risk either by still taking PrEP (32/91, 35.2%), consistently using condoms, or limiting number of sex acts or partners (58/91, 52.7%). No HIV seroconversion was reported.

There is growing evidence that the benefits of systematic screening for Neisseria gonorrhoeae and Chlamydia trachomatis among men who have sex with men (MSM) using HIV pre-exposure prophylaxis (PrEP) are scarce and that screening leads to high antimicrobial consumption. The PrEP clinic of the Institute of Tropical Medicine (ITM) in Antwerp, Belgium, discontinued systematic screening for these infections in MSM taking PrEP in 2023. In this study, we estimated the effect of reducing the frequency of screening on the incidence of these infections and antimicrobial use among MSM using PrEP. We did a retrospective cohort analysis of medical records, laboratory results, and antimicrobial prescriptions (ceftriaxone, doxycycline, and azithromycin) of MSM attending the PrEP clinic of the ITM in Antwerp, Belgium, between Jan 1, 2019, and Dec 31, 2024. We estimated yearly testing rates for N gonorrhoeae and C trachomatis, incidence rates of overall and symptomatic infections, and antimicrobial prescription rates. Results were analysed using Poisson regression, with the number of events as the outcome, years as a continuous predictor and the log(person-time) as offset. Additionally, we did three sensitivity analyses: limiting our study population to individuals engaged in PrEP care in 2019; excluding participants of the Gonoscreen study; and using time as a categorical variable. Between Jan 1, 2019, and Dec 31, 2024, 3955 MSM attended the clinic. Over the study period, 11 720 tests were done during 9853·85 person-years. The testing rate decreased significantly from 2267·78 tests per 1000 person-years (95% CI 2176·49-2361·92) in 2019 to 552·81 tests per 1000 person-years (521·53-585·47) in 2024 (yearly rate ratio 0·78, 95% CI 0·77-0·78; p<0·0001). The incidence of N gonorrhoeae decreased from 170·84 cases per 1000 person-years (95% CI 146·47-198·11) in 2019 to 85·81 cases per 1000 person-years (73·77-99·27) in 2024 (yearly incidence rate ratio [IRR] 0·91, 95% CI 0·88-0·94; p<0·0001). In the same period, the incidence of C trachomatis decreased from 198·17 cases per 1000 person-years (95% CI 171·85-227·39) in 2019 to 60·69 cases per 1000 person-years (50·63-72·16) in 2024 (yearly IRR 0·84, 95% CI 0·81-0·87; p<0·0001). There was no increase in the incidence of symptomatic N gonorrhoeae (IRR 0·98, 95% CI 0·92-1·03), C trachomatis (0·95, 0·88-1·01), or lymphogranuloma venereum (0·95, 0·84-1·09). Ceftriaxone, doxycycline, and azithromycin prescriptions decreased (rate ratio 0·95, 95% CI 0·91-0·99; p=0·023, 0·47, 0·43-0·52; p<0·0001, and 0·90, 0·87-0·94; p<0·0001, respectively). Similar results were found in the first sensitivity analysis. In the sensitivity analysis excluding participants of the Gonoscreen study, rates of ceftriaxone and doxycycline prescriptions decreased between 2019 and 2024 but became non-significant. In the third sensitivity analysis, using time as a categorical variable, the prescription rates of ceftriaxone were lower in 2024 compared with 2019 and the incidence rates of symptomatic C trachomatis were significantly lower in 2024 compared with 2019. The incidence of symptomatic N gonorrhoeae and C trachomatis infections did not increase over time despite less frequent screening and antimicrobial prescriptions decreased. Our findings contribute to the evidence supporting the potential of reducing the frequency of screening as an antimicrobial stewardship intervention among MSM using PrEP. Future studies are needed to confirm our findings. None.

Objective The available epidemiological and clinical evidence from the currently ongoing monkeypox (MPX) outbreak in non-endemic areas suggests an important factor of sexual transmission. However, limited information on the behaviour and experiences of individuals with an MPX infection has to date been provided. We aimed to describe the initial phase of the MPX outbreak in Belgium, and to provide a more in-depth description of sexual behaviour and transmission contexts. Methods We used routine national surveillance data of 139 confirmed MPX cases with date of symptom onset until 19 June 2022, complemented with 12 semistructured interviews conducted with a subsample of these cases. Results Sexualised environments, including large festivals and cruising venues for gay men, were the suspected exposure setting for the majority of the cases in the early outbreak phase. In-depth narratives of sexual behaviour support the hypothesis of MPX transmission through close physical contact during sex. Despite awareness of the ongoing MPX outbreak, low self-perceived risk of MPX acquisition and confusing initial signs and symptoms for other STIs or skin conditions delayed early detection of an MPX infection. In addition, we describe relevant contextual factors beyond individual behaviour, related to sexual networks, interpersonal interactions and health systems. Some of these factors may complicate early MPX detection and control efforts. Conclusion Our results highlight the role of sexual contact and networks in the transmission of MPX during the early phase of the outbreak in Belgium. Risk communication messages should consistently and transparently state the predominant sexual transmission potential of MPX virus, and prevention and control measures must be adapted to reflect multilevel factors contributing to MPX transmission risk.