Marcus et al. BMC Public Health (2023) 23:8 https://doi.org/10.1186/s12889-022-14891-2 RESEARCH Open Access Association of internalised homonegativity with partner notification after diagnosis of syphilis or gonorrhoea among men having sex with men in 49 countries across four continents Ulrich Marcus1*, Kai Jonas2, Rigmor Berg3,4, Maria Amelia Veras5, Carlos F. Caceres6, Jordi Casabona7,8,9,10, Susanne B. Schink1 and Axel J. Schmidt11 Abstract Background: Partner notification (PN) after a sexually transmitted infection (STI) diagnosis is being promoted as a means to interrupt transmission chains. We investigated whether Internalised Homonegativity (IH) is associated with PN among men having sex with men (MSM). Methods: PN, defined as notifying at least one partner after diagnosis of syphilis and gonorrhoea, was queried in two internet-based self-completion surveys conducted between Oct 2017 and May 2018 in 68 countries in Europe, Latin America, Canada, and the Philippines. IH is defined by a man’s level of agreement or disagreement with nega- tive social beliefs about male homosexuality. Covariates included in a multivariate regression model with a random intercept at country level were age, HIV diagnosis, partnership status, sexual self-efficacy, HIV serostatus communi- cation during last sex with a non-steady partner, place where this partner was met, and PN-related socio-historical background of the country of residence. We grouped countries in three areas: North- and Central-Western European countries plus Canada, former socialist countries, and Latin-American/Mediterranean countries plus the Philippines. In each of the three areas individuals were assigned to 4 subgroups based on IH quartiles and PN rates were determined for each subgroup. Results: PN rates were calculated for 49 countries (excluding countries with less than 10 diagnoses). Mean propor- tions of MSM notifying their partners were 68.1% and 72.9% after syphilis and gonorrhoea diagnoses, respectively. PN rates were lower in Latin American countries and the Philippines compared to European countries. Within Europe, a North–South divide with lower PN rates in Mediterranean countries was observed. In each of the three regions we mostly observed a stepwise increase of PN rates with decreasing IH. Regression analysis showed lower IH scores associated with higher PN rates. Higher perceived self-efficacy, living in a partnership, and HIV status communication were positively associated with PN. Men who had met their last partner in *Correspondence: MarcusU@rki.de 1 Department of Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany Full list of author information is available at the end of the article © The Author(s) 2023. 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The Creative Commons Public Domain Dedication waiver (http://​creat​iveco​ mmons.​org/​publi​cdoma​in/​zero/1.​0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Marcus et al. BMC Public Health (2023) 23:8 Page 2 of 12 a gay social venue were more likely to have notified their partners of a syphilis diagnosis compared to men who had met this partner online. Men with diagnosed HIV were less likely to report PN. Conclusions: We could demonstrate that IH was associated with PN among MSM across all countries included in our analysis. Reducing cultural homophobia and ensuring inclusive policies may contribute to STI prevention and control. Keywords: Contact tracing, Syphilis, Gonorrhoea, Sexual and gender minorities, Internalised homonegativity, Regression analysis, Europe, Latin America, Canada, Philippines Background outcomes. In terms of individual behaviour, issues of Partner notification (PN) after the diagnosis of an acute self-efficacy and empowerment have been shown to sexually transmitted infection (STI) has long been advo- influence notification behaviours [9–12]. Schwartz et al. cated for as a means to interrupt transmission chains. PN found that a positive intention to notify partners was alerts sex partners of their exposure and allows them to a significant predictor of notification. They confirmed get treated and/or tested for STIs without delay, and fur- associations between self-efficacy, attitudes, and behav- thermore prevents reinfection from the same partners. ioural intentions; higher levels of self-efficacy and more Partners can be informed by the patient (patient referral) positive attitudes about notification were associated or by a health professional (provider referral). In practice, with greater intention to notify partners [13]. Being patient referral is the most commonly used method [1, 2]. out about ones’ sexual orientation and low internal- Implementation of PN varies considerably across coun- ised homonegativity (IH) have been shown to be ben- tries. In most countries, it is recommended while some eficial for successful and open communication between countries mandate PN by law (usually without any means homosexual partners [14–16]. IH refers to negative of enforcement) and some provide dedicated notification attitudes that MSM may have towards homosexual- services [1, 2]. ity in general, and towards their own sexual orienta- Individuals diagnosed with an STI can be in different tion [17] and the degree to which those beliefs affect partnerships simultaneously, with different patterns of the development of an affirmative sexual identity [18]. communication, perceived exposure risk, and anticipated Homophobic policies and a homophobic socio-cultural consequences of notification or concealment. For all indi- environment are strongly related to structural stigma viduals, PN involves disclosure of private and oftentimes and increased IH [19, 20]. Low IH has been shown to secret information that could impact a partnership [3]. be likely related to increased self-esteem and a sense Sexual orientation stigmatization poses another hurdle of connectedness within sexual minority communities; for men who have sex with men (MSM) and other sexual both are factors that have previously been shown to minorities. In addition to informing partners of an STI be associated with improved health outcomes [21, 22]. diagnosis, which can be difficult in itself, PN may reveal Several studies suggested that IH interferes with sex- other potentially stigmatizing information related to ual minority identity formation, impacts on openness sexual orientation and sexual practices, and frequently about sexual orientation, disclosure, and gay commu- changing partners. nity connection and gay social support overall [23, 24]. Previous work showed that notification and commu- However, few studies to date have explored the effect of nication about potential STI exposures are determined psychosocial constructs such as IH on PN activities of by the type of partnership, the length of the relationship, MSM, and none have focused on the association of IH standards of communication between partners, and/ with PN among MSM [25]. or availability of contact information [4–8]. In steady Historically, PN or ‘contact tracing’ was rigorous in partnerships, open communication is often assumed. the Soviet Union and most former socialist countries in In contrast, an absence of emotional commitment with central and eastern Europe [26, 27]. The Scandinavian non-steady or anonymous partners is often coupled with countries, the United Kingdom (UK), and Canada are a lack of communication and a reduced sense of respon- known to encourage PN and have established PN sup- sibility for these partners’ well-being. For anonymous port systems. A survey conducted in 1998 – 99 reported encounters, the lack of contact information precludes that PN at that time was not part of STI case manage- notification. However, partners first met online can ment in France, Spain, and Italy [28], indicating large often also be notified online while keeping their identity cultural differences regarding the practice of STI PN anonymous. in Europe. Garcia et al. reported in an overview on STI Previous studies have addressed individual-, partner-, management and control in Latin America that PN rates and network-level pathways that define notification in Latin America are usually low [29]. Given historically Marcus et al. BMC Public Health (2023) 23:8 Page 3 of 12 determined differences across countries, it is important RR/8805), and by the committees of the Universidad to update geo-cultural determinants as well. Peruana Cayetano Heredia (612–19-17), the Salvador We set out to analyse the role of IH for self-reported PN Allende School of Public Health, Faculty of Medicine, after a diagnosis of syphilis or gonorrhoea in two large University of Chile (009–2017), Santa Casa de Misericór- datasets of MSM living in Europe, Latin America, Can- dia de São Paulo, Brazil (2,457,744), the National Com- ada, and the Philippines. We would expect that IH might mittee for Health Ethics, Guatemala (39–2017), and the influence the extent of PN among MSM via its impact on Faculty of Psychology and Neuroscience of the Univer- perceived self-efficacy, ability to communicate with sex- sity of Maastricht, the Netherlands (18–01-12–2017) for ual partners, and a higher sense of connectedness. LAMIS. Methods Dependent variables Recruitment and surveys We had two primary outcomes: partner notification for The detailed methods of the European MSM Internet (1) syphilis and (2) gonorrhoea. All respondents were Survey 2017 (EMIS) and the corresponding Latin Ameri- asked “Have you ever been diagnosed with syphilis?” Men can survey 2018 (LAMIS) have been reported elsewhere who answered yes, were asked “When were you last diag- [30, 31]. In summary, both were multi-language, internet- nosed with syphilis?” and offered answers to indicate how based, self-completion surveys for MSM living in Europe recently this had been. Matching questions were asked and in Latin America. Recruitment was from 13 Oct for gonorrhoea. Those who reported a diagnosis of syphi- 2017 to 31 Jan 2018 (EMIS) and from 24 Jan to 13 May lis or gonorrhoea were asked: “The last time you were 2018 (LAMIS). The EMIS data collection additionally diagnosed with [syphilis/gonorrhoea], did you (or your included a few non-European countries, namely Israel, healthcare provider) inform your recent sexual partners Lebanon, Canada, and the Philippines. EMIS and LAMIS that they also needed a test/treatment?” Response options were nearly identical in use of instruments and questions were “No, none of them”, “Yes, some of them”, “Yes, all of to collect data about morbidities, behaviours, needs and them”, and “I don’t remember”. The two “Yes” options and interventions. Regarding morbidities, respondents were the first and last responses were combined into a binary asked about diagnoses of HIV, syphilis, gonorrhoea, and outcome variable to measure the association between IH chlamydia. In terms of behaviours, the respondents were and notification of at least one partner. asked about communication about HIV status and use of antiretroviral drugs with their last non-steady partner(s), Independent variables where they had met this/these partner(s), and how many Internalised Homonegativity of the people they knew were aware of their sexual attrac- IH was measured by a continuous scale composed of tion to men because they are open about sexual identity seven statements. Each of them could be rated on a (outness). There were two questions about sexual self- seven-point agreement scale (0–6) and an additional efficacy. We measured IH with the Short Internalised “does not apply to me” response option [32] (see also Homonegativity Scale (SIHS), based on seven state- Supplemental Table S1). ments [32]. While the scale was presented to half of the EMIS respondents (at random, to keep the questionnaire Sexual self‑efficacy short), all LAMIS respondents were presented the scale. Self-efficacy was measured by a 5-point disagree-agree EMIS was available in 33 languages across 50 countries, response to the statement “The sex I have is always as safe LAMIS in three languages across 18 countries. Partici- as I want it to be”. Responses were dichotomized into a pants were recruited through trans-national dating apps binary variable for this analysis, combining neutral and (PlanetRomeo, Grindr and Hornet accounted for 69% two “agree”-options vs. the two “disagree” options. of participants to both surveys collectively, other dating platforms and apps for another 9%), through Facebook, Behaviours Twitter, Instagram (8%), and through a variety of local Hypothesizing that previous communication with non- online promotion, mostly through website banners (8%). steady sex partners about sensitive issues would affect No financial incentives were given to participants. No PN after an STI diagnosis, we constructed a binary vari- personal identifying information (including IP addresses) able: any HIV status communication vs. none, based on was collected. Further background information, includ- HIV serostatus communications during the last sexual ing all 33 language versions of the questionnaires, is avail- encounter with one or more non-steady partners in the able at www.​emis2​017.​eu. Ethics approval was granted by previous twelve months. Respondents not reporting non- the Ethics Committee of the London School of Hygiene steady partner(s) in the previous twelve months were and Tropical Medicine for EMIS-2017 (reference 14421/ classified as “no serostatus communication”. Depending Marcus et al. BMC Public Health (2023) 23:8 Page 4 of 12 on the place where the last non-steady sex partners Statistical analysis were met, we constructed a variable with the categories For continuous variables mean, Standard Deviation “online”, “gay sex venue”, “social venue”, and “no non- (SD), median and interquartile range (IQR) were used. steady partner sex or not answered”. For nominal variables count and percentages were used. Based on literature, a list of variables, potentially associated with the dependent variables, was developed Survey artefacts for both outcome variables. Besides IH, which was the The wording for the French translation for STI diagno- primary focus of our analysis, the covariates included ses, while technically correct, may have been misunder- a question on sexual self-efficacy, HIV diagnosis, cur- stood by some European French-speaking respondents: rent partnership status, HIV serostatus communication the questions on diagnosed syphilis and gonorrhoea with the last non-steady partner, and meeting place of may have been understood by some men as having been the last non-steady partner. The last two variables not tested rather than having received a positive test result. necessarily refer to the partner(s) who have been noti- This problem affected all three countries with large fied of the reported STI diagnosis. However, supported sub-samples using the French questionnaire, notably by published findings, we assume that individual behav- France (93%), Belgium (36%), and Switzerland (19%). All iours with the last non-steady partner represent a more respondents who answered affirmatively to the question general behaviour pattern at a population level [33, 34]. were asked about PN. Since respondents who had only The variables were first tested in a bivariate analysis and been tested and not been diagnosed with syphilis or gon- then included in a two-level logistic regression model orrhoea would feel no need to inform their partners, a with a random intercept at country level. The random larger proportion would be expected to report no PN. To component accounts for the hierarchical nature of the control for a potential underestimation of PN in surveys data. All available cases were included in the analysis. completed in French, a binary language variable (French We developed a model for both dependent variables. – not French) was constructed. We further controlled for We then sequentially entered statistically significant major discrepancies (discrepant answers for age, steady (based on bivariate analysis) variables for each model. partners, or non-steady partners), using a binary vari- Age was included as confounder to be controlled for able. Such discrepancies occur when respondents either as potentially associated with the outcome variables. give random answers or always select the first response The final models were then estimated with the pool of option. significantly associated variables. We used the likeli- Countries with less than 10 respondents diagnosed hood ratio (LR) test to compare the new model with with syphilis or gonorrhoea were excluded from our the nested model to establish the model improve- analysis. ment. For all statistical tests, significance was indicated by p < 0.05. The final model estimated the adjusted Sample composition odds ratios (aORs) and the corresponding 95% confi- In the multivariable regression models age was included dence interval (95% CI) for factors associated with the as age groups < 25, 25–39, 40 + . HIV diagnosis was Analyses were carried out using Stata® Version 17.1 dependent variable. included as a binary variable. Partnership status was cat- egorized as “single”, “having a steady partner”, and “not (College Station, TX: StataCorp LP), graphs were com- sure / it’s complicated”. piled in R and R Studio 4.1.2 (The R Foundation for Sta- tistical Computing). Maps were generated in EMMa: ECDC Map Maker, European Centre for Disease Preven- Grouping of individuals by cultural/socio‑historical tion and Control, 2022. Administrative boundaries: © background of the country of residence and IH quartile EuroGeographics © UN-FAO © Turkstat. The bounda- To determine whether the impact of IH on PN was ries and names shown on this map do not imply official independent of the broader cultural/socio-historical endorsement or acceptance by the European Union. Map background we grouped individuals by three areas with produced on 18 Jul 2022. similar socio-historical backgrounds regarding STI PN, i.e. North- and Central-Western European countries plus Canada, former socialist countries, Latin American/ Mediterranean countries plus the Philippines, which we Results found to empirically cluster in terms of PN rates, with Partner notification rates for syphilis and gonorrhoea each 4 subgroups (based on IH quartiles). Individu- could be calculated for 49 countries (excluding 19 coun- als’ characteristics on these two variables resulted in 12 tries with less than 10 respondents diagnosed with syphi- groups. lis or gonorrhoea; see Supplemental Table S2). Marcus et al. BMC Public Health (2023) 23:8 Page 5 of 12 For these 49 countries, the country median of MSM Romanic languages are spoken (Italy, France, Spain, Por- who notified their partner(s) about STI diagnosis was 69% tugal), Eastern Mediterranean countries (Greece, Turkey, for syphilis (range 28.6%–91.0%), and 71.4% for gonor- Israel), and the Philippines; area 2 included the former rhoea (range 25.0%–100%). The overall mean proportion socialist countries in Central-East, East, and South-East of MSM notifying their partners after a syphilis diagnosis Europe; and area 3 included Canada and the remain- across the 49 countries was 68.1%, for gonorrhoea notifi- ing countries in North and Central-West Europe. When cation the mean was 72.9%. Due to the potentially down- we grouped individuals by the socio-historical back- ward biased PN rates of the three countries with larger ground of the country they lived in and IH quartiles proportions of French questionnaires, PN rates for these into 12 groups (quartile 1 score 0–0.571, quartile 2 score countries were calculated only based on reported partner 0.572–1.286, quartile 3 score 1.287–2.286, and quartile 4 notifications in non-French questionnaires. score 2.287–5.143), we saw distinct differences primarily The correlation between syphilis and gonorrhoea PN between area 1 and area 2 and 3. In each country area we rates was high, but larger discrepancies with lower syphi- observed a stepwise increase of PN rates with decreas- lis PN rates were observed in seven countries (Croatia, ing IH—except for two strata, one in the former social- Ukraine, Cyprus, Honduras, Uruguay, Philippines, and ist country area, and one in the North and Central-West Bolivia, see Fig. 1). In five of these countries this may European area, which included relatively small numbers be explained by measurement errors due to low overall of individuals (see Table 1). numbers of diagnoses. There was a discernible general trend towards lower Multilevel multivariate analysis of factors associated PN rates in Latin American countries and the Philippines with syphilis PN compared to European countries. Within Europe, we Lower IH scores were associated with higher PN rates, observed a North–South divide with lower PN rates in as was higher perceived self-efficacy. Living in a steady Mediterranean countries such as Turkey, Israel, Greece, partnership was positively associated with PN, as was Italy, France, Spain, and Portugal. HIV status communication with the last non-steady The grouping of countries based on cultural patterns partner(s). Men with diagnosed HIV were less likely of PN and socio-cultural, historical and cultural simi- to notify their partners about a syphilis diagnosis. Men larities is shown in Fig. 2: area 1 included countries in who had met their last non-steady partner in a gay social Latin America, Western Mediterranean countries where venue were more likely to have notified their partners Fig.1 Correlation between syphilis and gonorrhoea partner notification – Scatterplot of 49 countries Marcus et al. BMC Public Health (2023) 23:8 Page 6 of 12 Fig.2 Regional patterns of syphilis and gonorrhoea partner notification by men having sex with men participating in EMIS and LAMIS after having been diagnosed with syphilis compared to men who had met their last non-steady partner(s) online. Table 1 Syphilis and gonorrhoea partner notification (PN) by socio-cultural background and internalised homonegativity score quartiles in 49 countries Syphilis-PN Gonorrhoea-PN IH quartiles No partner Partner Total % with PN No partner Partner Total % with PN notification notification notification notification Latin/Mediterranean countries 0.0–0.57 566 1,023 1,589 64.4% 363 646 1.009 64.0% 0.57–1.28 422 734 1,156 63.5% 249 397 646 61.5% 1.28–2.28 569 717 1,286 55.8% 319 455 774 58.8% 2.28–5.14 672 691 1,363 50.7% 463 473 936 50.5% Total 2,229 3,165 5,394 58.7% 1,394 1,971 3,365 58.6% Former socialist countries 0.0–0.57 12 39 51 76.5% 3 36 39 92.3% 0.57–1.28 16 42 58 72.4% 7 27 34 79.4% 1.28–2.28 23 81 104 77.9% 19 58 77 75.3% 2.28–5.14 30 58 88 65.9% 22 50 72 69.4% Total 81 220 301 73.1% 51 171 222 77.0% Canada, North- and Central-West European countries 0.0-–0.57 67 392 459 85.4% 117 713 830 85.9% 0.57–1.28 44 148 192 77.1% 69 337 406 83.0% 1.28–2.28 48 154 202 76.2% 79 303 382 79.3% 2.28–5.14 33 124 157 79.0% 57 200 257 77.8% Total 192 818 1,010 81.0% 322 1,553 1,875 82.8% IH short internalised homonegativity score (range 0–6) Marcus et al. BMC Public Health (2023) 23:8 Page 7 of 12 Downgrading of PN rates by the French translation PN rates for MSM conducted in the Netherlands in issue was confirmed for syphilis. Age was not significant. 2010–2011 [35], the self-reported PN rates from EMIS- The cultural background of the country had a major 2017 participants living in the Netherlands were very impact on the reported likelihood to notify partners (see similar to the PN rates in the Dutch study. This may sug- Table 2). gest that self-reported PN-rates may refer primarily to notifiable partners and might neglect anonymous, non- Multilevel multivariate analysis of factors associated notifiable partners. with gonorrhoea PN Other factors associated with PN that had been iden- As for syphilis, lower values on the IH scale were also tified by previous research such as partnership status, associated with higher PN rates after gonorrhoea diag- place where sexual partners met, and perceived sexual nosis, as was higher perceived self-efficacy. Living in a self-efficacy were confirmed by our analysis. We identi- steady partnership was positively associated with PN, fied a history of HIV status communication with the last albeit for gonorrhoea to a slightly smaller extent than non-steady partner as an additional factor, probably as a for syphilis. Communication with the last non-steady surrogate for the ability to converse meaningfully about partner(s) about HIV status was again positively associ- delicate topics with casual sex partners. Also, HIV diag- ated with higher odds for PN. Contrasting with syphilis nosis was negatively associated with PN. This negative PN, the effect of HIV diagnosis on gonorrhoea PN was association probably reflects an effect of HIV-associated not significant. Men who had met their last non-steady stigma; persons diagnosed with HIV fear that PN for partner in a gay sex venue were less likely to have noti- syphilis – more than for gonorrhoea – might take away fied their partners after having been diagnosed with their control over HIV status disclosure and fear of sub- gonorrhoea compared to men who had met their last sequent rejection based on HIV status [36, 37]. This fear non-steady partner(s) online. may be based on the stronger association between syphi- Compared to syphilis, PN rates for gonorrhoea were lis and HIV diagnosis among MSM and the fact that not significantly affected by the French translation issue. both syphilis and HIV are usually diagnosed on a blood Age 40 and older was associated with significant lower sample. odds for partner notification. Another factor with a strong impact on PN that we The cultural background of the country where partici- identified by our analysis was the sociocultural back- pants were living had an even larger impact on the will- ground of the country where people lived regarding the ingness to notify partners as for syphilis (see Table 2). concept of STI PN. It remains unclear what the basis for these sociocultural differences is. Empirically we identi- Discussion fied three clusters of countries: cluster 1 was composed We set out to examine PN rates after diagnosis of syphi- of Romanic speaking and other Eastern Mediterranean lis or gonorrhoea among MSM from 68 countries on countries, Latin American countries, and the Philippines; four continents, and the impact of IH on PN. As we had cluster 2 was composed of the former socialist countries hypothesized, IH was strongly associated with PN in all in eastern and central Europe; and cluster 3 was com- regions included in our analysis, for both syphilis and posed of North- and Central-West European countries gonorrhoea. After grouping the 49 countries with large and Canada. For cluster 1 with the lowest PN rates, we enough samples by historical and socio-cultural back- know from previous research that PN was not a rou- ground in three areas, we were able to demonstrate a tine part of STI case management until at least the late strong “dose–response” relationship between IH and PN 1990s in the European Romanic speaking countries [28], in all three areas. and that there is low emphasis on PN in Latin America We had to exclude 19 countries from the analy- [29]. For cluster 2 we know that PN for STI was man- sis because the samples were too small. In most of the aged rigorously by a dedicated STI care system before the remaining 49 countries, a majority of respondents political transformation of these countries in the 1990s reported some kind of partner notification. The propor- [26, 27]. STI care and control have changed considerably tions of respondents reporting any kind of PN, i.e. who since then with greater emphasis on confidentiality, but informed at least one partner, demonstrated large inter- still a dedicated STI care system is in place. An empha- country variability. More than half of those reporting sis on PN may have partly survived at least in the pub- any PN reported that they had informed all of their sex lic health sector, particularly since the region was struck partners. However, the question on PN was not detailed by a major (heterosexual) syphilis epidemic in the 1990s enough to allow an exact calculation of the proportion of as a consequence of the socioeconomic changes and a eligible partners who had been informed. If we compare partial breakdown of public health systems during the reported PN rates from our study with a study reporting transformation period [38–40]. Stronger social norms Table 2 Uni- and multivariable multilevel regression analysis of variables associated with syphilis and gonorrhoea partner notification (PN) among MSM in 49 countries Syphilis PN (N = 6,705) Syphilis PN (N = 6,492) Gonorrhoea PN (N = 5,462) Gonorrhoea PN (N = 5,340) OR 95% CI p aOR 95% CI p OR 95% CI p aOR 95% CI p French language questionnaire No ref ref ref ref Yes 0.53 0.34 – 0.83 0.006 0.55 0.36 – 0.82 0.004 0.72 0.47 – 1.11 0.133 0.80 0.53 – 1.21 0.294 Marcus et al. BMC Public Health Age < 25 ref ref ref 25–39 1.03 0.90 – 1.18 0.651 1.09 0.95 – 1.26 0.224 1.07 0.93 – 1.25 0.345 1.04 0.89 – 1.22 0.599 40 + 0.97 0.82 – 1.15 0.716 1.01 0.84 – 1.21 0.943 0.85 0.70 – 1.03 0.105 0.81 0.66 – 1.00 0.047 Partnership status (2023) 23:8 No steady partner ref ref ref ref A steady partner 2.15 1.90 – 2.43 0.000 2.08 1.83 – 2.36 0.000 1.68 1.46 – 1.93 0.000 1.67 1.44 – 1.93 0.000 It’s complicated 1.58 1.30 – 1.92 0.000 1.56 1.28 – 1.91 0.000 1.39 1.11 – 1.74 0.005 1.40 1.11 – 1.76 0.005 HIV diagnosis No HIV diagnosis ref ref ref ref HIV diagnosed 0.74 0.67 – 0.82 0.000 0.77 0.69 – 0.86 0.000 0.85 0.73 – 0.98 0.027 0.87 0.74 – 1.01 0.074 Place where last non-steady partner was met Online ref ref ref ref Sex venue 0.84 0.71 – 0.99 0.038 0.85 0.72 – 1.02 0.076 0.62 0.50 – 0.76 0.000 0.66 0.53 – 0.82 0.000 Social venue 1.22 1.03 – 1.44 0.018 1.22 1.03 – 1.45 0.021 1.12 0.92 – 1.36 0.257 1.13 0.93 – 1.39 0.218 No sex with non-steady partners or not answered 1.17 0.99 – 1.38 0.074 1.27 1.06 – 1.51 0.008 1.07 0.86 – 1.33 0.532 1.23 0.98 – 1.53 0.074 HIV status communication at last non-steady partner sex No ref Ref Ref Ref Yes 1.94 1.71 – 2.21 0.000 1.87 1.63 – 2.14 0.000 1.69 1.48 – 1.94 0.000 1.67 1.45 – 1.92 0.000 I find it easy to say ‘no’ to sex I don’t want Agree or neutral 1.35 1.20 – 1.52 0.000 1.27 1.13 – 1.44 0.000 1.26 1.09 – 1.45 0.002 1.17 1.01 – 1.36 0.038 Disagree ref Ref Ref Ref IH Per score-point increase 0.84 0.81 – 0.88 0.000 0.85 0.82 – 0.89 0.000 0.85 0.81 – 0.89 0.000 0.86 0.82 – 0.90 0.000 Cultural background (country-level) Latin/Mediterranean ref ref ref ref Former socialist 2.18 1.48 – 3.23 0.000 1.86 1.23 – 2.81 0.008 2.52 1.59 – 3.99 0.000 2.37 1.49 – 3.76 0.000 Canada, North- and Central-West Europe 3.26 2.38 – 4.47 0.000 2.78 1.98 – 3.90 0.000 3.80 2.73 – 5.30 0.000 3.04 2.06 – 4.48 0.000 Constant 2.06 1.67 – 2.53 0.000 1.06 0.83 – 1.37 0.621 2.43 1.92 – 3.06 0.000 1.25 0.95 – 1.67 0.116 Random component country 0.40 0.23 – 0.69 0.11 0.05 – 0.25 0.55 0.33 – 0.92 0.16 0.08 – 0.32 CI confidence interval, OR odds ratio, aOR adjusted odds ratio, Bold OR/aOR, statistically significant, ref. reference, IH short internalised homonegativity score (range 0–6) Page 8 of 12 Marcus et al. BMC Public Health (2023) 23:8 Page 9 of 12 regarding syphilis PN in this region may also contribute setting where the STI was diagnosed, which of the part- to an equalization of the effect of IH on syphilis PN in ners had subsequently been informed and if not, why the lower three quartiles as shown in Table 1. Cluster 3 not. The number of respondents that we could include comprises countries which placed traditionally a strong in the multivariate analysis was halved in the EMIS data- emphasis on PN and partly offer clinical PN support ser- set because EMIS participants were randomly assigned vices like the Scandinavian countries, UK and Canada, to answer the seven-question IH scale. Finally, PN out- but also include German-speaking and Benelux countries comes and IH were collected in a cross-sectional study. where this was hardly the case. This diversity of PN poli- We could neither assess causality, nor could we investi- cies in cluster 3 may also partly explain the weaker dose– gate the role of intermediary, more sociological concepts response effect of IH on syphilis PN. that would explain the causal pathway of IH further. One possibility could be that the differences between the clusters reflects different levels of PN-supportive Conclusions counselling by sexual health care providers and gay com- In addition of confirming previously identified individual munity organizations in the three regions. It remains an predictors of PN, we were able to demonstrate that IH area for further research to identify sociocultural factors is associated with PN among MSM across all countries and concepts that explain the differences in MSM PN included in our analysis. This finding contributes to the rates across these three regions. growing evidence of adverse health effects of homopho- In terms of implications for the provision of sexual bic policies and cultures. Reducing homophobia and health care and counselling related to PN, our results sug- ensuring inclusive policies in a welcoming environment gest a sexual orientation affirmative approach, emphasiz- may contribute to STI prevention and control. ing gay community cohesion and mutual responsibility. Achieving a sense of community can reduce IH and foster PN at the same time. Stigma based on sexual orientation Abbreviations aOR: Adjusted odds ratio; CI: Confidence interval; EMIS: European MSM Inter- in healthcare is counterproductive and particularly has net Survey; HIV: Human immunodeficiency virus; IH: Internalised homonega- no place in sexual health care. This suggestion is matched tivity; IP address: Internet protocol address; IQR: Interquartile range; LAMIS: by the conclusion of a systematic review on PN for STI in Latin American MSM Internet Survey 2018; LR: Likelihood ratio; MSM: Men who have sex with men; PN: Partner notification; SD: Standard Deviation; SIHS: developing countries, which recommends counselling of Short Internalised Homonegativity Scale; STI: Sexually transmitted infection; index STI patients to raise awareness of PN and eliminate UK: United Kingdom. stigma and fear related to STIs [9]. Supplementary Information The online version contains supplementary material available at https://​doi.​ Strengths and limitations org/​10.​1186/​s12889-​022-​14891-2. A strength of our analysis is that we used the same method to collect data from 49 countries. Sexual orien- Additional file 1: Supplemental Table S1. Short Internalised Homon- tation and PN are self-reported, avoiding biases due to egativity Scale (SIHS). differing capabilities of healthcare providers for eliciting Additional file 2: Supplemental Table S2. Self-reported rates of syphilis this information in discussion with their clients. At the and gonorrhoea partner notification (PN) in EMIS and LAMIS countries, sorted by syphilis PN in three country groups. same time, relying on self-reported PN is also a limita- tion, because it can be biased by social desirability, recall, Acknowledgements erroneous assessment which partners had been exposed EMIS: We thank all study participants and collaborators for being part of to a transmission risk, and differences regarding STI something huge. EMIS-2017 is coordinated by Sigma Research at the London diagnoses based on differences within and between School of Hygiene and Tropical Medicine (LSHTM) in association with the Robert Koch Institute (RKI) in Berlin. The following list acknowledges all countries in terms of STI screening practices. The sur- partners in EMIS by country. Individual names are mentioned if a freelancer veys were convenience samples recruited on the internet was the main contact and/or translator or where input on the questionnaire and on apps. The samples may not be representative of development came from a person not formally representing an organisation. The order (if available) is main NGO partner, other NGO partners, academic all MSM in a country and/or region. PN rates are less partners, governmental partners, individuals. Europe: PlanetRomeo, European reliable for smaller countries with limited numbers of AIDS Treatment Group (EATG), Eurasian Coalition on Male Health (ECOM), respondents that could be asked about PN. Although we European Centre for Disease Prevention and Control (ECDC), European Monitoring Centre for Drugs & Drug Addiction (EMCDDA), European Com- excluded countries with very small numbers of respond- mission (DG SANTE). AL: Arian Boci. AT: Aids Hilfe Wien, Dr Frank M. Amort. BA: ents, there was huge variation in the number of respond- lgbti.ba, Masha Durkalić. BE: SENSOA, exaequo, Observatoire du SIDA et des ents by country. As a result, trends from countries with sexualités, Sciensano. BG: HUGE, GLAS Foundation, Dr Emilia Naseva, Petar Tsintsarski. BY: Vstrecha. CA: Health Initiative for Men, Rézo, Gay Men’s Sexual large numbers of respondents may be overrepresented in Health Alliance of Ontario, CATIE, Ontario HIV Treatment Network, Université regional trends. We lack more detailed information on du Quebec & Montréal, University of Toronto, Ryerson University, University whether the issue of PN was addressed in the healthcare of Windsor, University of Victoria, Public Health Agency of Canada, Rob Gair. Marcus et al. BMC Public Health (2023) 23:8 Page 10 of 12 CH: Swiss AIDS Federation, Cantonal Hospital St. Gallen, Centre Hospitalier and interpretation. UM wrote the first manuscript draft. SBS revised the Universitaire Vaudois, University Hospital Zurich, Swiss Federal Office of Public language and was responsible for visualizations. All authors were actively Health. CY: AIDS Solidarity Movement. CZ: AIDS pomoc, National Institute involved in critical revision of the manuscript and finally approved of the ver- of Public Health, Tereza Zvolska, Dr Michal Pitoňák. DE: Deutsche AIDS-Hilfe, sion to be published. Robert Koch Institute, BZgA, Dr Michael Bochow, Dr Richard Lemke. DK: AIDS-Fondet, Statens Serum Institut, François Pinchon, Jakob Haff. EE: Eesti Funding LGBT, VEK LGBT, Estonia National Institute for Health Development, Dr Kristi Open Access funding enabled and organized by Projekt DEAL. EMIS: UM, Rüütel. ES: Stop Sida, CEEISCAT, Ministerio de Sanidad. FI: Positiiviset, Hivpoint, service contract 2015 71 01 between Robert Koch-Institute and Consumers, SeksiPertti, Trasek, National Institute for Health and Welfare. FR: AIDES, Coali- Health, Agriculture and Food Executive Agency (Chafea), acting under powers tion PLUS, SexoSafe, Santé Publique France, INSERM. GR: Ath Checkpoint, delegated by the Commission of the European Union (https://​ec.​europa.​eu/​ Thess Checkpoint; Positive Voice. HR: Iskorak, gay.hr, Zoran Dominković, Vjeko chafea/​index_​en.​htm). The funders had no role in study design, data collec- Vacek. HU: Háttér Society, Tamás Bereczky. IE: Gay Health Network, Man2Man, tion and analysis, decision to publish, or preparation of the manuscript. HIV Ireland, Outhouse, GOSHH, Sexual Health Centre Cork, AIDSWEST, Gay Community News, Health Service Executive, Gay Men’s Health Service, Sexual Availability of data and materials Health and Crisis Pregnancy Programme, Health Protection Surveillance The EMIS-2017 and the LAMIS datasets used for this analysis have been Centre. IL: Israel AIDS Task Force, Israel Ministry of Health, Dr Zohar Mor. IS: obtained from the London School of Hygiene and Tropical Medicine (EMIS- Samtökin’78. IT: Arcigay, Fondazione LILA Milano ONLUS, University of Verona, 2017) and from CEEISCAT, Barcelona (LAMIS) under data transfer agreements Dr Raffaele Lelleri. LB: SIDC, Dr Ismaël Maatouk. LT: demetra, LGL, Gayline. LV: that prohibit to sharing the datasets publicly. Although we cannot make study Testpunkts, Baltic HIV Association, Dr Antons Mozalevskis, Indra Linina. MD: data publicly accessible at the time of publication, all authors commit to make GENDERDOC-M. ME: Juventas. MK: Subversive Front, Dr Kristefer Stojanovski. the data underlying the findings of the study available in compliance with the MT: Malta LGBTIQ Rights Movement, Allied Rainbow Communities, Infectious BMC Public Health Data Availability Policy. Disease Prevention and Control Unit, Silvan Agius, Russel Sammut. NL: Results Data requests for the LAMIS dataset should be addressed to CEEISCAT/Fun- in Health, Maastricht University, Amsterdam Pink Panel, Soa Aids Nederland, dació IGTP, Ctra. De Canyet s/n, 08916 Badalona – Catalonia, Spain: nlorente@ Rutgers, Dr Wim Vanden Berghe, Marije Veenstra. NO: Helseutvalget, Norwe- coalitionplus.org, and the first author (MarcusU@rki.de). gian Directorate of Health, Folkehelseinstituttet, Dr Rigmor C. Berg. PH: Bisdak Data requests for the EMIS-2017 dataset should be addressed to the London Pride-Cebu, Cebu Plus, HASH, Pinoy Plus, UP Babaylanes, YPEER, TLF, Office School of Hygiene and Tropical Medicine Research Operations Office Data of the WHO Representative in the Philippines, Natasha Montevirgen, Mikael Management Lead: alex.hollander@lshtm.ac.uk, the first author (MarcusU@rki. N. Navarro. PL: Spoleczny Komitet ds AIDS, Kampania Przeciw Homofobii, de), and the Principal Investigator of EMIS-2017 (Peter.Weatherburn@lshtm. Lambda Warszawa, Dr Łukasz Henszel. PT: GAT Portugal, CheckpointLX, Asso- ac.uk). ciação ABRAÇO, rede ex aequo, SexED, dezanove, ILGA Portugal, Trombeta Individuals requesting data should present their research objective(s) and Bath, ISPUP. RO: Association “Eu sunt! Tu?”, PSI Romania, ARAS Romania, Tudor enclose a list of requested variables. To protect the confidentiality of partici- Kovacs. RS: Association Duga, Association Red Line, Omladina JAZAS-a Novi pants, data sharing is contingent upon appropriate data handling and good Sad, Institute of Public Health of Serbia, Sladjana Baros, Dr Marija Pantelic. RU: scientific practice by the person requesting the data and should furthermore The Charity Foundation For Support of Social Initiatives and Public Health/ be in accordance with all applicable local requirements. The London School LaSky Project. SE: RFSL, University of Gothenburg, Folkhålsomyndigheten. SI: of Hygiene and Tropical Medicine administrative offices are located at Keppel ŠKUC, Legebitra, LJUDMILA. SK: PRIDE Košice, Light-House Slovakia, Slovak Street, London WC1E 7HT, United Kingdom. Medical University, Public Health Authority of the Slovak Republic, Dr Zuzana Klocháňová. TR: Pozitif Yaşam, Sami S. Yazıcılaroğlu. UA: Alliance for Public Health, alliance.global, msmua.org, Oleksii Shestakovskyi. UK: Terrence Higgins Declarations Trust, NAM, PrEPster, Antidote, Horizon Drugs and Alcohol Support, LGBT Foundation, Yorkshire MESMAC, MESMAC Newcastle, Derbyshire LGBT+, Trade Ethics approval and consent to participate Sexual Health, London Friend, GMFA, Spectra, International HIV Partnerships, Ethics approval was granted by the Ethics Committee of the London School of International Planned Parenthood Federation, Bristol University, University Col- Hygiene and Tropical Medicine for EMIS-2017 (reference 14421/RR/8805), and lege London, Sigma Research, Raul Soriano. Other: Dr John Pachankis, Dr Mark by the committees of the Universidad Peruana Cayetano Heredia (612–19-17), Hatzenbühler, Dr Valeria Stuardo Ávila, Dr Michael W. Ross. the Salvador Allende School of Public Health, Faculty of Medicine, University LAMIS has been possible thanks to the contributions in the form of human, of Chile (009–2017), Santa Casa de Misericórdia de São Paulo, Brazil (2,457,744), intellectual and economic resources of the member institutions of the Red the National Committee for Health Ethics, Guatemala (39–2017), and the Iberoamericana de Estudios en Hombres Gay, otros HSH y Personas Trans (The Faculty of Psychology and Neuroscience of the University of Maastricht, the CEEISCAT assumed the economic and legal aspects of hosting the database Netherlands (18–01-12–2017) for LAMIS. and the general coordination of the project; the Institute of Public Health of Information on the surveys was provided on an entry page before the online the University of Porto contributed funds to host the survey in Portuguese questionnaire started. Participants gave informed consent by clicking “yes” and to the promotion of the survey; the CIISSS of the Cayetano Heredia to the question “Have you read and understood the above information?” This University paid the domain for the web page of the survey; and the Faculty procedure had been approved by the above-mentioned Ethics Committees. of Medical Sciences of Santa Casa de São Paulo paid the domain for the study All methods were carried out in accordance with relevant guidelines and website and took charge of its graphic design) and the Faculty of Psychology regulations. and Neuroscience at Maastricht University, which paid for hosting the Dutch survey in the platform. For its implementation, LAMIS used resources from Consent for publication the EMIS-2017 study, which was funded by the European Commission Health Not applicable. Program 2014-2020, and, in particular, from Sigma Research (questionnaire design, graphic arts of banners for promotion, secondary variables syntax Competing interests and EMIS-2017 variables manual) and the Robert Koch Institute (negotia- The authors declare that they have no competing interests. tions with web pages/apps for free promotion of LAMIS). Also, LAMIS was possible thanks to the support of the collaborating partners in each of the 18 Author details 1 participating countries (www.​estud​iolam​is.​org). Special thanks to Grindr and Department of Infectious Disease Epidemiology, Robert Koch Institute, Berlin, PlanetRomeo, both of whom sent free instant messages for promotion to their Germany. 2 Faculty of Psychology and Neuroscience, Maastricht University, user. Furthermore, the authors thank for the support provided by the LAMIS Maastricht, The Netherlands. 3 Division for the Health Services, Norwegian Editorial Board. 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