Similar findings were reported in another study where MSM who practised receptive penile–anal intercourse were 48% less likely to be diagnosed in the primary stage than other MSM, implying occult primary lesions are probably undiagnosed 13. A retrospective study in Australia reported that MSM who practised receptive penile–anal sex were four times more likely to present with secondary syphilis than those who practised insertive penile–anal sex, suggesting primary anorectal lesions are often missed 12. A study examining the shedding of Treponema pallidum showed three out of 54 (6%) MSM with primary syphilis had syphilis lesions in the anorectum confirming the presence of primary syphilis lesions at the sites that are often overlooked 11. These primary lesions may go unnoticed if they occur at hidden sites such as the vaginal or inside the anal canal. Primary syphilis classically presents as a painless chancre at the point of inoculation 10. Reducing the duration of the infectious period is one of the main strategies underpinning interventions for syphilis control. Despite these measures, syphilis cases continue to rise prompting the need for additional strategies for syphilis control 9. Previous public health strategies included regular serological screenings of MSM who are considered at a higher risk of acquiring syphilis, improved contact tracing, and behavioural interventions to increase condom use 6, 7, 8. Syphilis continues to rise among gay, bisexual and other men who have sex with men (MSM) in high-income countries despite numerous public health interventions to improve syphilis prevention and control 1, 2, 3, 4, 5. Studies are required to determine the effectiveness of ASE for syphilis detection. Almost two-thirds of MSM who had never performed ASE were willing to adopt ASE practice in the future. Among 66% (374) who had never performed ASE, 68% (250) would consider performing ASE in the future with a preferred median frequency of 2 times per 4 weeks (IQR 1–4), whilst men who were already performing ASE were performing it at median 1 per 4 weeks (IQR 0.2–3). A total of 568 MSM completed the survey (median age: 34 ): 32% (183) had previously performed ASE.
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An online anonymous cross-sectional survey among MSM over 18 years of age living in Australia, was conducted between July and November 2020 and recruitment was from a sexual health clinic and social media. We aimed to explore the attitudes of MSM on performing ASE to detect primary anorectal syphilis. If men could detect anorectal lesions in the primary stage by regular anal self-examination (ASE), transmission could be reduced by early diagnosis and treatment. Studies suggest men who have sex with men (MSM) practising receptive anal sex are more likely to present with secondary syphilis, implying primary anorectal lesions are likely to be missed.