{"paper_id":"05ef593d-49c9-4cdc-93a6-bcb738d7d484","body_text":"European Men-Who-Have-Sex-With-Men and Trans People Internet Survey (EMIS-2024): Design and Methods | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article European Men-Who-Have-Sex-With-Men and Trans People Internet Survey (EMIS-2024): Design and Methods Liana Aphami, Tamás Bereczky, Jules Casalini, Nikolay Lunchenkov, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6991809/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 19 Mar, 2026 Read the published version in Sexuality Research and Social Policy → Version 1 posted You are reading this latest preprint version Abstract Men who have sex with men (MSM), as well as transgender and non-binary individuals, continue to face a disproportionate burden of stigma, mental health challenges, HIV, and other sexually transmitted infections. To address their needs, public health planners require reliable and comparable data. Monitoring behaviours in these populations also supports the evaluation of health policies. The European MSM Internet Survey (EMIS-2024) builds on our international surveys conducted in 2010 and 2017, expanding its scope to include transgender women and non-binary people explicitly. It provides much-needed data for planning interventions, promoting health, and harmonising behavioural surveillance. A key strength of EMIS-2024 is the use of a shared sampling frame and core questionnaire across all participating countries. This approach allows meaningful cross-national comparisons, unlike many national surveys with varying methods. The three core consortium partners led the EMIS-2017 questionnaire’s revision, with broader but less partner involvement in content development being more limited than in previous rounds. Over 60 partners from 40 countries played a key role in the survey’s success, providing high-quality translations in 35 languages and actively promoting the survey. National partners ensured the survey’s visibility, credibility, and relevance, once dating app advertisements or invitations appeared. The survey ran online during the first half of 2024. Overall, 165,380 responses were received, of which 50,330 qualified for the analytic sample. EMIS-2024 demonstrates that large-scale, multi-country sexual health surveys are feasible with public funding. A harmonised questionnaire, shared sampling strategy, and meaningful community involvement were key to generating robust, comparable data across Europe. Sexual Health Mental Health Epidemiology HIV Sexually Transmitted Infections MSM Transgender Figures Figure 1 Figure 2 Figure 3 Background Effective planning for the prevention of HIV and sexually transmitted infections (STIs) relies on robust data regarding the distribution of risk and precaution behaviours, as well as the extent of unmet prevention needs—that is, the motivations, opportunities and capabilities to engage in protective practices). Data on HIV/STI among men who have sex with men (MSM), and trans and non-binary individuals, remain highly inconsistent across countries. This includes variations in data on infections and diagnoses, risk and precautionary behaviours, prevention needs, and the performance of related services. For trans and non-binary individuals in particular, data is often entirely lacking, or these groups are grouped under MSM, which prevents key population-specific reporting. For the first time, EMIS includes trans and non-binary participants using a tailored survey instrument. Infection surveillance systems differ widely in terms of coverage, representativeness, and comprehensiveness. This makes it challenging to compare annual HIV/STI diagnosis rates across countries—and sometimes within countries over time, especially in the context of emerging pathogens such as the mpox virus. Additionally, novel prevention strategies, such as Doxycycline pre- or post-exposure prophylaxis, are emerging, but their uptake among key populations remain poorly understood. Reliable surveillance data are essential for monitoring the HIV/STI disease burden. Knowing our epidemics is key to tailoring effective responses. The European Centre for Disease Prevention and Control (ECDC) is the European Union (EU) agency responsible for strengthening countries’ capacity to prevent and control infectious diseases, including HIV and STIs. ECDC is mandated to enhance and coordinate behavioural surveillance of infectious diseases at the EU level and support countries to conduct behavioural surveillance related to HIV and STIs (ECDC & WHO-Europe, 2024). Similarly comparable surveillance data are needed from Eastern Europe and Central Asia (EECA) and have been included in EMIS. Current Overview of HIV/STI Diagnoses Men-who-have-sex-with-men in WHO European Region The latest data from 2023 reported 112,883 HIV diagnoses in 47 of the 53 countries in the WHO European region. Within European Economic Area (EEA), 24,731 diagnoses were recorded. In Eastern Europe, 77.601 infections were reported, with 11.7% attributed to sex between men. The proportion of HIV diagnoses attributed to sex between men decreased from 52.1% in 2014 to 46.9% in 2023. Despite some progress, HIV remains a major public health issue, with 21 out of 47 countries reporting increases (ECDC & WHO-Europe, 2024). In many EEA countries, HIV disproportionately affects key populations such as MSM, transgender and non-binary individuals, sex workers, certain migrant groups, and people who inject drugs (ECDC & WHO-Europe, 2024). Among migrant MSM, HIV diagnoses rose by 37.7% from 2014 (n = 2,659) to 2023 (n = 3,661), especially among those from Latin America, the Caribbean, and central and Eastern Europe. STIs, particularly gonorrhoea and syphilis, are common among MSM in Europe (Mitja et al., 2023 ). Since the 2022 mpox outbreak, MSM have also been disproportionately affected (ECDC & WHO-Europe, 2024). Syphilis cases increased by 13% between 2022 and 2023, with 72% of cases among MSM (ECDC, 2025 ). Gonorrhoea cases in 2023 reached a decade-high, especially among young people and MSM (Nerlander et al., 2024 ). Other STIs like Lymphogranuloma venereum remain underdiagnosed among MSM (Cole et al., 2020 ). Since March 2022, 28,632 mpox cases were reported in the WHO European Region, 97% among MSM. HIV prevalence among mpox patients ranged from 39.5% (Spain) (Orviz et al., 2022 ), 47% (Italy) (Candela et al., 2023 ), 46.9% (Germany) (Hoffmann et al., 2023 ), and 56.3% (Italy) (Salvo et al., 2023 ), underlining the need for integrated care. Transgender and non-binary individuals face significant health inequities, including poor health outcomes, violence, stigma, and systemic barriers such as criminalization and discrimination (Burgwal et al., 2019 ; Falck & Branstrom, 2023 ; Karniej et al., 2025 ; Transgender Europe, 2017 ; Winter et al., 2016 ). Gaps in health literacy and limited access to healthcare continue to hinder their well-being (van der Warth, Körner, & Farin-Glattacker, 2024). HIV and STI prevalence is disproportionately high among transgender women and other transgender individuals assigned male at birth (Stutterheim et al., 2021 ; Wang et al., 2024 ), yet transgender men remain underrepresented in research, often due to small sample sizes (American Psychological Association, 2015 ). Trans men are frequently perceived as lower risk, though data to support or refute this is limited. The ECDC highlights that transgender and non-binary populations are critically underrepresented in health surveillance, excluding them from essential healthcare strategies and perpetuating structural inequalities (ECDC & WHO-Europe, 2024). Design and Methods A Collaborative Survey EMIS-2024 was conceived as a large-scale partnership, with a strong emphasis on involving organisations and representatives of affected communities in the study’s design and recruitment. Each step of the process engaged the EMIS Network, drawing on its collective knowledge and needs. In addition to generating data from MSM, EMIS-2024 aimed to include trans and non-binary individuals more broadly, build research capacity, transfer knowledge about online surveys, generate datasets in countries with fewer resources, facilitate dialogue between community, academic, and public health, and maximise the educational impact of survey completion. A key benefit of EMIS has been the availability of the questionnaire in all official EEA languages, crucial for countries with large proportions of migrants from southern, eastern, or southeastern Europe. For the same reason we also provided the survey in Arabic, as it has been the most common languages among refugees coming to Europe since 2014. The approach to working with these organisations varied between the Eastern and Western regions (as defined below), depending on local possibilities, requirements, and the complexity of organisational and legal settings. The large number of partners required flexibility from the investigators and coordinators in structuring and operating the collaboration. Populations of Concern: MSM, Transgender and Non-binary Individuals We defined MSM as individuals identifying as men, including both cisgender and transgender men, or non-binary persons, who have sex with men or are sexually attracted to men. \"Cisgender\" refers to individuals whose gender identity aligns with the sex they were assigned at birth (American Psychological Association, 2015 ). Participants were required to be at least 16 years old, except in Cyprus and Ireland (17 years) and Türkiye (18 years). In contrast to EMIS-2017, EMIS-2024 expanded recruitment to include transgender women and non-binary individuals. Non-binary individuals, an integral part of the transgender community, are often marginalised, with limited data on their health neds (Matsuno & Budge, 2017 ). This highlights the importance of understanding their sexual health requirements (Druckler et al., 2022 ). However, cisgender women were not included in the study and were not considered part of the population of concern. Methods of Generating Data in EMIS-2024 Collecting robust data on minority groups, especially those with stigmatised identities or sexual behaviours, remains challenging. This is particularly true for transgender populations, as global estimates of their size are limited. Determining this population’s size is further complicated by diverse gender identities, varied transition experiences, and the stigma they face. Population-based surveys suggest that around 0.3–1.3% of individuals identify as transgender, with a minority identifying as non-binary, though not all non-binary individuals consider themselves transgender (Reisner et al., 2016 ). Research on transgender health is constrained by a lack of population-based studies, longitudinal research, and consistent public health surveillance. The exclusion of transgender-inclusive measures in surveys further limits data collection, hindering the assessment of health disparities. Transgender health risks and resilience are shaped by biological, behavioural, social, and structural factors, underlining the need for an inclusive approach (Winter et al., 2016 ). Defining populations such as men who have sex with men (MSM) and transgender individuals is complex. The stigma attached to same-sex sexual activity and transgender identities, alongside the absence of sampling frames, makes random sampling difficult in many countries. While small representative samples can be incorporated into national population surveys (Mercer et al., 2016 ), larger-scale studies often rely on convenience sampling, limiting their generalizability (Semlyen & Hagger-Johnson, 2017 ). EMIS-2024 expanded to include trans individuals more broadly and built on prior multi-country research. EMIS-2024 followed EMIS-2010 (The EMIS Network, 2013 ; Weatherburn et al., 2013 ) and EMIS-2017 (The EMIS Network, 2019 ; Weatherburn et al., 2020 ) as part of a multi-language, pan-European surveillance effort focussed on morbidities, behaviours, prevention needs, and intervention performance. Recruitment shifted largely to gay dating apps, which are now widely used (Dhoest, 2022 ). The first wave of EMIS was undertaken just before the advent of smartphone-based geo-spatial apps. Such apps now play a major role in reaching participants, though fatigue was evident, seen in lower participant yield compared to EMIS-2017. Most online surveys focus on regional or national populations of MSM and/or trans people, with comparability between countries being challenging due to differences in recruitment methods, questionnaire items, and response sets. Additionally, different definitions of MSM lead to varying sample compositions. Establishing the Eastern and Western Regions of EMIS-2024 Unlike previous EMIS waves, EMIS-2024 had a more complex funding and operational structure due to political circumstances, including the wars in Russia and Ukraine, and Israel/Gaza. The geographical scope was thus divided into two regions: Eastern and Western, with distinct timelines and recruitment strategies. Countries receiving national funding are shown in dark blue, those in lighter blue were included without funding, as their languages were already covered. Countries co-funded by ECDC are highlighted in light green, and those funded by Germany’s Global Health Protection Programme (GHPP) are in dark green. EMIS-2024 was coordinated by DAH and RKI, as illustrated in Fig. 1 . Belarus and Lebanon were part of previous EMIS waves but not included in EMIS-2024, mostly due to lack of national partners. Western Region DAH was responsible for the organisational, financial, and contractual arrangements in the Western region, which included EEA countries, as well as Israel, Switzerland, the UK, and the four microstates. The coordination of translations, recruitment and communication in Germany was jointly organised by RKI and DAH. Coordination in Türkiye was a joint responsibility of RKI and DAH. Coordination in Russia was a joint responsibility of RKI, DAH, and the University of Tromsø – The Arctic University of Norway. Formal agreements were established with NGOs and community organisations in the region to carry out translations and support recruitment efforts. Each organisation was compensated with a standard fee for its contributions. Eastern Region RKI managed the organisational, financial, and contractual arrangements in the Eastern Region, which included the Western Balkans, Eastern Europe and parts of Central Asia. GHPP funding supported translations and survey promotion in this region, but did not include Uzbekistan, Turkmenistan, Kyrgyzstan, or Tajikistan—limiting Central Asian participation to Kazakhstan. RKI subcontracted ECOM (for Armenia, Azerbaijan, Georgia, Kazakhstan, Moldova, and Ukraine) and SEE RCN (for the Western Balkans) to coordinate activities, drawing on their regional expertise and strong HIV/STI prevention networks. Recruitment Targets Our goal was to recruit at least 100 eligible residents in each of the 46 target countries, which we considered a viable sample size for national planning purposes. We also extended the invitation to include individuals residing in the four non-EU microstates adjacent to or encompassed by these countries. Although we did not expect to recruit more than 50 participants from these microstates, we felt it was important not to exclude them from the opportunity to participate. Cases from these microstates were therefore included in the datasets of neighbouring countries: Andorra with Spain, Liechtenstein with Switzerland, Monaco with France, and San Marino with Italy. We committed to creating and sharing national datasets with lead agencies in countries that achieved at least 50 eligible respondents, while recognising that this might not be feasible in countries with small populations. Countries falling below this threshold are clearly marked in the data maps generated for EMIS-2024, and caution is advised when interpretating findings for these countries, as their sample sizes may be too small to support reliable conclusions. (Re-)Building the Network The formal process of building and re-establishing the EMIS network began in August 2023, although informal discussions around participation and logistics had already started in early 2023. Using contact details from EMIS-2017, both regional coordinators systematically reached out to organisations and individuals to assess their interest and readiness to take part. In addition to reconnecting with EMIS-2017 partners, the coordinators actively contracted new NGOs and community organisations to ensure broad and effective outreach to key populations. Specific efforts were made by one of the co-authors (JLC) to engage trans organisations across Europe. Questionnaire Design EMIS-2024 was designed to replicate EMIS-2017 and EMIS-2010, generating essential data for planning and monitoring interventions related to HIV, STIs, and viral hepatitis. Core questions remained largely unchanged to enable trend analyses. At the request of ECDC, key additions included items on hepatitis testing and STI treatment. At the request of ECDC, new items were added on hepatitis testing and STI treatment. The core team further expanded the survey with sections on antibiotic STI prophylaxis, HPV, and mpox (formerly \"monkeypox\"), and incorporating emerging issues such as intra-minority stress. While the core team led content development, the wider EMIS network played a key role in translating the questionnaire into 34 languages. Given the sensitive and nuanced nature of sexual health topics, community-based translation ensured culturally appropriateness and comparability across countries. The questionnaire continued to centre on MSM, while acknowledging the distinct yet intimately interconnected aspects of sexuality and gender identity. A key aim was to meet emerging needs within the community, particularly among transgender individuals, who are often misclassified within MSM categories in traditional HIV surveillance, which masks their specific vulnerabilities (Stutterheim et al., 2021 ). EMIS-2024 aimed to disaggregate data by gender identity and sex assigned at birth to address these gaps. Tailored filters and question routing were developed to reflect participants' lived experiences. Respondents were told, “In this survey, we use ‘sex’ to mean physical contact to orgasm (or close to orgasm) for one or both partners”. This definition identified those who had ever had sex with men, but individuals attracted to men who had not had sex with men were also included, recognising the relevance of their inclusion for future planning. The study aimed to guide effective HIV and STI prevention and treatment interventions by assessing prevalence of morbidities, risks and precautionary behaviours, broader needs and interventions performance—particularly around mental health and substance use. This syndemic-informed, holistic approach aligns with the work of our collaborators across these health domains. To balance continuity and innovation, core questions from EMIS-2017 were retained, while new items were added on mpox, Doxy-P(r)EP, stigma and intra-minority stress. Previously removed questions on sexual practices with non-steady partner were re-included, reflecting evidence of the impact of sexual repertoire on STI risk (Schmidt & Marcus, 2023 ). We carefully refined questions to improve clarity, comparability, and minimise participant burden. Development was guided by a conceptual map derived from EMIS-2017. Ineffective or unclear items were removed, and new sections added to reflect current health trends, including chemsex and trans-specific topics. In June 2023 a dedicated trans sub-study was incorporated. While trans-related questions had been included previously, this was the first time the survey featured tailored routing content for trans participants. Language was made more inclusive of diverse trans experiences, and new questions covered passing, gender-affirming care, body image, stigma; internalised transnegativity, and trans-related competition and exclusion sub-scales (adapted from Pachankis et al., 2020 ). Participants whose gender identity differed from their sex assigned at birth were asked if they identified as part of the transgender community. Those who did received a set of trans-specific questions, routed based on their current body parts. The draft survey was developed in English on Qualtrics XM (Qualtrics International Inc., Provo, Utah, USA) and pre-tested by the EMIS Network. Consultations took place from November 2023 and February 2024—earlier in the Eastern Region due to funding timelines. Feedback informed refinements to both the English and translated versions. In the Eastern Region, some final adjustments were made after the survey went live. We conducted an item analysis to ensure balanced coverage across demographics, morbidities, behaviours, needs, and interventions. The final version of the EMIS-2024 questionnaire, completed in February 2024, reflects an iterative and collaborative development process—balancing comprehensiveness, cultural relevance, data quality, and respondent experience. Translations Translation was coordinated within the EMIS Network. Translators were offered payment in countries that did not co-fund EMIS, since in co-funding countries, translation was considered part of their non-financial contribution. Translations were based on Excel exports from Qualtrics, with colour coding to highlight new, modified, or trans-specific items. Three documents supported translators: their language’s EMIS-2017 translation (for consistency); a detailed survey structure, and written, visual, and verbal instructions to reduce errors and safe time. Language and terminology were updated for the trans sub-study. Additionally, 34 new items were added for the trans participants, and 112 new items overall. A broad range of issues was raised during the review process, all of which were carefully considered and addressed. This led to further refinements, corrections of translation and routing errors, and identification of technical issues. Translators were asked to use previous translations unless a change was justified, and to update the EMIS-2017 version accordingly. National partners checked routing and confirmed terminology matched norms for their target group. They signed off the main language version(s) for each country. Proof-readers ensured consistency while preserving appropriate cultural variations— e.g ., explicitness or formal/informal address. Simple rather than specialised terms were preferred throughout. The survey was available in 35 languages: Albanian, Arabic, Armenian, Azeri, Bosnian/Croatian/Montenegrin/Serbian, Bulgarian, Czech, Danish, Dutch, English, Estonian, Finnish, French, Georgian, German, Greek, Hebrew, Hungarian, Italian, Kazakh, Latvian, Lithuanian, Macedonian, Malti, Norwegian, Polish, Portuguese, Romanian, Russian, Slovak, Slovenian, Spanish, and Swedish, Turkish and Ukrainian. Translation issues were minimal. Missing headers were added (English, Dutch, Russian and Spanish), and translation errors corrected (Russian, Turkish, Italian, Spanish), without compromising data quality. One question was removed from Turkish, Arabic, and Armenian versions due to an error. Further detail is available in Annex 1 . Duration Evaluation Three people in the Netherlands and Germany tested the timed survey. The final version took on average 30 minutes to complete—longer than in 2017. Despite efforts to reduce length, the diverse stakeholder priorities meant further cuts unfeasible. Estimated duration was shown on the survey’s entry page. Final Integrated Questionnaire The final questionnaire included 441 data items, though not all were shown to every respondent. Routing was used to minimise time—for instance, only participants with a steady partner were asked about relationship length. The final English version formed the basis for the ethics application, which received a positive opinion from Maastricht University’s Ethics Review Committee Psychology and Neuroscience on 30 October 2023 (ref: ERCPN-OZL_262_08_01_2023). To improve usability, each question appeared on a separate page in both the desktop and mobile versions. Questionnaire Structure Figure 2 outlines the main sections of the questionnaire. Figure 3 illustrates the content of the final questionnaire, structured into five conceptual layers. These layers follow a causal logic: interventions shape needs, needs influence behaviours, and behaviours impact health. While the model informed the survey design and the distribution of items, its purpose was not to test the model itself, but to identify behavioural targets and uncover the unmet needs driving them. Question Formats Some concepts were measured by single questions; others needed validated multi-item scales. Recency-based event questions asked “When did you last do X?”, allowing both recent ( e.g. , within the last 4 weeks, 6 months, 12 months) and lifetime experience. This format shows population-level activity density but not individual frequency. EMIS-2024 enables calculation of 31 Dublin Declaration Monitoring (DDM) indicators on HIV/STIs among MSM (ECDC, 2024 ). Variables were selected in collaboration with ECDC. Recruitment Identifying Recruitment Settings EMIS-2024 was promoted through a mix of channels: (1) websites of supporting national and international organisation (public, commercial, and NGO sectors in HIV/LGBT communities); (2) general society media platforms ( e.g ., Facebook, Instagram, LinkedIn); and (3) MSM-targeted dating apps and websites, notably Grindr, ROMEO, and Hornet). Recruitment strategies and timelines varied across countries and between the Eastern and Western Regions. Initial promotion began in December 2023 via paid Grindr messages in Germany and the Western Balkans and through Hornet in Russia, Azerbaijan, Armenia, Georgia, Kazakhstan, Moldova, and Ukraine. In January 2024, Grindr campaigns expanded to Hungary, the Netherlands, the UK and Ireland, Portugal, Romania, Italy, and Czechia, and Slovakia. Hornet inbox messages followed in Türkiye and France. February saw continued Grindr campaigns (text and inbox messages) in Romania, Italy, Czechia, Slovakia, and Poland, alongside additional promotions led by local partners across Europe, Western and Central Asia and Israel. Grindr4Equality (G4E) led two pan-European campaigns free of charge in April and June 2024, reaching 43 countries with targeted messages. ROMEO joined the effort in May 2024, further boosting visibility. In the Eastern Region, local HIV/STI prevention organisations distributed the survey directly. NGOs were incentivised via a tiered payment system. For instance, in Armenia, Azerbaijan, Georgia, Ukraine, Moldova and Kazakhstan, outreach workers received EUR 4 per recruit and shared the survey in person during client visits or via messenger services such as WhatsApp or Telegram. Advertising Management The G4E campaign featured bilingual pop-up messages—first in English and local languages, later expanded to include Arabic and Russian, reflecting widely spoken migrant languages. Study staff liaised with national partners to support promotional planning. In the Western Region, NGOs received modest funding to coordinate local promotions. Due to technical limitations in Qualtrics, URL tracking of recruitment links was less precise than with Demographics in 2017. Nonetheless, 75 unique URLs were issued to different recruiters and partners. A visual identity for EMIS-2024, developed by an external consultant in February 2024, was made available free of charge. All promotional elements could be adapted locally. The English tagline “Your voice—our strength!” was translated or localised as needed. Offline materials were rarely used but made available in printable formats where necessary. Soft Launch Following translation testing by partner organisations, a ‘soft launch’ began on 15 December 2023 in the Eastern Region. Test links allowed partners and translators to explore the survey in English and local languages. Feedback was to coordinators, and. changes were centrally implemented by the data coordinator at Maastricht University, with strict version control. Updates were made to a master version of the survey and then cloned for recruitment use. This process continued to June 2024. Major modifications are discussed in the Limitations section. Active promotion commenced on 22 December 2023 in Germany, Armenia, Azerbaijan, Georgia, Kazakhstan, Moldova, Russia, Ukraine and the Western Balkans. The survey was made available in 18 languages initially, with additional languages (including Portuguese, Italian, French, Latvian, Slovak, Lithuanian, Bulgarian, Czech, Greek, Polish, Slovenian, Spanish, Turkish, Swedish, Hebrew, Malti and Norwegian) added in February 2024. The survey remained open for six months (22 December 2023–31 June 2024). Due to regional differences in recruitment pace, timelines were staggered. No participant incentives were offered beyond the opportunity to contribute. Monitoring occurred bi-weekly, allowing recruitment strategies to be adjusted for efficiency and reach. The original deadline (March 2024) was extended twice to accommodate for slower uptake, aiming to maximise both visibility and participation. Results Returns and Exclusions Partially completed surveys—where participants navigated away before clicking ‘submit’—were included if 95% or more of the questionnaire had been completed. These entries were captured and included in the final dataset after a 30-days grace period. Inclusion in the final dataset required completion of at least 95% of the survey. Data cleaning followed a four-step procedure. Initial filtering removed entries with less than 95% completion, duplicate entries, participants who did not give consent, and responses missing answers to compulsory questions. Eligibility screening excluded cis women, individuals not residing in eligible countries, those under the minimum age (16 years; 17 years in Ireland and Cyprus, 18 in Türkiye), and people who neither had sex with men nor expressed interest in doing so. Logical consistency checks targeted highly inconsistent responses—for instance, reporting retirement under the age of 30; age mismatches between current age, age at first sex/intercourse, years living in the country of residence post migration, or HIV diagnosis; implausible partners counts; and gender identity inconsistencies ( e.g. , identifying as a man, assigned at female at birth but not identifying as part of the trans community). Non-binary participants were retained regardless of their sex assigned at birth. Time-based exclusions identified submissions with unrealistically short response times. Timing variables were categorised as: <3 seconds, 3–5.99 seconds, 6–12 seconds, and > 12 seconds. Responses where the average time per answer was under three seconds were removed. Out of 165,380 submissions, 50,330 cases qualified. Full details of inclusion and exclusion processes, and final case counts per country, are provided in Annex 2 . Recruitment Numbers and Response Rates Table 1 presents the number of qualifying cases by country, alongside summary totals (bolded) for: all countries combined; EEA countries; non-EEA advanced economies (Switzerland, the UK, and Israel); the Western Balkans and Türkiye; and EECA countries, comprising non-Baltic countries of the former Soviet Union states. Recruitment rates were calculated by dividing the number of qualifying cases by the estimated adult male population (aged 15–64). Across all countries, the overall recruitment rate was 1.9 per 10,000 (EEA: 2.9). Country level rates ranged from 0.01 (Kosovo and Türkiye) to 11.6 (Malta) and 12.4 (Norway). For the purposes of prevention planning among MSM, we provide a crude estimate of the MSM population based on 3% of the adult male population (aged 15–64). This estimate does not account for the likely reality that, just as MSM within a country tend to concentrate in larger, more gay-friendly cities, they may also migrate from countries with high levels of homonegativity to those with lower levels. As a result, estimates in more homonegative countries may be inflated, while those in more inclusive countries may be underestimated. The literature suggests that the proportion of MSM generally ranges between 2% and 4% (Mercer et al., 2013 ; Schmidt & Altpeter, 2019 ). Datasets Data were organised into national datasets based on country of residence, regardless of the language used or country of birth. A combined pan-European dataset was also created. National datasets were produced for all 42 countries with at least 50 qualifying cases. Eight countries did not reach this threshold. In three of these (Andorra [9 cases], Monaco [2 cases], Liechtenstein [4 cases]), cases were merged into datasets of adjoining or surrounding countries (Spain, France, Switzerland, respectively), because a viable sample size was never expected. No responses were received from San Marino. Four other countries—Iceland (19 cases), Albania (31 cases), Kosovo (5 cases), and Montenegro (21 cases)—are not included in any national dataset. Table 1 EMIS-2024 qualifiers and recruitment rates Country Qualifying cases N Cisgender men N Non-binary individuals N Transgender individuals Total male population aged 15–64, in 1000s Relative response rate** Crude MSM estimate, in 1000s*** Total 50 330 46 881 1 813 1 636 279 719 1.9 8 392 EEA 41 424 38 659 1 398 1 367 145 064 2.9 4 352 Austria 1 082 967 65 50 2 965 3.6 89 Belgium 964 888 46 30 3 660 2.6 110 Bulgaria 208 186 10 12 2 154 1.0 65 Croatia 361 353 5 3 1 236 6.7 37 Cyprus 187 180 4 3 312 6.0 9 Czechia 1008 950 29 29 3 481 2.9 104 Denmark 426 381 29 16 1 879 2.3 56 Estonia 174 114 21 39 426 4.1 13 Finland 1126 841 116 169 1 720 6.5 52 France* 3 531 3 360 88 83 21 040 1.7 631 Germany 10 592 10 037 312 243 26 636 4.0 799 Greece 934 896 31 7 3 295 2.8 99 Hungary 826 777 28 21 3 149 1.1 95 Iceland 18 16 1 1 124 1.4 4 Ireland 868 771 33 64 1 645 5.3 49 Italy 3 635 3 549 68 18 18 594 2.0 558 Latvia 181 166 5 10 591 3.1 18 Lithuania 118 114 3 1 912 1.3 27 Luxembourg 130 123 3 4 223 5.8 7 Malta 206 188 6 12 177 11.6 5 Netherlands 1 413 1 314 51 48 5 717 2.5 172 Norway 2 194 2 002 57 135 1 763 12.4 53 Poland 1 294 1 219 43 32 12 426 1.0 373 Portugal* 1 974 1 847 86 41 3 313 6.0 99 Romania 732 670 23 39 6 189 1.2 186 Slovakia 452 403 30 19 1 821 2.5 55 Slovenia 258 235 14 9 674 3.8 20 Spain* 4 002 3 837 115 50 15 653 2.6 470 Sweden 2 530 2 275 76 179 3 240 7.8 97 Non-EEA advanced economies 3 726 3 379 206 141 26 868 1.4 806 Israel 403 321 43 39 2 865 1.4 86 Switzerland* 1 509 1 399 74 36 2 894 5.2 87 United Kingdom* 1 814 1 659 89 66 21 096 0.9 633 Western Balkans and Türkiye 939 861 55 23 34 713 0.3 1 041 Albania 32 31 1 0 944 0.3 28 Bosnia and Herzegovina 89 88 1 0 1 083 0.8 33 Kosovo ‡ 5 5 0 0 590 0.1 18 Montenegro 22 19 2 1 203 1.1 6 North Macedonia 71 68 2 1 679 1.0 20 Serbia 316 299 9 8 2 197 1.4 66 Türkiye 404 351 40 13 29 016 0.1 871 Eastern Europe and Central Asia 4 241 3 982 154 105 73 074 0.7 2 192 Armenia 53 47 5 1 945 0.6 28 Azerbaijan 337 279 19 39 3 612 0.9 108 Georgia 169 158 7 4 1 207 1.4 36 Kazakhstan 592 558 19 15 6 083 1.0 183 Moldova 156 144 7 5 933 1.7 28 Russia 1 874 1 778 69 27 47 373 0.4 1 421 Ukraine 1 060 1 018 28 14 12 920 0.8 388 * Includes microstate and/or overseas areas; ** Qualifying cases divided by 10,000 males aged 15–64; *** at 3% of the male population aged 15–64; ‡ This designation is without prejudice to positions on status and is in line with UNSCR 1244/1999 and the International Court of Justice Opinion on the Kosovo declaration of independence. EMIS Recruitment Sources Many EMIS partners actively promoted EMIS-2024 through their websites and social media channels and encouraged other national organisations to support recruitment efforts. Survey URLs were widely shared among recruiting organisations and individuals. Although the original goal of precisely tracking how many participants each recruiter generated could not be achieved due to technical limitations, we were able to categorise recruitment contributions across the three main dating apps and EMIS partners. Table 2 shows the total number of qualifying cases by country, broken down by recruitment source. It also includes summary totals (bolded) for: all countries combined; countries within the EEA; non-EEA advanced economies; the Western Balkans and Türkiye; and EECA. Table 2 Recruitment sources Country Qualifying cases % via Grindr & G4E % via ROMEO % via Hornet % via NGO partners Total 50 330 43.0 15.0 5.0 37.0 EEA 41 424 46.1 16.7 0.3 36.8 Austria 1 082 35.4 32.1 0.1 32.4 Belgium 964 41.2 23.1 0.0 35.7 Bulgaria 208 33.7 11.1 0.5 54.8 Croatia 361 63.4 12.2 0.0 24.4 Cyprus 187 16.0 3.7 0.5 79.7 Czechia 1008 27.0 2.9 0.0 70.1 Denmark 426 50.0 5.9 0.0 44.1 Estonia 174 14.4 6.3 0.0 79.3 Finland 1126 8.2 3.9 0.0 87.9 France* 3 531 75.8 16.8 3.1 4.3 Germany 10 592 41.7 38.3 0.0 20.0 Greece 934 19.2 11.2 0.1 69.5 Hungary 826 30.8 8.1 0.0 61.1 Iceland 18 77.8 11.1 0.0 11.1 Ireland 868 85.9 0.6 0.0 13.5 Italy 3 635 76.8 16.5 0.0 6.6 Latvia 181 28.2 3.3 0.6 68.0 Lithuania 118 39.8 5.1 0.0 55.1 Luxembourg 130 26.9 24.6 0.0 48.5 Malta 206 8.3 2.9 0.0 88.8 Netherlands 1 413 65.7 20.5 0.0 13.7 Norway 2 194 4.3 1.5 0.0 94.2 Poland 1 294 81.7 3.3 0.2 14.8 Portugal* 1 974 59.5 1.9 0.0 38.7 Romania 732 57.7 8.2 0.0 34.2 Slovakia 452 40.0 3.8 0.0 56.2 Slovenia 258 40.7 10.5 0.0 48.8 Spain* 4 002 48.0 4.0 0.0 48.0 Sweden 2 530 11.7 1.0 0.0 87.2 Non-EEA advanced economies 3 726 52.7 14.4 0.1 32.9 Israel 403 6.0 0.7 0.7 92.6 Switzerland* 1 509 28.0 26.7 0.0 45.3 United Kingdom* 1 814 83.5 7.2 0.0 9.3 Western Balkans and Türkiye 939 51.3 8.5 33.5 6.6 Albania 32 90.6 6.2 0.0 3.1 Bosnia and Herzegovina 89 88.8 7.9 0.0 3.4 Kosovo 5 40.0 60.0 0.0 0.0 Montenegro 22 77.3 9.1 4.5 9.1 North Macedonia 71 88.7 9.9 0.0 1.4 Serbia 316 82.6 14.9 0.0 2.5 Türkiye 404 7.7 3.0 77.7 11.6 Eastern Europe and Central Asia 4 241 2.0 0.2 48.9 48.9 Armenia 53 28.3 0.0 17.0 54.7 Azerbaijan 337 3.6 0.0 6.2 90.2 Georgia 169 11.8 0.0 8.3 79.9 Kazakhstan 592 1.5 0.3 1.9 96.3 Moldova 156 3.2 1.3 3.2 92.3 Russia 1 874 0.9 0.1 90.1 8.9 Ukraine 1 060 0.8 0.3 30.8 68.2 * Includes microstate and/or overseas areas. The proportion of participants recruited through the three dating apps varied by country, as did the contribution of national recruitment efforts to overall participation. Overall, Grindr was the most common recruitment source, accounting for 43% of all qualifying participants (n = 21,646). Recruitment though partner NGOs was the second most common, contributing 37% of the sample (n = 18,622). Among transgender and non-binary participants, 66.1% were recruited via NGOs, followed by 26.7% through Grindr, 4.3% via Hornet, and 2.9% via ROMEO. NGO recruitment was particularly effective in reaching transgender individuals, whereas dating apps tended to be more successful in recruiting non-binary participants. In some countries, promotional messages were sent via paid messages on Hornet and Grindr. On Hornet, 17% of recipients opened the message, with open rates ranging from 5.9% and 32.8% depending on the country. Of those who opened the message, 35% clicked on the survey link, with click-through rates varying from 2.7–96.5%. Among those who clicked the link, 25% started the survey and 31% completed it. In contrast, Grindr showed a lower initial engagement: only 11% of users clicked on the link (ranging from 6.9–15.8%). However, among those who clicked, 45% started the survey and 52% completed it—indicating higher conversion rates at later stages of participation. Discussion EMIS-2024 collected comparable data from MSM, transgender and non-binary individuals in 35 languages, promoted via transnational apps and through the websites and social media of primarily non-governmental organisations across 50 countries. We have previously demonstrated the feasibility of such a large, multi-country, multi-language, online-only survey (Weatherburn et al., 2020 ; Weatherburn et al., 2013 ), and the validity of the resulting self-reported HIV prevalence data (Marcus et al., 2012 ). We recruited 50,330 qualifying respondents across all covered countries. Compared to 2017, EMIS-2024 resulted in fewer eligible participants overall and in every country. In 2017, recruitment rates were notably higher, averaging 4.6 overall and 6.5 in the EU (The EMIS Network, 2019 ). Recruitment volume was partly determined by lower advertising budgets than in EMIS-2017. For researchers seeking larger sample sizes, a shorter and more focussed survey may be more effective, particularly as most participants completed EMIS-2024 on smartphones, which was challenging given the median completion time of 35 minutes. EMIS national datasets are available for analysis in 42 countries. National MSM samples are particularly valuable in countries where gay communities and HIV prevention infrastructures are underdeveloped. The cost savings of generating data in this way may also be considerable. Wide-range recruitment was made possible through meaningful involvement of many collaborators in survey design and promotion. Funders can support such outcomes by encouraging stakeholder involvement, clarifying research values and objectives, and defining transparent development and decision-making processes. Our collaboration required flexibility to accommodate diverse national needs and ensure the survey’s suitability across different contexts. Careful design, piloting and presentation helped ensure the survey was acceptable and had both authority and perceived community benefit. Recruiting transgender and non-binary individuals for surveys presents challenges, as stigma, discrimination and confidentiality concerns can deter participation. Inadequate translation, unclear survey design, and poor cultural sensitivity can also hinder engagement. Collaborating with transgender advocacy and community organisations is essential for inclusive recruitment. To engage transgender and non-binary individuals, researchers must foster trust through transparent, culturally aware research methods to ensure accurate representation (Goodman et al., 2019 ). To reach broad coverage across Europe, recruitment was achieved through a patchwork of commercial and community partners. High levels of partner involvement and committed funders were essential. Recognising and respecting the diversity of surveyed communities was key to sustaining broad collaboration. Limitations The scale nature of this study and its diverse populations led to some technical issues. To reduce respondent burden, a routing system was used. Despite pre-testing, this introduced routing errors and missing data for some variables. The data are subject to three main sources of bias: unequal internet access and varying reliance on dating apps; self-selection bias (Evans et al., 2007 ; Mercer et al., 2016 ; Prah et al., 2016 ); and difficulty ensuring equivalent meaning across different language versions of the questionnaire. Geopolitical changes during the survey period also affected data collection. Some countries were excluded from funding for political reasons, and conflict hampered participation in other areas. Representative samples of MSM, transgender and non-binary people are unavailable, so EMIS participants are unlikely to be fully representative. However, online samples of homosexually active men tend to be more diverse than those recruited through gay venues and are broadly demographically representative for MSM who have sex exclusively with men (Prah et al., 2016 ). This is not yet demonstrable for trans or non-binary people due to lack of health data. Online recruitment via dating apps offers efficient access to key populations for HIV prevention and care. Geolocation features allow targeted outreach, and trust in familiar organisations boosts participation (Ocasio et al., 2021 ). Younger MSM tend to see dating apps as a typical way of meeting partners (Arthur & Cabaniss, 2021 ). Those recruited via dating apps tend to be younger, more sexually active, engage in more risk and precautionary behaviours, and report more sexual harms (Prah et al., 2016 )— an important focus within EMIS-2024. As these groups are the target of prevention efforts, these recruitment biases are acceptable. Engagement is also enhanced when people feel the survey is relevant and impactful (Brosnan et al., 2019 ). In this respect, receiving dedicated long-term core funding — as EMIS did in previous rounds through the EU Health Programme — can lend greater authority, including in relation to national public health institutions. The EMIS-2024 experience also highlights that, in many countries across the WHO European Region, collaboration between NGOs and governmental bodies could be strengthened. Moreover, the defunding of HIV prevention in several countries has negatively affected both the capacity and willingness of community organisations to engage in such studies. For national stakeholders, however, it may be more cost-effective to conduct fewer standalone studies in this population and instead rely on international approaches that produce comparable data across countries. Multilingual surveys help include ethnic minorities and expand the scope of questions (Im et al., 2016 ). Offering EMIS in 35 languages improved accessibility and may have yielded samples more reflective of MSM diversity, especially among migrant MSM, than other convenience sampling. Nonetheless, translation challenges remain. Cultural and linguistic differences can distort meaning. Instruments developed in one cultural context may not translate seamlessly to another (Im et al., 2016 ). Both qualitative and statistical checks are necessary to ensure conceptual equivalence (Ware et al., 1995 ). Using gender-neutral language in translations posed further issues, especially in languages with gendered grammar ( e.g. , German, French, Italian, Spanish, Portuguese, Greek), or non-gendered languages ( e.g. , Turkish, Hungarian) (Hord, 2016 ). Conclusions A harmonised questionnaire, shared sampling strategy, and meaningful community involvement were key to generating robust, comparable data across Europe. Up-to-date information is available at www.emis2024.eu . Abbreviations AFAB Assigned female at birth AMAB Assigned male at birth DAH Deutsche Aidshilfe (German AIDS Federation) ECDC European Centre for Disease Prevention and Control EECA Eastern Europe and Central Asia EEA European Economic Area ECOM Eurasian Coalition on Health, Rights, Gender and Sexual Diversity EMIS European MSM Internet Survey EU European Union G4E Grindr for Equality GHPP Global Health Protection Programme HIV Human Immunodeficiency Virus MSM Men who have sex with men NGO Non-governmental organisation LGBT Lesbian, gay, bisexual, trans RKI Robert Koch Institute SEE RCN South Eastern Europe Regional TB and HIV Community Network STI Sexually transmitted infection WHO World Health Organization Declarations Funding The funding structure for EMIS-2024 was developed in collaboration with the implementing partners—German AIDS Federation (DAH), Maastricht University, and Robert Koch Institute (RKI) between March 2022 and August 2023. The following organisations contributed financially to EMIS-2024:German Ministry of Health ( Bundesministerium für Gesundheit , DE ) / Global Health Protection Programme (GHPP, DE ); European Centre for Disease Prevention and Control (ECDC, EU ); Swiss AIDS Federation, Swiss Federal Office of Public Health ( CH ); Luxembourg Health Directorate ( Ministère de la Santé et de la Sécurité sociale , LU ); Norwegian Directorate of Health ( Helsedirektoratet , NO ); The Public Health Agency of Sweden ( Folkhälsomyndigheten , SE ); Sciensano ( Institut Scientifique de Santé Publique , BE ); Estonian Ministry of Social Affairs ( Sotsiaalministeerium , EE ); Health Service Executive ( IE ); Portuguese Directorate-General of Health ( Direção-Geral da Saúde , PT ); Spanish Ministry of Health ( Ministerio de Sanidad , ES ); Central Health Department, Israeli Ministry of Health (משרד הבריאות, IL ); National Institute for Public Health and the Environment (RIVM) / SOAids Nederland ( NL ). Funding for conducting the online survey in Germany was provided by the German Federal Ministry of Health and granted to RKI and DAH. Data collection in the Western Balkans and in Eastern European/Central Asian countries (except Belarus and Russia) was supported through a grant to RKI from the Global Health Protection Programme (GHPP), which is also funded by the German Federal Ministry of Health. All other financial contributions and contractual arrangements were based on a standard contract template with minor adaptations to accommodate the specific needs and capacities of each partner. Conflicts of Interest The authors declare that they have no conflict of interest. Data availability National data has been shared with the funding and community partners. Multi-country EMIS-2024 data is available upon application to the EMIS scientific board. Up-to-date information is available at www.emis2024.eu. Code availability Available upon request from the authors. Authors’ Contributions xx All authors contributed to and approved the final version of the manuscript. Ethics approval Ethics approval for the EMIS-2024 study was granted by the xx on the 30 th of October 2023. Acknowledgements We begin by expressing our sincere thanks to everyone who participated in EMIS-2024. Special appreciation goes to our NGO partners who were instrumental in recruitment—accounting for 37% of all respondents—by promoting the survey through their platforms, social media channels, and by displaying EMIS banners on their websites. We are deeply grateful to all our funders for their financial contributions and continued support, and to each study participant for making their voices heard! A special thank you goes to Steph Niaupari at Grindr for Equality for their instrumental support in recruitment via free messages on Grindr, which significantly contributed to the success of EMIS-2024. The following list acknowledges all EMIS partners by country. Individual names are included when a freelancer served as the main contact or contributed to questionnaire development without formal organisational representation. The order is: main NGO partner, other NGO partners, academic partners, governmental partners, and individuals. Europe: Grindr for Equality, Grindr, ROMEO, Hornet, Aids Action Europe, European AIDS Treatment Group, Eurasian Coalition on Health, Rights, Gender and Sexual Diversity (ECOM), South Eastern Europe Regional TB and HIV Community Network (SEE RCN). Acknowledgements We begin by expressing our sincere thanks to everyone who participated in EMIS-2024. Special appreciation goes to our NGO partners who were instrumental in recruitment—accounting for 37% of all respondents—by promoting the survey through their platforms, social media channels, and by displaying EMIS banners on their websites. We are deeply grateful to all our funders for their financial contributions and continued support, and to each study participant for making their voices heard! A special thank you goes to Steph Niaupari at Grindr for Equality for their instrumental support in recruitment via free messages on Grindr, which significantly contributed to the success of EMIS-2024. The following list acknowledges all EMIS partners by country. Individual names are included when a freelancer served as the main contact or contributed to questionnaire development without formal organisational representation. The order is: main NGO partner, other NGO partners, academic partners, governmental partners, and individuals. Europe: Grindr for Equality, Grindr, ROMEO, Hornet, Aids Action Europe, European AIDS Treatment Group, Eurasian Coalition on Health, Rights, Gender and Sexual Diversity (ECOM), South Eastern Europe Regional TB and HIV Community Network (SEE RCN). AL: Albanian Association of PLWHA. AM: New Generation Humanitarian NGO. AT: Aids Hilfe Wien . BA: Partnerships in Health. BE: Sensoa, Exaequo, Sciensano. BG: GLAS Foundation. CH: Swiss AIDS Federation, Swiss Federal Office of Public Health. CY: AIDS Solidarity Movement, Christos Krasidis. CZ: Česká společnost AIDS pomoc . DE: Deutsche AIDS-Hilfe , Robert Koch Institute, IWWIT. DK: Statens Serum Institut , Dr. Susan Cowan, Dr. Maria Wessmann. EE: Estonia National Institute for Health Development, Dr. Kristi Rüütel, Dr. Sigrid Vorobjov. ES: SEISIDA, STOPSIDA, CEEISCAT, Ministerio de Sanidad . FI: Positiiviset ry . GE: Equality Movement. GR: Positive Voice. HR: Iskorak, Zoran Dominković. HU: Háttér Society. IE: EMIS-2024 Ireland Promotion Sub-Committee, Health Service Executive, Mick Quinlan. IL: Israel AIDS Task Force, Ministry of Health, Prof. Zohar Mor. IT: Fondazione LILA Milano ONLUS, University of Verona. KZ: Global Health Research Center of Central Asia (GHRCCA), Human Health Institute, Public Fund “Community Friends”. LT: Demetra, National Public Health Center. LV: AGIHAS. LU: Ministère de la Santé et de la Sécurité sociale . MD: GENDERDOC-M Information Centre. ME: Cazas – Montenegrin Association against AIDS. MK: Stronger Together (Association for Support of People Living with HIV, Zaedno Posilni). MT: HIV Malta, Infectious Disease Prevention and Control Unit. NL: SOAids, Maastricht University, RIVM; NO: Helseutvalget , University of Tromsø –The Artic University of Norway, Norwegian Institute of Public Health, Prof. Rigmor C. Berg. PL: Fundacja Edukacji Społecznej , Iwona Wawer; PT: GAT Portugal , Instituto de Saúde Pública da Universidade do Porto , Portuguese Directorate-General of Health. RO: ARAS, Tudor Kovacs. RS: TOC – Association for the Development of Sustainable Communities; Institute of Public Health of Serbia, Sladjana Baros. SE: RFSL, Folkhålsomyndigheten . SI: LEGEBITRA, ŠKUC. SK: Pride Kosice. TR: Sami Sarper Yazıcılaroğlu. UA: Alliance for Public Health, Alliance Global. XK: LGBTI Equal Rights Association for Western Balkans and Turkey. Other: Sigma Research, London School of Hygiene & Tropical Medicine. Our sincere thanks extend to Lina Nerlander, Anastasia Pharris, and Teymur Noori (ECDC); Dirk Sander, Jonathan Gregory, Ferenc Bagyinszky, Alexandra Gurinova, Holger Sweers, and Silke Klumb (German AIDS Federation); Marc Eggenberger, Vinicio Albani, Florian Vock (Swiss AIDS Federation); Stefan Enggist (Swiss Federal Office of Public Health); Binod Mahanty (German Ministry of Health); Julia del Amo Valero (Spanish Ministry of Health). 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O., Pires-Afonso, Y., Putnina, R., Rudaitis, K., Siakallis, G., de Stoppelaar, S., Suligoi, B., Hannila-Handelberg, T., Velicko, I., Cabral Verissimo, V., Visser, M., Wessman, M., & Mardh, O. (2024). Sharp increase in gonorrhoea notifications among young people, EU/EEA, July 2022 to June 2023. Euro Surveill, 29 (10). https://doi.org/10.2807/1560-7917.ES.2024.29.10.2400113 Ocasio, M. A., Fernandez, M. I., Joseph, J. M., Rezai, R., & Team, A. C. (2021). Engaging Sexual and Gender Minority Youth in HIV Interventions Through Gay Dating Apps: Recruitment Protocol. JMIR Res Protoc, 10 (6), e28864. https://doi.org/10.2196/28864 Orviz, E., Negredo, A., Ayerdi, O., Vazquez, A., Munoz-Gomez, A., Monzon, S., Clavo, P., Zaballos, A., Vera, M., Sanchez, P., Cabello, N., Jimenez, P., Perez-Garcia, J. A., Varona, S., Del Romero, J., Cuesta, I., Delgado-Iribarren, A., Torres, M., Sagastagoitia, I., Palacios, G., Estrada, V., Sanchez-Seco, M. P., & Grupo Viruela del Simio Madrid. (2022). Monkeypox outbreak in Madrid (Spain): Clinical and virological aspects. J Infect, 85 (4), 412-417. https://doi.org/10.1016/j.jinf.2022.07.005 Pachankis, J. E., Clark, K. A., Burton, C. L., Hughto, J. M. W., Branstrom, R., & Keene, D. E. (2020). Sex, status, competition, and exclusion: Intraminority stress from within the gay community and gay and bisexual men's mental health. J Pers Soc Psychol, 119 (3), 713-740. https://doi.org/10.1037/pspp0000282 Prah, P., Hickson, F., Bonell, C., McDaid, L. M., Johnson, A. M., Wayal, S., Clifton, S., Sonnenberg, P., Nardone, A., Erens, B., Copas, A. J., Riddell, J., Weatherburn, P., & Mercer, C. H. (2016). Men who have sex with men in Great Britain: comparing methods and estimates from probability and convenience sample surveys. Sex Transm Infect https://doi.org/10.1136/sextrans-2015-052389 Reisner, S. L., Poteat, T., Keatley, J., Cabral, M., Mothopeng, T., Dunham, E., Holland, C. E., Max, R., & Baral, S. D. (2016). Global health burden and needs of transgender populations: a review. Lancet, 388 (10042), 412-436. https://doi.org/10.1016/S0140-6736(16)00684-X Salvo, P. F., Farinacci, D., Lombardi, F., Ciccullo, A., Tamburrini, E., Santangelo, R., Borghetti, A., & Di Giambenedetto, S. (2023). Clinical presentation of human monkeypox virus infection during the 2022 outbreak: descriptive case series from a large italian Research Hospital. Virol J, 20 (1), 214. https://doi.org/10.1186/s12985-023-02178-w Schmidt, A. J., & Altpeter, E. (2019). The Denominator problem: estimating the size of local populations of men-who-have-sex-with-men and rates of HIV and other STIs in Switzerland. Sex Transm Infect, 95 (4), 285-291. https://doi.org/10.1136/sextrans-2017-053363 Schmidt, A. J., & Marcus, U. (2023). What's on the rise in Sexually Transmitted Infections? Lancet Reg Health Eur, 34 , 100764. https://doi.org/10.1016/j.lanepe.2023.100764 Semlyen, J., & Hagger-Johnson, G. (2017). Sampling frame for sexual minorities in public health research. J Public Health (Oxf), 39 (3), 644. https://doi.org/10.1093/pubmed/fdw078 Stutterheim, S. E., van Dijk, M., Wang, H., & Jonas, K. J. (2021). The worldwide burden of HIV in transgender individuals: An updated systematic review and meta-analysis. PLoS One, 16 (12), e0260063. https://doi.org/10.1371/journal.pone.0260063 The EMIS Network. (2013). EMIS 2010 – The European Men-Who-Have-Sex-With-Men Internet Survey. Findings from 38 countries. https://www.emis-project.eu/european-report-2010/ The EMIS Network. (2019). EMIS-2017 – The European Men-Who-Have-Sex-With-Men Internet Survey. Key findings from 50 countries . European Centre for Disease Prevention and Control. https://www.emis-project.eu/european-report-2017/ Transgender Europe. (2017). Overdiagnosed but Underserved . https://tgeu.org/overdiagnosed-but-underserved-trans-health-survey Wang, H., Kolstee, J., Casalini, J. L., Hakim, S., Zimmermann, H. M., & Jonas, K. J. (2024). Likelihood of HIV and recent bacterial sexually transmitted infections among transgender and non-binary individuals in 20 European countries, October 2023 to April 2024. Euro Surveill, 29 (48). https://doi.org/10.2807/1560-7917.ES.2024.29.48.2400347 Ware, J. E., Jr., Keller, S. D., Gandek, B., Brazier, J. E., & Sullivan, M. (1995). Evaluating translations of health status questionnaires. Methods from the IQOLA project. International Quality of Life Assessment. Int J Technol Assess Health Care, 11 (3), 525-551. https://doi.org/10.1017/s0266462300008710 Weatherburn, P., Hickson, F., Reid, D. S., Marcus, U., & Schmidt, A. J. (2020). European Men-Who-Have-Sex-With-Men Internet Survey (EMIS-2017): Design and Methods. Sexuality Research and Social Policy, 17 (4), 543-557. https://doi.org/10.1007/s13178-019-00413-0 Weatherburn, P., Schmidt, A. J., Hickson, F., Reid, D., Berg, R. C., Hospers, H. J., Marcus, U., & The EMIS network. (2013). The European Men-who-have-sex-with-men Internet Survey (EMIS): Design and Methods. Sex Res Social Policy, 10 ( 4), 243-257. http://link.springer.com/article/10.1007%2Fs13178-013-0119-4 Winter, S., Diamond, M., Green, J., Karasic, D., Reed, T., Whittle, S., & Wylie, K. (2016). Transgender people: health at the margins of society. Lancet, 388 (10042), 390-400. https://doi.org/10.1016/S0140-6736(16)00683-8 Additional Declarations No competing interests reported. Supplementary Files Annex1and2.docx Cite Share Download PDF Status: Published Journal Publication published 19 Mar, 2026 Read the published version in Sexuality Research and Social Policy → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-6991809\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":true,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":486368072,\"identity\":\"cfe585c6-75ff-46fe-9d5e-dad635133ec6\",\"order_by\":0,\"name\":\"Liana Aphami\",\"email\":\"data:image/png;base64,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\",\"orcid\":\"\",\"institution\":\"Maastricht University\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Liana\",\"middleName\":\"\",\"lastName\":\"Aphami\",\"suffix\":\"\"},{\"id\":486368073,\"identity\":\"194265c0-ece8-4a91-9bd1-98af901c4500\",\"order_by\":1,\"name\":\"Tamás Bereczky\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Deutsche Aidshilfe\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Tamás\",\"middleName\":\"\",\"lastName\":\"Bereczky\",\"suffix\":\"\"},{\"id\":486368074,\"identity\":\"896d93db-0e33-4f53-965c-2dcba0ab88d0\",\"order_by\":2,\"name\":\"Jules Casalini\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Maastricht University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Jules\",\"middleName\":\"\",\"lastName\":\"Casalini\",\"suffix\":\"\"},{\"id\":486368075,\"identity\":\"eb228ba5-8b82-43c6-b59a-31c62ea4021c\",\"order_by\":3,\"name\":\"Nikolay Lunchenkov\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Robert Koch Institute\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Nikolay\",\"middleName\":\"\",\"lastName\":\"Lunchenkov\",\"suffix\":\"\"},{\"id\":486368076,\"identity\":\"6963e24f-1964-4494-ab6a-87437061e075\",\"order_by\":4,\"name\":\"Kai J. 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This includes variations in data on infections and diagnoses, risk and precautionary behaviours, prevention needs, and the performance of related services. For trans and non-binary individuals in particular, data is often entirely lacking, or these groups are grouped under MSM, which prevents key population-specific reporting.\\u003c/p\\u003e\\u003cp\\u003eFor the first time, EMIS includes trans and non-binary participants using a tailored survey instrument. Infection surveillance systems differ widely in terms of coverage, representativeness, and comprehensiveness. This makes it challenging to compare annual HIV/STI diagnosis rates across countries\\u0026mdash;and sometimes within countries over time, especially in the context of emerging pathogens such as the mpox virus. Additionally, novel prevention strategies, such as Doxycycline pre- or post-exposure prophylaxis, are emerging, but their uptake among key populations remain poorly understood.\\u003c/p\\u003e\\u003cp\\u003eReliable surveillance data are essential for monitoring the HIV/STI disease burden. Knowing our epidemics is key to tailoring effective responses. The European Centre for Disease Prevention and Control (ECDC) is the European Union (EU) agency responsible for strengthening countries\\u0026rsquo; capacity to prevent and control infectious diseases, including HIV and STIs. ECDC is mandated to enhance and coordinate behavioural surveillance of infectious diseases at the EU level and support countries to conduct behavioural surveillance related to HIV and STIs (ECDC \\u0026amp; WHO-Europe, 2024). Similarly comparable surveillance data are needed from Eastern Europe and Central Asia (EECA) and have been included in EMIS.\\u003c/p\\u003e\\n\\u003ch3\\u003eCurrent Overview of HIV/STI Diagnoses \\u003c/h3\\u003e\\n\\u003ch3\\u003eMen-who-have-sex-with-men in WHO European Region\\u003c/h3\\u003e\\n\\u003cp\\u003eThe latest data from 2023 reported 112,883 HIV diagnoses in 47 of the 53 countries in the WHO European region. Within European Economic Area (EEA), 24,731 diagnoses were recorded. In Eastern Europe, 77.601 infections were reported, with 11.7% attributed to sex between men. The proportion of HIV diagnoses attributed to sex between men decreased from 52.1% in 2014 to 46.9% in 2023. Despite some progress, HIV remains a major public health issue, with 21 out of 47 countries reporting increases (ECDC \\u0026amp; WHO-Europe, 2024). In many EEA countries, HIV disproportionately affects key populations such as MSM, transgender and non-binary individuals, sex workers, certain migrant groups, and people who inject drugs (ECDC \\u0026amp; WHO-Europe, 2024). Among migrant MSM, HIV diagnoses rose by 37.7% from 2014 (n = 2,659) to 2023 (n = 3,661), especially among those from Latin America, the Caribbean, and central and Eastern Europe.\\u003c/p\\u003e\\u003cp\\u003eSTIs, particularly gonorrhoea and syphilis, are common among MSM in Europe (Mitja et al., \\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e2023\\u003c/span\\u003e). Since the 2022 mpox outbreak, MSM have also been disproportionately affected (ECDC \\u0026amp; WHO-Europe, 2024). Syphilis cases increased by 13% between 2022 and 2023, with 72% of cases among MSM (ECDC, \\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e2025\\u003c/span\\u003e). Gonorrhoea cases in 2023 reached a decade-high, especially among young people and MSM (Nerlander et al., \\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e2024\\u003c/span\\u003e). Other STIs like \\u003cem\\u003eLymphogranuloma venereum\\u003c/em\\u003e remain underdiagnosed among MSM (Cole et al., \\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e2020\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eSince March 2022, 28,632 mpox cases were reported in the WHO European Region, 97% among MSM. HIV prevalence among mpox patients ranged from 39.5% (Spain) (Orviz et al., \\u003cspan citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e2022\\u003c/span\\u003e), 47% (Italy) (Candela et al., \\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e2023\\u003c/span\\u003e), 46.9% (Germany) (Hoffmann et al., \\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e2023\\u003c/span\\u003e), and 56.3% (Italy) (Salvo et al., \\u003cspan citationid=\\\"CR30\\\" class=\\\"CitationRef\\\"\\u003e2023\\u003c/span\\u003e), underlining the need for integrated care.\\u003c/p\\u003e\\u003cp\\u003eTransgender and non-binary individuals face significant health inequities, including poor health outcomes, violence, stigma, and systemic barriers such as criminalization and discrimination (Burgwal et al., \\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e2019\\u003c/span\\u003e; Falck \\u0026amp; Branstrom, \\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e2023\\u003c/span\\u003e; Karniej et al., \\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e2025\\u003c/span\\u003e; Transgender Europe, \\u003cspan citationid=\\\"CR37\\\" class=\\\"CitationRef\\\"\\u003e2017\\u003c/span\\u003e; Winter et al., \\u003cspan citationid=\\\"CR42\\\" class=\\\"CitationRef\\\"\\u003e2016\\u003c/span\\u003e). Gaps in health literacy and limited access to healthcare continue to hinder their well-being (van der Warth, Körner, \\u0026amp; Farin-Glattacker, 2024). HIV and STI prevalence is disproportionately high among transgender women and other transgender individuals assigned male at birth (Stutterheim et al., \\u003cspan citationid=\\\"CR34\\\" class=\\\"CitationRef\\\"\\u003e2021\\u003c/span\\u003e; Wang et al., \\u003cspan citationid=\\\"CR38\\\" class=\\\"CitationRef\\\"\\u003e2024\\u003c/span\\u003e), yet transgender men remain underrepresented in research, often due to small sample sizes (American Psychological Association, \\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e2015\\u003c/span\\u003e). Trans men are frequently perceived as lower risk, though data to support or refute this is limited. The ECDC highlights that transgender and non-binary populations are critically underrepresented in health surveillance, excluding them from essential healthcare strategies and perpetuating structural inequalities (ECDC \\u0026amp; WHO-Europe, 2024).\\u003c/p\\u003e\"},{\"header\":\"Design and Methods\",\"content\":\"\\u003cp\\u003eA Collaborative Survey\\u003c/p\\u003e\\u003cp\\u003eEMIS-2024 was conceived as a large-scale partnership, with a strong emphasis on involving organisations and representatives of affected communities in the study’s design and recruitment. Each step of the process engaged the EMIS Network, drawing on its collective knowledge and needs.\\u003c/p\\u003e\\u003cp\\u003eIn addition to generating data from MSM, EMIS-2024 aimed to include trans and non-binary individuals more broadly, build research capacity, transfer knowledge about online surveys, generate datasets in countries with fewer resources, facilitate dialogue between community, academic, and public health, and maximise the educational impact of survey completion.\\u003c/p\\u003e\\u003cp\\u003eA key benefit of EMIS has been the availability of the questionnaire in all official EEA languages, crucial for countries with large proportions of migrants from southern, eastern, or southeastern Europe. For the same reason we also provided the survey in Arabic, as it has been the most common languages among refugees coming to Europe since 2014.\\u003c/p\\u003e\\u003cp\\u003eThe approach to working with these organisations varied between the Eastern and Western regions (as defined below), depending on local possibilities, requirements, and the complexity of organisational and legal settings. The large number of partners required flexibility from the investigators and coordinators in structuring and operating the collaboration.\\u003c/p\\u003e\\u003cp\\u003ePopulations of Concern: MSM, Transgender and Non-binary Individuals\\u003c/p\\u003e\\u003cp\\u003eWe defined MSM as individuals identifying as men, including both cisgender and transgender men, or non-binary persons, who have sex with men or are sexually attracted to men. \\\"Cisgender\\\" refers to individuals whose gender identity aligns with the sex they were assigned at birth (American Psychological Association, \\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e2015\\u003c/span\\u003e). Participants were required to be at least 16 years old, except in Cyprus and Ireland (17 years) and Türkiye (18 years).\\u003c/p\\u003e\\u003cp\\u003eIn contrast to EMIS-2017, EMIS-2024 expanded recruitment to include transgender women and non-binary individuals. Non-binary individuals, an integral part of the transgender community, are often marginalised, with limited data on their health neds (Matsuno \\u0026amp; Budge, \\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e2017\\u003c/span\\u003e). This highlights the importance of understanding their sexual health requirements (Druckler et al., \\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e2022\\u003c/span\\u003e). However, cisgender women were not included in the study and were not considered part of the population of concern.\\u003c/p\\u003e\\u003cp\\u003eMethods of Generating Data in EMIS-2024\\u003c/p\\u003e\\u003cp\\u003eCollecting robust data on minority groups, especially those with stigmatised identities or sexual behaviours, remains challenging. This is particularly true for transgender populations, as global estimates of their size are limited. Determining this population’s size is further complicated by diverse gender identities, varied transition experiences, and the stigma they face. Population-based surveys suggest that around 0.3–1.3% of individuals identify as transgender, with a minority identifying as non-binary, though not all non-binary individuals consider themselves transgender (Reisner et al., \\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e2016\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eResearch on transgender health is constrained by a lack of population-based studies, longitudinal research, and consistent public health surveillance. The exclusion of transgender-inclusive measures in surveys further limits data collection, hindering the assessment of health disparities. Transgender health risks and resilience are shaped by biological, behavioural, social, and structural factors, underlining the need for an inclusive approach (Winter et al., \\u003cspan citationid=\\\"CR42\\\" class=\\\"CitationRef\\\"\\u003e2016\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eDefining populations such as men who have sex with men (MSM) and transgender individuals is complex. The stigma attached to same-sex sexual activity and transgender identities, alongside the absence of sampling frames, makes random sampling difficult in many countries. While small representative samples can be incorporated into national population surveys (Mercer et al., \\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e2016\\u003c/span\\u003e), larger-scale studies often rely on convenience sampling, limiting their generalizability (Semlyen \\u0026amp; Hagger-Johnson, \\u003cspan citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e2017\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eEMIS-2024 expanded to include trans individuals more broadly and built on prior multi-country research. EMIS-2024 followed EMIS-2010 (The EMIS Network, \\u003cspan citationid=\\\"CR35\\\" class=\\\"CitationRef\\\"\\u003e2013\\u003c/span\\u003e; Weatherburn et al., \\u003cspan citationid=\\\"CR41\\\" class=\\\"CitationRef\\\"\\u003e2013\\u003c/span\\u003e) and EMIS-2017 (The EMIS Network, \\u003cspan citationid=\\\"CR36\\\" class=\\\"CitationRef\\\"\\u003e2019\\u003c/span\\u003e; Weatherburn et al., \\u003cspan citationid=\\\"CR40\\\" class=\\\"CitationRef\\\"\\u003e2020\\u003c/span\\u003e) as part of a multi-language, pan-European surveillance effort focussed on morbidities, behaviours, prevention needs, and intervention performance. Recruitment shifted largely to gay dating apps, which are now widely used (Dhoest, \\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e2022\\u003c/span\\u003e). The first wave of EMIS was undertaken just before the advent of smartphone-based geo-spatial apps. Such apps now play a major role in reaching participants, though fatigue was evident, seen in lower participant yield compared to EMIS-2017.\\u003c/p\\u003e\\u003cp\\u003eMost online surveys focus on regional or national populations of MSM and/or trans people, with comparability between countries being challenging due to differences in recruitment methods, questionnaire items, and response sets. Additionally, different definitions of MSM lead to varying sample compositions.\\u003c/p\\u003e\\u003ch2\\u003eEstablishing the Eastern and Western Regions of EMIS-2024\\u003c/h2\\u003e\\u003cp\\u003eUnlike previous EMIS waves, EMIS-2024 had a more complex funding and operational structure due to political circumstances, including the wars in Russia and Ukraine, and Israel/Gaza. The geographical scope was thus divided into two regions: Eastern and Western, with distinct timelines and recruitment strategies.\\u003c/p\\u003e\\u003cp\\u003eCountries receiving national funding are shown in dark blue, those in lighter blue were included without funding, as their languages were already covered. Countries co-funded by ECDC are highlighted in light green, and those funded by Germany’s Global Health Protection Programme (GHPP) are in dark green. EMIS-2024 was coordinated by DAH and RKI, as illustrated in Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e. Belarus and Lebanon were part of previous EMIS waves but not included in EMIS-2024, mostly due to lack of national partners.\\u003c/p\\u003e\\u003ch3\\u003eWestern Region\\u003c/h3\\u003e\\u003cp\\u003eDAH was responsible for the organisational, financial, and contractual arrangements in the Western region, which included EEA countries, as well as Israel, Switzerland, the UK, and the four microstates.\\u003c/p\\u003e\\u003cp\\u003eThe coordination of translations, recruitment and communication in Germany was jointly organised by RKI and DAH. Coordination in Türkiye was a joint responsibility of RKI and DAH. Coordination in Russia was a joint responsibility of RKI, DAH, and the University of Tromsø – The Arctic University of Norway. Formal agreements were established with NGOs and community organisations in the region to carry out translations and support recruitment efforts. Each organisation was compensated with a standard fee for its contributions.\\u003c/p\\u003e\\u003ch3\\u003eEastern Region\\u003c/h3\\u003e\\u003cp\\u003eRKI managed the organisational, financial, and contractual arrangements in the Eastern Region, which included the Western Balkans, Eastern Europe and parts of Central Asia. GHPP funding supported translations and survey promotion in this region, but did not include Uzbekistan, Turkmenistan, Kyrgyzstan, or Tajikistan—limiting Central Asian participation to Kazakhstan. RKI subcontracted ECOM (for Armenia, Azerbaijan, Georgia, Kazakhstan, Moldova, and Ukraine) and SEE RCN (for the Western Balkans) to coordinate activities, drawing on their regional expertise and strong HIV/STI prevention networks.\\u003c/p\\u003e\\u003cp\\u003eRecruitment Targets\\u003c/p\\u003e\\u003cp\\u003eOur goal was to recruit at least 100 eligible residents in each of the 46 target countries, which we considered a viable sample size for national planning purposes. We also extended the invitation to include individuals residing in the four non-EU microstates adjacent to or encompassed by these countries. Although we did not expect to recruit more than 50 participants from these microstates, we felt it was important not to exclude them from the opportunity to participate. Cases from these microstates were therefore included in the datasets of neighbouring countries: Andorra with Spain, Liechtenstein with Switzerland, Monaco with France, and San Marino with Italy.\\u003c/p\\u003e\\u003cp\\u003eWe committed to creating and sharing national datasets with lead agencies in countries that achieved at least 50 eligible respondents, while recognising that this might not be feasible in countries with small populations. Countries falling below this threshold are clearly marked in the data maps generated for EMIS-2024, and caution is advised when interpretating findings for these countries, as their sample sizes may be too small to support reliable conclusions.\\u003c/p\\u003e\\u003cp\\u003e(Re-)Building the Network\\u003c/p\\u003e\\u003cp\\u003eThe formal process of building and re-establishing the EMIS network began in August 2023, although informal discussions around participation and logistics had already started in early 2023. Using contact details from EMIS-2017, both regional coordinators systematically reached out to organisations and individuals to assess their interest and readiness to take part. In addition to reconnecting with EMIS-2017 partners, the coordinators actively contracted new NGOs and community organisations to ensure broad and effective outreach to key populations. Specific efforts were made by one of the co-authors (JLC) to engage trans organisations across Europe.\\u003c/p\\u003e\\u003cp\\u003eQuestionnaire Design\\u003c/p\\u003e\\u003cp\\u003eEMIS-2024 was designed to replicate EMIS-2017 and EMIS-2010, generating essential data for planning and monitoring interventions related to HIV, STIs, and viral hepatitis. Core questions remained largely unchanged to enable trend analyses. At the request of ECDC, key additions included items on hepatitis testing and STI treatment. At the request of ECDC, new items were added on hepatitis testing and STI treatment. The core team further expanded the survey with sections on antibiotic STI prophylaxis, HPV, and mpox (formerly \\\"monkeypox\\\"), and incorporating emerging issues such as intra-minority stress.\\u003c/p\\u003e\\u003cp\\u003eWhile the core team led content development, the wider EMIS network played a key role in translating the questionnaire into 34 languages. Given the sensitive and nuanced nature of sexual health topics, community-based translation ensured culturally appropriateness and comparability across countries.\\u003c/p\\u003e\\u003cp\\u003eThe questionnaire continued to centre on MSM, while acknowledging the distinct yet intimately interconnected aspects of sexuality and gender identity. A key aim was to meet emerging needs within the community, particularly among transgender individuals, who are often misclassified within MSM categories in traditional HIV surveillance, which masks their specific vulnerabilities (Stutterheim et al., \\u003cspan citationid=\\\"CR34\\\" class=\\\"CitationRef\\\"\\u003e2021\\u003c/span\\u003e). EMIS-2024 aimed to disaggregate data by gender identity and sex assigned at birth to address these gaps.\\u003c/p\\u003e\\u003cp\\u003e Tailored filters and question routing were developed to reflect participants' lived experiences. Respondents were told, “In this survey, we use ‘sex’ to mean physical contact to orgasm (or close to orgasm) for one or both partners”. This definition identified those who had ever had sex with men, but individuals attracted to men who had not had sex with men were also included, recognising the relevance of their inclusion for future planning.\\u003c/p\\u003e\\u003cp\\u003eThe study aimed to guide effective HIV and STI prevention and treatment interventions by assessing prevalence of morbidities, risks and precautionary behaviours, broader needs and interventions performance—particularly around mental health and substance use. This syndemic-informed, holistic approach aligns with the work of our collaborators across these health domains.\\u003c/p\\u003e\\u003cp\\u003eTo balance continuity and innovation, core questions from EMIS-2017 were retained, while new items were added on mpox, Doxy-P(r)EP, stigma and intra-minority stress. Previously removed questions on sexual practices with non-steady partner were re-included, reflecting evidence of the impact of sexual repertoire on STI risk (Schmidt \\u0026amp; Marcus, \\u003cspan citationid=\\\"CR32\\\" class=\\\"CitationRef\\\"\\u003e2023\\u003c/span\\u003e). We carefully refined questions to improve clarity, comparability, and minimise participant burden.\\u003c/p\\u003e\\u003cp\\u003eDevelopment was guided by a conceptual map derived from EMIS-2017. Ineffective or unclear items were removed, and new sections added to reflect current health trends, including chemsex and trans-specific topics.\\u003c/p\\u003e\\u003cp\\u003eIn June 2023 a dedicated trans sub-study was incorporated. While trans-related questions had been included previously, this was the first time the survey featured tailored routing content for trans participants. Language was made more inclusive of diverse trans experiences, and new questions covered passing, gender-affirming care, body image, stigma; internalised transnegativity, and trans-related competition and exclusion sub-scales (adapted from Pachankis et al., \\u003cspan citationid=\\\"CR27\\\" class=\\\"CitationRef\\\"\\u003e2020\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eParticipants whose gender identity differed from their sex assigned at birth were asked if they identified as part of the transgender community. Those who did received a set of trans-specific questions, routed based on their current body parts.\\u003c/p\\u003e\\u003cp\\u003eThe draft survey was developed in English on Qualtrics XM (Qualtrics International Inc., Provo, Utah, USA) and pre-tested by the EMIS Network. Consultations took place from November 2023 and February 2024—earlier in the Eastern Region due to funding timelines. Feedback informed refinements to both the English and translated versions. In the Eastern Region, some final adjustments were made after the survey went live.\\u003c/p\\u003e\\u003cp\\u003eWe conducted an item analysis to ensure balanced coverage across demographics, morbidities, behaviours, needs, and interventions. The final version of the EMIS-2024 questionnaire, completed in February 2024, reflects an iterative and collaborative development process—balancing comprehensiveness, cultural relevance, data quality, and respondent experience.\\u003c/p\\u003e\\u003ch3\\u003eTranslations\\u003c/h3\\u003e\\u003cp\\u003eTranslation was coordinated within the EMIS Network. Translators were offered payment in countries that did not co-fund EMIS, since in co-funding countries, translation was considered part of their non-financial contribution. Translations were based on Excel exports from Qualtrics, with colour coding to highlight new, modified, or trans-specific items.\\u003c/p\\u003e\\u003cp\\u003eThree documents supported translators: their language’s EMIS-2017 translation (for consistency); a detailed survey structure, and written, visual, and verbal instructions to reduce errors and safe time. Language and terminology were updated for the trans sub-study. Additionally, 34 new items were added for the trans participants, and 112 new items overall. A broad range of issues was raised during the review process, all of which were carefully considered and addressed. This led to further refinements, corrections of translation and routing errors, and identification of technical issues. Translators were asked to use previous translations unless a change was justified, and to update the EMIS-2017 version accordingly.\\u003c/p\\u003e\\u003cp\\u003eNational partners checked routing and confirmed terminology matched norms for their target group. They signed off the main language version(s) for each country. Proof-readers ensured consistency while preserving appropriate cultural variations—\\u003cem\\u003ee.g\\u003c/em\\u003e., explicitness or formal/informal address. Simple rather than specialised terms were preferred throughout.\\u003c/p\\u003e\\u003cp\\u003eThe survey was available in 35 languages: Albanian, Arabic, Armenian, Azeri, Bosnian/Croatian/Montenegrin/Serbian, Bulgarian, Czech, Danish, Dutch, English, Estonian, Finnish, French, Georgian, German, Greek, Hebrew, Hungarian, Italian, Kazakh, Latvian, Lithuanian, Macedonian, Malti, Norwegian, Polish, Portuguese, Romanian, Russian, Slovak, Slovenian, Spanish, and Swedish, Turkish and Ukrainian.\\u003c/p\\u003e\\u003cp\\u003eTranslation issues were minimal. Missing headers were added (English, Dutch, Russian and Spanish), and translation errors corrected (Russian, Turkish, Italian, Spanish), without compromising data quality. One question was removed from Turkish, Arabic, and Armenian versions due to an error. Further detail is available in \\u003cb\\u003eAnnex 1\\u003c/b\\u003e.\\u003c/p\\u003e\\u003ch3\\u003eDuration Evaluation\\u003c/h3\\u003e\\u003cp\\u003eThree people in the Netherlands and Germany tested the timed survey. The final version took on average 30 minutes to complete—longer than in 2017. Despite efforts to reduce length, the diverse stakeholder priorities meant further cuts unfeasible. Estimated duration was shown on the survey’s entry page.\\u003c/p\\u003e\\u003ch2\\u003eFinal Integrated Questionnaire\\u003c/h2\\u003e\\u003cp\\u003eThe final questionnaire included 441 data items, though not all were shown to every respondent. Routing was used to minimise time—for instance, only participants with a steady partner were asked about relationship length.\\u003c/p\\u003e\\u003cp\\u003e The final English version formed the basis for the ethics application, which received a positive opinion from Maastricht University’s Ethics Review Committee Psychology and Neuroscience on 30 October 2023 (ref: ERCPN-OZL_262_08_01_2023).\\u003c/p\\u003e\\u003cp\\u003eTo improve usability, each question appeared on a separate page in both the desktop and mobile versions.\\u003c/p\\u003e\\u003ch3\\u003eQuestionnaire Structure\\u003c/h3\\u003e\\u003cp\\u003eFigure \\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e outlines the main sections of the questionnaire. Figure\\u0026nbsp;3 illustrates the content of the final questionnaire, structured into five conceptual layers.\\u003c/p\\u003e\\u003cp\\u003eThese layers follow a causal logic: interventions shape needs, needs influence behaviours, and behaviours impact health. While the model informed the survey design and the distribution of items, its purpose was not to test the model itself, but to identify behavioural targets and uncover the unmet needs driving them.\\u003c/p\\u003e\\u003ch3\\u003eQuestion Formats\\u003c/h3\\u003e\\u003cp\\u003eSome concepts were measured by single questions; others needed validated multi-item scales. Recency-based event questions asked “When did you last do X?”, allowing both recent (\\u003cem\\u003ee.g.\\u003c/em\\u003e, within the last 4 weeks, 6 months, 12 months) and lifetime experience. This format shows population-level activity density but not individual frequency.\\u003c/p\\u003e\\u003cp\\u003eEMIS-2024 enables calculation of 31 Dublin Declaration Monitoring (DDM) indicators on HIV/STIs among MSM (ECDC, \\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e2024\\u003c/span\\u003e). Variables were selected in collaboration with ECDC.\\u003c/p\\u003e\\u003cp\\u003eRecruitment\\u003c/p\\u003e\\u003ch2\\u003eIdentifying Recruitment Settings\\u003c/h2\\u003e\\u003cp\\u003eEMIS-2024 was promoted through a mix of channels: (1) websites of supporting national and international organisation (public, commercial, and NGO sectors in HIV/LGBT communities); (2) general society media platforms (\\u003cem\\u003ee.g\\u003c/em\\u003e., Facebook, Instagram, LinkedIn); and (3) MSM-targeted dating apps and websites, notably Grindr, ROMEO, and Hornet). Recruitment strategies and timelines varied across countries and between the Eastern and Western Regions.\\u003c/p\\u003e\\u003cp\\u003eInitial promotion began in December 2023 via paid Grindr messages in Germany and the Western Balkans and through Hornet in Russia, Azerbaijan, Armenia, Georgia, Kazakhstan, Moldova, and Ukraine. In January 2024, Grindr campaigns expanded to Hungary, the Netherlands, the UK and Ireland, Portugal, Romania, Italy, and Czechia, and Slovakia. Hornet inbox messages followed in Türkiye and France. February saw continued Grindr campaigns (text and inbox messages) in Romania, Italy, Czechia, Slovakia, and Poland, alongside additional promotions led by local partners across Europe, Western and Central Asia and Israel.\\u003c/p\\u003e\\u003cp\\u003eGrindr4Equality (G4E) led two pan-European campaigns free of charge in April and June 2024, reaching 43 countries with targeted messages. ROMEO joined the effort in May 2024, further boosting visibility.\\u003c/p\\u003e\\u003cp\\u003eIn the Eastern Region, local HIV/STI prevention organisations distributed the survey directly. NGOs were incentivised via a tiered payment system. For instance, in Armenia, Azerbaijan, Georgia, Ukraine, Moldova and Kazakhstan, outreach workers received EUR 4 per recruit and shared the survey in person during client visits or via messenger services such as WhatsApp or Telegram.\\u003c/p\\u003e\\u003ch2\\u003eAdvertising Management\\u003c/h2\\u003e\\u003cp\\u003eThe G4E campaign featured bilingual pop-up messages—first in English and local languages, later expanded to include Arabic and Russian, reflecting widely spoken migrant languages. Study staff liaised with national partners to support promotional planning. In the Western Region, NGOs received modest funding to coordinate local promotions.\\u003c/p\\u003e\\u003cp\\u003eDue to technical limitations in Qualtrics, URL tracking of recruitment links was less precise than with Demographics in 2017. Nonetheless, 75 unique URLs were issued to different recruiters and partners.\\u003c/p\\u003e\\u003cp\\u003eA visual identity for EMIS-2024, developed by an external consultant in February 2024, was made available free of charge. All promotional elements could be adapted locally. The English tagline “Your voice—our strength!” was translated or localised as needed. Offline materials were rarely used but made available in printable formats where necessary.\\u003c/p\\u003e\\u003ch2\\u003eSoft Launch\\u003c/h2\\u003e\\u003cp\\u003eFollowing translation testing by partner organisations, a ‘soft launch’ began on 15 December 2023 in the Eastern Region. Test links allowed partners and translators to explore the survey in English and local languages. Feedback was to coordinators, and. changes were centrally implemented by the data coordinator at Maastricht University, with strict version control. Updates were made to a master version of the survey and then cloned for recruitment use. This process continued to June 2024. Major modifications are discussed in the Limitations section.\\u003c/p\\u003e\\u003cp\\u003eActive promotion commenced on 22 December 2023 in Germany, Armenia, Azerbaijan, Georgia, Kazakhstan, Moldova, Russia, Ukraine and the Western Balkans. The survey was made available in 18 languages initially, with additional languages (including Portuguese, Italian, French, Latvian, Slovak, Lithuanian, Bulgarian, Czech, Greek, Polish, Slovenian, Spanish, Turkish, Swedish, Hebrew, Malti and Norwegian) added in February 2024.\\u003c/p\\u003e\\u003cp\\u003eThe survey remained open for six months (22 December 2023–31 June 2024). Due to regional differences in recruitment pace, timelines were staggered. No participant incentives were offered beyond the opportunity to contribute. Monitoring occurred bi-weekly, allowing recruitment strategies to be adjusted for efficiency and reach. The original deadline (March 2024) was extended twice to accommodate for slower uptake, aiming to maximise both visibility and participation.\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003eReturns and Exclusions\\u003c/p\\u003e\\u003cp\\u003ePartially completed surveys\\u0026mdash;where participants navigated away before clicking \\u0026lsquo;submit\\u0026rsquo;\\u0026mdash;were included if 95% or more of the questionnaire had been completed. These entries were captured and included in the final dataset after a 30-days grace period. Inclusion in the final dataset required completion of at least 95% of the survey.\\u003c/p\\u003e\\u003cp\\u003eData cleaning followed a four-step procedure.\\u003c/p\\u003e\\u003cp\\u003e\\u003col\\u003e\\u003cspan\\u003e\\u003cli\\u003e\\u003cp\\u003e\\u003cb\\u003eInitial filtering\\u003c/b\\u003e removed entries with less than 95% completion, duplicate entries, participants who did not give consent, and responses missing answers to compulsory questions.\\u003c/p\\u003e\\u003c/li\\u003e\\u003c/span\\u003e\\u003cspan\\u003e\\u003cli\\u003e\\u003cp\\u003e\\u003cb\\u003eEligibility screening\\u003c/b\\u003e excluded cis women, individuals not residing in eligible countries, those under the minimum age (16 years; 17 years in Ireland and Cyprus, 18 in T\\u0026uuml;rkiye), and people who neither had sex with men nor expressed interest in doing so.\\u003c/p\\u003e\\u003c/li\\u003e\\u003c/span\\u003e\\u003cspan\\u003e\\u003cli\\u003e\\u003cp\\u003e\\u003cb\\u003eLogical consistency checks\\u003c/b\\u003e targeted highly inconsistent responses\\u0026mdash;for instance, reporting retirement under the age of 30; age mismatches between current age, age at first sex/intercourse, years living in the country of residence post migration, or HIV diagnosis; implausible partners counts; and gender identity inconsistencies (\\u003cem\\u003ee.g.\\u003c/em\\u003e, identifying as a man, assigned at female at birth but not identifying as part of the trans community). Non-binary participants were retained regardless of their sex assigned at birth.\\u003c/p\\u003e\\u003c/li\\u003e\\u003c/span\\u003e\\u003cspan\\u003e\\u003cli\\u003e\\u003cp\\u003e\\u003cb\\u003eTime-based exclusions\\u003c/b\\u003e identified submissions with unrealistically short response times. Timing variables were categorised as: \\u0026lt;3 seconds, 3\\u0026ndash;5.99 seconds, 6\\u0026ndash;12 seconds, and \\u0026gt;\\u0026thinsp;12 seconds. Responses where the average time per answer was under three seconds were removed.\\u003c/p\\u003e\\u003c/li\\u003e\\u003c/span\\u003e\\u003c/ol\\u003e\\u003c/p\\u003e\\u003cp\\u003eOut of 165,380 submissions, 50,330 cases qualified. Full details of inclusion and exclusion processes, and final case counts per country, are provided in \\u003cb\\u003eAnnex 2\\u003c/b\\u003e.\\u003c/p\\u003e\\u003cp\\u003eRecruitment Numbers and Response Rates\\u003c/p\\u003e\\u003cp\\u003eTable\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e presents the number of qualifying cases by country, alongside summary totals (bolded) for: all countries combined; EEA countries; non-EEA advanced economies (Switzerland, the UK, and Israel); the Western Balkans and T\\u0026uuml;rkiye; and EECA countries, comprising non-Baltic countries of the former Soviet Union states.\\u003c/p\\u003e\\u003cp\\u003eRecruitment rates were calculated by dividing the number of qualifying cases by the estimated adult male population (aged 15\\u0026ndash;64). Across all countries, the overall recruitment rate was 1.9 per 10,000 (EEA: 2.9). Country level rates ranged from 0.01 (Kosovo and T\\u0026uuml;rkiye) to 11.6 (Malta) and 12.4 (Norway).\\u003c/p\\u003e\\u003cp\\u003eFor the purposes of prevention planning among MSM, we provide a crude estimate of the MSM population based on 3% of the adult male population (aged 15\\u0026ndash;64). This estimate does not account for the likely reality that, just as MSM within a country tend to concentrate in larger, more gay-friendly cities, they may also migrate from countries with high levels of homonegativity to those with lower levels. As a result, estimates in more homonegative countries may be inflated, while those in more inclusive countries may be underestimated. The literature suggests that the proportion of MSM generally ranges between 2% and 4% (Mercer et al., \\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e2013\\u003c/span\\u003e; Schmidt \\u0026amp; Altpeter, \\u003cspan citationid=\\\"CR31\\\" class=\\\"CitationRef\\\"\\u003e2019\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eDatasets\\u003c/p\\u003e\\u003cp\\u003eData were organised into national datasets based on country of residence, regardless of the language used or country of birth. A combined pan-European dataset was also created. National datasets were produced for all 42 countries with at least 50 qualifying cases. Eight countries did not reach this threshold.\\u003c/p\\u003e\\u003cp\\u003eIn three of these (Andorra [9 cases], Monaco [2 cases], Liechtenstein [4 cases]), cases were merged into datasets of adjoining or surrounding countries (Spain, France, Switzerland, respectively), because a viable sample size was never expected. No responses were received from San Marino.\\u003c/p\\u003e\\u003cp\\u003eFour other countries\\u0026mdash;Iceland (19 cases), Albania (31 cases), Kosovo (5 cases), and Montenegro (21 cases)\\u0026mdash;are not included in any national dataset.\\u003c/p\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e\\u003ccaption language=\\\"En\\\"\\u003e\\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e\\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\u003cp\\u003eEMIS-2024 qualifiers and recruitment rates\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/caption\\u003e\\u003ccolgroup cols=\\\"8\\\"\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c6\\\" colnum=\\\"6\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c7\\\" colnum=\\\"7\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c8\\\" colnum=\\\"8\\\"\\u003e\\u003c/div\\u003e\\u003cthead\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eCountry\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eQualifying cases\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003eN Cisgender men\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003eN Non-binary individuals\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003eN Transgender individuals\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003eTotal male population aged 15\\u0026ndash;64, in 1000s\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003eRelative response rate**\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003eCrude MSM estimate, in 1000s***\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eTotal\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e50 330\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e46 881\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e1 813\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e1 636\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e279 719\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e1.9\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e8 392\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eEEA\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e41 424\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e38 659\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e1 398\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e1 367\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e145 064\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e2.9\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e4 352\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003c/thead\\u003e\\u003ctbody\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eAustria\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e1 082\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e967\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e65\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e50\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e2 965\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e3.6\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e89\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eBelgium\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e964\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e888\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e46\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e30\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e3 660\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e2.6\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e110\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eBulgaria\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e208\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e186\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e10\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e12\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e2 154\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e1.0\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e65\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eCroatia\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e361\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e353\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e5\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e3\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e1 236\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e6.7\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e37\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eCyprus\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e187\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e180\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e4\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e3\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e312\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e6.0\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e9\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eCzechia\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e1008\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e950\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e29\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e29\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e3 481\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e2.9\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e104\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eDenmark\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e426\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e381\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e29\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e16\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e1 879\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e2.3\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e56\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eEstonia\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e174\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e114\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e21\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e39\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e426\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e4.1\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e13\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eFinland\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e1126\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e841\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e116\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e169\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e1 720\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e6.5\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e52\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eFrance*\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e3 531\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e3 360\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" 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colname=\\\"c6\\\"\\u003e\\u003cp\\u003e203\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e1.1\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e6\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eNorth Macedonia\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e71\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e68\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e2\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e1\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e679\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e1.0\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e20\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eSerbia\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e316\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e299\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e9\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e8\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e2 197\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e1.4\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e66\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eT\\u0026uuml;rkiye\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e404\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e351\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e40\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e13\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e29 016\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e0.1\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e871\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eEastern Europe and Central Asia\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e4 241\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e3 982\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e154\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e105\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e73 074\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e0.7\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003e2 192\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eArmenia\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e53\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e47\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e5\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e1\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e945\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e0.6\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e28\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eAzerbaijan\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e337\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e279\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e19\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e39\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e3 612\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e0.9\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e108\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eGeorgia\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e169\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e158\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e7\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e4\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e1 207\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e1.4\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e36\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eKazakhstan\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e592\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e558\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e19\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e15\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e6 083\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e1.0\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e183\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eMoldova\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e156\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e144\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e7\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e5\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e933\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e1.7\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e28\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eRussia\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e1 874\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e1 778\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e69\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e27\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e47 373\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e0.4\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e1 421\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eUkraine\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e1 060\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e1 018\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e28\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e14\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e12 920\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e0.8\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e388\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tbody\\u003e\\u003c/colgroup\\u003e\\u003c/table\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003e* Includes microstate and/or overseas areas; ** Qualifying cases divided by 10,000 males aged 15\\u0026ndash;64; *** at 3% of the male population aged 15\\u0026ndash;64; \\u003csup\\u003e\\u0026Dagger;\\u003c/sup\\u003eThis designation is without prejudice to positions on status and is in line with UNSCR 1244/1999 and the International Court of Justice Opinion on the Kosovo declaration of independence.\\u003c/p\\u003e\\u003cdiv id=\\\"Sec15\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eEMIS Recruitment Sources\\u003c/h2\\u003e\\u003cp\\u003eMany EMIS partners actively promoted EMIS-2024 through their websites and social media channels and encouraged other national organisations to support recruitment efforts. Survey URLs were widely shared among recruiting organisations and individuals. Although the original goal of precisely tracking how many participants each recruiter generated could not be achieved due to technical limitations, we were able to categorise recruitment contributions across the three main dating apps and EMIS partners.\\u003c/p\\u003e\\u003cp\\u003eTable\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e shows the total number of qualifying cases by country, broken down by recruitment source. It also includes summary totals (bolded) for: all countries combined; countries within the EEA; non-EEA advanced economies; the Western Balkans and T\\u0026uuml;rkiye; and EECA.\\u003c/p\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e\\u003ccaption language=\\\"En\\\"\\u003e\\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e\\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\u003cp\\u003eRecruitment sources\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/caption\\u003e\\u003ccolgroup cols=\\\"6\\\"\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c6\\\" colnum=\\\"6\\\"\\u003e\\u003c/div\\u003e\\u003cthead\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eCountry\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eQualifying cases\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e% via Grindr \\u0026amp; G4E\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e% via ROMEO\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e% via Hornet\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e% via NGO partners\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eTotal\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e50 330\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e43.0\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e15.0\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e5.0\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e37.0\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eEEA\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e41 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colname=\\\"c2\\\"\\u003e\\u003cp\\u003e156\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e3.2\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e1.3\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e3.2\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e92.3\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eRussia\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e1 874\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e0.9\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.1\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e90.1\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e8.9\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eUkraine\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e1 060\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e0.8\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.3\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e30.8\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e68.2\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tbody\\u003e\\u003c/colgroup\\u003e\\u003c/table\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003e* Includes microstate and/or overseas areas.\\u003c/p\\u003e\\n\\u003cp\\u003eThe proportion of participants recruited through the three dating apps varied by country, as did the contribution of national recruitment efforts to overall participation.\\u003c/p\\u003e\\u003cp\\u003eOverall, Grindr was the most common recruitment source, accounting for 43% of all qualifying participants (n\\u0026thinsp;=\\u0026thinsp;21,646). Recruitment though partner NGOs was the second most common, contributing 37% of the sample (n\\u0026thinsp;=\\u0026thinsp;18,622). Among transgender and non-binary participants, 66.1% were recruited via NGOs, followed by 26.7% through Grindr, 4.3% via Hornet, and 2.9% via ROMEO. NGO recruitment was particularly effective in reaching transgender individuals, whereas dating apps tended to be more successful in recruiting non-binary participants.\\u003c/p\\u003e\\u003cp\\u003eIn some countries, promotional messages were sent via paid messages on Hornet and Grindr. On Hornet, 17% of recipients opened the message, with open rates ranging from 5.9% and 32.8% depending on the country. Of those who opened the message, 35% clicked on the survey link, with click-through rates varying from 2.7\\u0026ndash;96.5%. Among those who clicked the link, 25% started the survey and 31% completed it.\\u003c/p\\u003e\\u003cp\\u003eIn contrast, Grindr showed a lower initial engagement: only 11% of users clicked on the link (ranging from 6.9\\u0026ndash;15.8%). However, among those who clicked, 45% started the survey and 52% completed it\\u0026mdash;indicating higher conversion rates at later stages of participation.\\u003c/p\\u003e\\u003c/div\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eEMIS-2024 collected comparable data from MSM, transgender and non-binary individuals in 35 languages, promoted via transnational apps and through the websites and social media of primarily non-governmental organisations across 50 countries. We have previously demonstrated the feasibility of such a large, multi-country, multi-language, online-only survey (Weatherburn et al., \\u003cspan citationid=\\\"CR40\\\" class=\\\"CitationRef\\\"\\u003e2020\\u003c/span\\u003e; Weatherburn et al., \\u003cspan citationid=\\\"CR41\\\" class=\\\"CitationRef\\\"\\u003e2013\\u003c/span\\u003e), and the validity of the resulting self-reported HIV prevalence data (Marcus et al., \\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e2012\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eWe recruited 50,330 qualifying respondents across all covered countries. Compared to 2017, EMIS-2024 resulted in fewer eligible participants overall and in every country. In 2017, recruitment rates were notably higher, averaging 4.6 overall and 6.5 in the EU (The EMIS Network, \\u003cspan citationid=\\\"CR36\\\" class=\\\"CitationRef\\\"\\u003e2019\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eRecruitment volume was partly determined by lower advertising budgets than in EMIS-2017. For researchers seeking larger sample sizes, a shorter and more focussed survey may be more effective, particularly as most participants completed EMIS-2024 on smartphones, which was challenging given the median completion time of 35 minutes.\\u003c/p\\u003e\\u003cp\\u003eEMIS national datasets are available for analysis in 42 countries. National MSM samples are particularly valuable in countries where gay communities and HIV prevention infrastructures are underdeveloped. The cost savings of generating data in this way may also be considerable.\\u003c/p\\u003e\\u003cp\\u003eWide-range recruitment was made possible through meaningful involvement of many collaborators in survey design and promotion. Funders can support such outcomes by encouraging stakeholder involvement, clarifying research values and objectives, and defining transparent development and decision-making processes. Our collaboration required flexibility to accommodate diverse national needs and ensure the survey\\u0026rsquo;s suitability across different contexts.\\u003c/p\\u003e\\u003cp\\u003eCareful design, piloting and presentation helped ensure the survey was acceptable and had both authority and perceived community benefit. Recruiting transgender and non-binary individuals for surveys presents challenges, as stigma, discrimination and confidentiality concerns can deter participation. Inadequate translation, unclear survey design, and poor cultural sensitivity can also hinder engagement.\\u003c/p\\u003e\\u003cp\\u003eCollaborating with transgender advocacy and community organisations is essential for inclusive recruitment. To engage transgender and non-binary individuals, researchers must foster trust through transparent, culturally aware research methods to ensure accurate representation (Goodman et al., \\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e2019\\u003c/span\\u003e). To reach broad coverage across Europe, recruitment was achieved through a patchwork of commercial and community partners. High levels of partner involvement and committed funders were essential. Recognising and respecting the diversity of surveyed communities was key to sustaining broad collaboration.\\u003c/p\\u003e\\u003cp\\u003eLimitations\\u003c/p\\u003e\\u003cp\\u003eThe scale nature of this study and its diverse populations led to some technical issues. To reduce respondent burden, a routing system was used. Despite pre-testing, this introduced routing errors and missing data for some variables.\\u003c/p\\u003e\\u003cp\\u003eThe data are subject to three main sources of bias: unequal internet access and varying reliance on dating apps; self-selection bias (Evans et al., \\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e2007\\u003c/span\\u003e; Mercer et al., \\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e2016\\u003c/span\\u003e; Prah et al., \\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e2016\\u003c/span\\u003e); and difficulty ensuring equivalent meaning across different language versions of the questionnaire.\\u003c/p\\u003e\\u003cp\\u003eGeopolitical changes during the survey period also affected data collection. Some countries were excluded from funding for political reasons, and conflict hampered participation in other areas.\\u003c/p\\u003e\\u003cp\\u003eRepresentative samples of MSM, transgender and non-binary people are unavailable, so EMIS participants are unlikely to be fully representative. However, online samples of homosexually active men tend to be more diverse than those recruited through gay venues and are broadly demographically representative for MSM who have sex exclusively with men (Prah et al., \\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e2016\\u003c/span\\u003e). This is not yet demonstrable for trans or non-binary people due to lack of health data.\\u003c/p\\u003e\\u003cp\\u003eOnline recruitment via dating apps offers efficient access to key populations for HIV prevention and care. Geolocation features allow targeted outreach, and trust in familiar organisations boosts participation (Ocasio et al., \\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e2021\\u003c/span\\u003e). Younger MSM tend to see dating apps as a typical way of meeting partners (Arthur \\u0026amp; Cabaniss, \\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2021\\u003c/span\\u003e). Those recruited via dating apps tend to be younger, more sexually active, engage in more risk and precautionary behaviours, and report more sexual harms (Prah et al., \\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e2016\\u003c/span\\u003e)\\u0026mdash; an important focus within EMIS-2024. As these groups are the target of prevention efforts, these recruitment biases are acceptable.\\u003c/p\\u003e\\u003cp\\u003eEngagement is also enhanced when people feel the survey is relevant and impactful (Brosnan et al., \\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e2019\\u003c/span\\u003e). In this respect, receiving dedicated long-term core funding \\u0026mdash; as EMIS did in previous rounds through the EU Health Programme \\u0026mdash; can lend greater authority, including in relation to national public health institutions. The EMIS-2024 experience also highlights that, in many countries across the WHO European Region, collaboration between NGOs and governmental bodies could be strengthened. Moreover, the defunding of HIV prevention in several countries has negatively affected both the capacity and willingness of community organisations to engage in such studies. For national stakeholders, however, it may be more cost-effective to conduct fewer standalone studies in this population and instead rely on international approaches that produce comparable data across countries.\\u003c/p\\u003e\\u003cp\\u003eMultilingual surveys help include ethnic minorities and expand the scope of questions (Im et al., \\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e2016\\u003c/span\\u003e). Offering EMIS in 35 languages improved accessibility and may have yielded samples more reflective of MSM diversity, especially among migrant MSM, than other convenience sampling.\\u003c/p\\u003e\\u003cp\\u003eNonetheless, translation challenges remain. Cultural and linguistic differences can distort meaning. Instruments developed in one cultural context may not translate seamlessly to another (Im et al., \\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e2016\\u003c/span\\u003e). Both qualitative and statistical checks are necessary to ensure conceptual equivalence (Ware et al., \\u003cspan citationid=\\\"CR39\\\" class=\\\"CitationRef\\\"\\u003e1995\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eUsing gender-neutral language in translations posed further issues, especially in languages with gendered grammar (\\u003cem\\u003ee.g.\\u003c/em\\u003e, German, French, Italian, Spanish, Portuguese, Greek), or non-gendered languages (\\u003cem\\u003ee.g.\\u003c/em\\u003e, Turkish, Hungarian) (Hord, \\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e2016\\u003c/span\\u003e).\\u003c/p\\u003e\"},{\"header\":\"Conclusions\",\"content\":\"\\u003cp\\u003eA harmonised questionnaire, shared sampling strategy, and meaningful community involvement were key to generating robust, comparable data across Europe.\\u003c/p\\u003e\\n\\u003cp\\u003eUp-to-date information is available at \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ewww.emis2024.eu\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/p\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003eAFAB\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 459px;\\\"\\u003e\\n \\u003cp\\u003eAssigned female at birth\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003eAMAB\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 459px;\\\"\\u003e\\n \\u003cp\\u003eAssigned male at birth\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003eDAH\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 459px;\\\"\\u003e\\n \\u003cp\\u003eDeutsche Aidshilfe (German AIDS Federation)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003eECDC\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 459px;\\\"\\u003e\\n \\u003cp\\u003eEuropean Centre for Disease Prevention and Control\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003eEECA\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 459px;\\\"\\u003e\\n \\u003cp\\u003eEastern Europe and Central Asia\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003eEEA\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 459px;\\\"\\u003e\\n \\u003cp\\u003eEuropean Economic Area\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003eECOM\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 459px;\\\"\\u003e\\n \\u003cp\\u003eEurasian Coalition on Health, Rights, Gender and Sexual Diversity\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003eEMIS\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 459px;\\\"\\u003e\\n \\u003cp\\u003eEuropean MSM Internet Survey\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003eEU\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 459px;\\\"\\u003e\\n \\u003cp\\u003eEuropean Union\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003eG4E\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 459px;\\\"\\u003e\\n \\u003cp\\u003eGrindr for Equality\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003eGHPP\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 459px;\\\"\\u003e\\n \\u003cp\\u003eGlobal Health Protection Programme\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003eHIV\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 459px;\\\"\\u003e\\n \\u003cp\\u003eHuman Immunodeficiency Virus\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003eMSM\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 459px;\\\"\\u003e\\n \\u003cp\\u003eMen who have sex with men\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003eNGO\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 459px;\\\"\\u003e\\n \\u003cp\\u003eNon-governmental organisation\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003eLGBT\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 459px;\\\"\\u003e\\n \\u003cp\\u003eLesbian, gay, bisexual, trans\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003eRKI\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 459px;\\\"\\u003e\\n \\u003cp\\u003eRobert Koch Institute\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003eSEE RCN\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 459px;\\\"\\u003e\\n \\u003cp\\u003eSouth Eastern Europe Regional TB and HIV Community Network\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003eSTI\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 459px;\\\"\\u003e\\n \\u003cp\\u003eSexually transmitted infection\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003eWHO\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 28px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 459px;\\\"\\u003e\\n \\u003cp\\u003eWorld Health Organization\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003ch3\\u003eFunding\\u003c/h3\\u003e\\n\\u003cp\\u003eThe funding structure for EMIS-2024 was developed in collaboration with the implementing partners\\u0026mdash;German AIDS Federation (DAH), Maastricht University, and Robert Koch Institute (RKI) between March 2022 and August 2023. The following organisations contributed financially to EMIS-2024:German Ministry of Health (\\u003cem\\u003eBundesministerium f\\u0026uuml;r Gesundheit\\u003c/em\\u003e, \\u003cstrong\\u003eDE\\u003c/strong\\u003e) / Global Health Protection Programme (GHPP, \\u003cstrong\\u003eDE\\u003c/strong\\u003e); European Centre for Disease Prevention and Control (ECDC, \\u003cstrong\\u003eEU\\u003c/strong\\u003e); Swiss AIDS Federation, Swiss Federal Office of Public Health (\\u003cstrong\\u003eCH\\u003c/strong\\u003e); Luxembourg Health Directorate (\\u003cem\\u003eMinist\\u0026egrave;re de la Sant\\u0026eacute; et de la S\\u0026eacute;curit\\u0026eacute; sociale\\u003c/em\\u003e, \\u003cstrong\\u003eLU\\u003c/strong\\u003e); Norwegian Directorate of Health (\\u003cem\\u003eHelsedirektoratet\\u003c/em\\u003e, \\u003cstrong\\u003eNO\\u003c/strong\\u003e); The Public Health Agency of Sweden (\\u003cem\\u003eFolkh\\u0026auml;lsomyndigheten\\u003c/em\\u003e, \\u003cstrong\\u003eSE\\u003c/strong\\u003e); Sciensano (\\u003cem\\u003eInstitut Scientifique de Sant\\u0026eacute; Publique\\u003c/em\\u003e, \\u003cstrong\\u003eBE\\u003c/strong\\u003e); Estonian Ministry of Social Affairs (\\u003cem\\u003eSotsiaalministeerium\\u003c/em\\u003e, \\u003cstrong\\u003eEE\\u003c/strong\\u003e); Health Service Executive (\\u003cstrong\\u003eIE\\u003c/strong\\u003e); Portuguese Directorate-General of Health (\\u003cem\\u003eDire\\u0026ccedil;\\u0026atilde;o-Geral da Sa\\u0026uacute;de\\u003c/em\\u003e, \\u003cstrong\\u003ePT\\u003c/strong\\u003e); Spanish Ministry of Health (\\u003cem\\u003eMinisterio de Sanidad\\u003c/em\\u003e, \\u003cstrong\\u003eES\\u003c/strong\\u003e); Central Health Department, Israeli Ministry of Health (משרד\\u0026nbsp;הבריאות, \\u003cstrong\\u003eIL\\u003c/strong\\u003e); National Institute for Public Health and the Environment (RIVM) \\u003cem\\u003e/ SOAids Nederland\\u003c/em\\u003e (\\u003cstrong\\u003eNL\\u003c/strong\\u003e). Funding for conducting the online survey in Germany was provided by the German Federal Ministry of Health and granted to RKI and DAH. Data collection in the Western Balkans and in Eastern European/Central Asian countries (except Belarus and Russia) was supported through a grant to RKI from the Global Health Protection Programme (GHPP), which is also funded by the German Federal Ministry of Health. All other financial contributions and contractual arrangements were based on a standard contract template with minor adaptations to accommodate the specific needs and capacities of each partner.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003ch3 id=\\\"_Toc201922476\\\"\\u003eConflicts of Interest\\u003c/h3\\u003e\\n\\u003cp\\u003eThe authors declare that they have no conflict of interest.\\u003c/p\\u003e\\n\\u003ch3 id=\\\"_Toc201922477\\\"\\u003eData availability\\u003c/h3\\u003e\\n\\u003cp\\u003eNational data has been shared with the funding and community partners. Multi-country EMIS-2024 data is available upon application to the EMIS scientific board.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eUp-to-date information is available at www.emis2024.eu.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003ch3 id=\\\"_Toc201922478\\\"\\u003eCode availability\\u003c/h3\\u003e\\n\\u003cp\\u003eAvailable upon request from the authors.\\u003c/p\\u003e\\n\\u003ch3 id=\\\"_Toc201922479\\\"\\u003eAuthors\\u0026rsquo; Contributions\\u003c/h3\\u003e\\n\\u003cp\\u003exx\\u003c/p\\u003e\\n\\u003cp\\u003eAll authors contributed to and approved the final version of the manuscript.\\u003c/p\\u003e\\n\\u003ch3 id=\\\"_Toc201922480\\\"\\u003eEthics approval\\u003c/h3\\u003e\\n\\u003cp\\u003eEthics approval for the EMIS-2024 study was granted by the xx on the 30\\u003csup\\u003eth\\u003c/sup\\u003e of October 2023.\\u0026nbsp;\\u003c/p\\u003e\\u003ch3\\u003eAcknowledgements\\u0026nbsp;\\u003c/h3\\u003e\\n\\u003cp\\u003eWe begin by expressing our sincere thanks to everyone who participated in EMIS-2024. Special appreciation goes to our NGO partners who were instrumental in recruitment\\u0026mdash;accounting for 37% of all respondents\\u0026mdash;by promoting the survey through their platforms, social media channels, and by displaying EMIS banners on their websites.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eWe are deeply grateful to all our funders for their financial contributions and continued support, and to each study participant for making their voices heard!\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eA special thank you goes to Steph\\u0026nbsp;Niaupari at Grindr for Equality for their instrumental support in recruitment via free messages on Grindr, which significantly contributed to the success of EMIS-2024.\\u003c/p\\u003e\\n\\u003cp\\u003eThe following list acknowledges all EMIS partners by country. Individual names are included when a freelancer served as the main contact or contributed to questionnaire development without formal organisational representation. The order is: main NGO partner, other NGO partners, academic partners, governmental partners, and individuals. \\u003cstrong\\u003eEurope:\\u003c/strong\\u003e Grindr for Equality, Grindr, ROMEO, Hornet, Aids Action Europe, European AIDS Treatment Group, Eurasian Coalition on Health, Rights, Gender and Sexual Diversity (ECOM), South Eastern Europe Regional TB and HIV Community Network (SEE RCN).\\u003c/p\\u003e\\u003ch3\\u003eAcknowledgements\\u0026nbsp;\\u003c/h3\\u003e\\n\\u003cp\\u003eWe begin by expressing our sincere thanks to everyone who participated in EMIS-2024. Special appreciation goes to our NGO partners who were instrumental in recruitment\\u0026mdash;accounting for 37% of all respondents\\u0026mdash;by promoting the survey through their platforms, social media channels, and by displaying EMIS banners on their websites.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eWe are deeply grateful to all our funders for their financial contributions and continued support, and to each study participant for making their voices heard!\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eA special thank you goes to Steph\\u0026nbsp;Niaupari at Grindr for Equality for their instrumental support in recruitment via free messages on Grindr, which significantly contributed to the success of EMIS-2024.\\u003c/p\\u003e\\n\\u003cp\\u003eThe following list acknowledges all EMIS partners by country. Individual names are included when a freelancer served as the main contact or contributed to questionnaire development without formal organisational representation. The order is: main NGO partner, other NGO partners, academic partners, governmental partners, and individuals. \\u003cstrong\\u003eEurope:\\u003c/strong\\u003e Grindr for Equality, Grindr, ROMEO, Hornet, Aids Action Europe, European AIDS Treatment Group, Eurasian Coalition on Health, Rights, Gender and Sexual Diversity (ECOM), South Eastern Europe Regional TB and HIV Community Network (SEE RCN).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAL:\\u003c/strong\\u003e Albanian Association of PLWHA. \\u003cstrong\\u003eAM:\\u003c/strong\\u003e New Generation Humanitarian NGO. \\u003cstrong\\u003eAT:\\u003c/strong\\u003e \\u003cem\\u003eAids Hilfe Wien\\u003c/em\\u003e. \\u003cstrong\\u003eBA:\\u003c/strong\\u003e Partnerships in Health. \\u003cstrong\\u003eBE:\\u003c/strong\\u003e Sensoa, Exaequo, Sciensano. \\u003cstrong\\u003eBG:\\u003c/strong\\u003e GLAS Foundation. \\u003cstrong\\u003eCH:\\u003c/strong\\u003e Swiss AIDS Federation, Swiss Federal Office of Public Health. \\u003cstrong\\u003eCY:\\u003c/strong\\u003e AIDS Solidarity Movement, Christos Krasidis. \\u003cstrong\\u003eCZ:\\u003c/strong\\u003e \\u003cem\\u003eČesk\\u0026aacute; společnost AIDS pomoc\\u003c/em\\u003e. \\u003cstrong\\u003eDE:\\u003c/strong\\u003e \\u003cem\\u003eDeutsche AIDS-Hilfe\\u003c/em\\u003e, Robert Koch Institute, IWWIT. \\u003cstrong\\u003eDK:\\u003c/strong\\u003e \\u003cem\\u003eStatens Serum Institut\\u003c/em\\u003e, Dr. Susan Cowan, Dr. Maria Wessmann. \\u003cstrong\\u003eEE:\\u003c/strong\\u003e Estonia National Institute for Health Development, Dr. Kristi R\\u0026uuml;\\u0026uuml;tel, Dr. Sigrid Vorobjov. \\u003cstrong\\u003eES:\\u003c/strong\\u003e SEISIDA, STOPSIDA, CEEISCAT, \\u003cem\\u003eMinisterio de Sanidad\\u003c/em\\u003e. \\u003cstrong\\u003eFI:\\u003c/strong\\u003e \\u003cem\\u003ePositiiviset ry\\u003c/em\\u003e. \\u003cstrong\\u003eGE:\\u003c/strong\\u003e Equality Movement. \\u003cstrong\\u003eGR:\\u003c/strong\\u003e Positive Voice. \\u003cstrong\\u003eHR:\\u003c/strong\\u003e Iskorak, Zoran Dominković. \\u003cstrong\\u003eHU:\\u003c/strong\\u003e H\\u0026aacute;tt\\u0026eacute;r Society. \\u003cstrong\\u003eIE:\\u003c/strong\\u003e EMIS-2024 Ireland Promotion Sub-Committee, Health Service Executive, Mick Quinlan. \\u003cstrong\\u003eIL:\\u003c/strong\\u003e Israel AIDS Task Force, Ministry of Health, Prof. Zohar Mor. \\u003cstrong\\u003eIT:\\u003c/strong\\u003e Fondazione LILA Milano ONLUS, University of Verona. \\u003cstrong\\u003eKZ:\\u003c/strong\\u003e Global Health Research Center of Central Asia (GHRCCA), Human Health Institute, Public Fund \\u0026ldquo;Community Friends\\u0026rdquo;.\\u0026nbsp;\\u003cstrong\\u003eLT:\\u003c/strong\\u003e Demetra, National Public Health Center. \\u003cstrong\\u003eLV:\\u003c/strong\\u003e AGIHAS. \\u003cstrong\\u003eLU:\\u003c/strong\\u003e \\u003cem\\u003eMinist\\u0026egrave;re de la Sant\\u0026eacute; et de la S\\u0026eacute;curit\\u0026eacute; sociale\\u003c/em\\u003e.\\u0026nbsp;\\u003cstrong\\u003eMD:\\u003c/strong\\u003e GENDERDOC-M Information Centre. \\u003cstrong\\u003eME:\\u003c/strong\\u003e Cazas \\u0026ndash; Montenegrin Association against AIDS. \\u003cstrong\\u003eMK:\\u003c/strong\\u003e Stronger Together (Association for Support of People Living with HIV, Zaedno Posilni). \\u003cstrong\\u003eMT:\\u003c/strong\\u003e HIV Malta, Infectious Disease Prevention and Control Unit. \\u003cstrong\\u003eNL:\\u003c/strong\\u003e SOAids, Maastricht University, RIVM; \\u003cstrong\\u003eNO:\\u003c/strong\\u003e \\u003cem\\u003eHelseutvalget\\u003c/em\\u003e, University of Troms\\u0026oslash; \\u0026ndash;The Artic University of Norway, Norwegian Institute of Public Health, Prof. Rigmor C. Berg. \\u003cstrong\\u003ePL:\\u003c/strong\\u003e \\u003cem\\u003eFundacja Edukacji Społecznej\\u003c/em\\u003e, Iwona Wawer; \\u003cstrong\\u003ePT:\\u003c/strong\\u003e GAT Portugal\\u003cem\\u003e, Instituto de Sa\\u0026uacute;de P\\u0026uacute;blica da Universidade do Porto\\u003c/em\\u003e, Portuguese Directorate-General of Health. \\u003cstrong\\u003eRO:\\u003c/strong\\u003e ARAS, Tudor Kovacs. \\u003cstrong\\u003eRS:\\u003c/strong\\u003e TOC \\u0026ndash; Association for the Development of Sustainable Communities; Institute of Public Health of Serbia, Sladjana Baros. \\u003cstrong\\u003eSE:\\u003c/strong\\u003e RFSL, \\u003cem\\u003eFolkh\\u0026aring;lsomyndigheten\\u003c/em\\u003e. \\u003cstrong\\u003eSI:\\u003c/strong\\u003e LEGEBITRA, \\u0026Scaron;KUC. \\u003cstrong\\u003eSK:\\u003c/strong\\u003e Pride Kosice. \\u003cstrong\\u003eTR:\\u003c/strong\\u003e Sami Sarper Yazıcılaroğlu. \\u003cstrong\\u003eUA:\\u003c/strong\\u003e Alliance for Public Health, Alliance Global. \\u003cstrong\\u003eXK:\\u003c/strong\\u003e LGBTI Equal Rights Association for Western Balkans and Turkey. \\u003cstrong\\u003eOther:\\u003c/strong\\u003e Sigma Research, London School of Hygiene \\u0026amp; Tropical Medicine.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eOur sincere thanks extend to Lina\\u0026nbsp;Nerlander, Anastasia\\u0026nbsp;Pharris, and Teymur\\u0026nbsp;Noori (ECDC); Dirk\\u0026nbsp;Sander, Jonathan\\u0026nbsp;Gregory, Ferenc\\u0026nbsp;Bagyinszky, Alexandra\\u0026nbsp;Gurinova, Holger\\u0026nbsp;Sweers, and Silke\\u0026nbsp;Klumb (German AIDS Federation); Marc\\u0026nbsp;Eggenberger, Vinicio\\u0026nbsp;Albani, Florian\\u0026nbsp;Vock (Swiss AIDS Federation); Stefan\\u0026nbsp;Enggist (Swiss Federal Office of Public Health); Binod\\u0026nbsp;Mahanty (German Ministry of Health); Julia\\u0026nbsp;del\\u0026nbsp;Amo\\u0026nbsp;Valero (Spanish Ministry of Health). We extend our thanks to Cinta\\u0026nbsp;Folch (CEEISCAT), Lorenzo\\u0026nbsp;Gios (University of Verona), Ahmed\\u0026nbsp;Awadalla, Iwona\\u0026nbsp;Waver, Aramazd\\u0026nbsp;Ghalamkaryan, Inola\\u0026nbsp;Shugliashvili, and Aliya\\u0026nbsp;Zhakupova for translating the survey into Spanish, Italian, Arabic, Polish, Armenian, Georgian, and Kazakh, respectively; Haoyi\\u0026nbsp;Wang (Maastricht University) for support with R-scripting, and Arturo\\u0026nbsp;de\\u0026nbsp;la\\u0026nbsp;Cruz\\u0026nbsp;Libardi (LSHTM) for his valuable support in producing maps in R.\\u003c/p\\u003e\\n\\u003cp\\u003eLast but not least, we would like to express our sincere gratitude to Peter Weatherburn and Ford Hickson (LSHTM) for providing the EMIS-2017 Design and Methods Paper, which served as the starting point and foundation for this updated version.\\u0026nbsp;\\u003c/p\\u003e\\n\\n\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003eAmerican Psychological Association. 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J., \\u0026amp; Marcus, U. (2023). What\\u0026apos;s on the rise in Sexually Transmitted Infections? \\u003cem\\u003eLancet Reg Health Eur, 34\\u003c/em\\u003e, 100764. https://doi.org/10.1016/j.lanepe.2023.100764\\u003c/li\\u003e\\n\\u003cli\\u003eSemlyen, J., \\u0026amp; Hagger-Johnson, G. (2017). Sampling frame for sexual minorities in public health research. \\u003cem\\u003eJ Public Health (Oxf), 39\\u003c/em\\u003e(3), 644. https://doi.org/10.1093/pubmed/fdw078\\u003c/li\\u003e\\n\\u003cli\\u003eStutterheim, S. E., van Dijk, M., Wang, H., \\u0026amp; Jonas, K. J. (2021). The worldwide burden of HIV in transgender individuals: An updated systematic review and meta-analysis. \\u003cem\\u003ePLoS One, 16\\u003c/em\\u003e(12), e0260063. https://doi.org/10.1371/journal.pone.0260063\\u003c/li\\u003e\\n\\u003cli\\u003eThe EMIS Network. (2013). EMIS 2010 \\u0026ndash; The European Men-Who-Have-Sex-With-Men Internet Survey. Findings from 38 countries. https://www.emis-project.eu/european-report-2010/\\u003c/li\\u003e\\n\\u003cli\\u003eThe EMIS Network. (2019). \\u003cem\\u003eEMIS-2017 \\u0026ndash; The European Men-Who-Have-Sex-With-Men Internet Survey. Key findings from 50 countries\\u003c/em\\u003e. European Centre for Disease Prevention and Control. https://www.emis-project.eu/european-report-2017/\\u003c/li\\u003e\\n\\u003cli\\u003eTransgender Europe. (2017). \\u003cem\\u003eOverdiagnosed but Underserved\\u003c/em\\u003e. https://tgeu.org/overdiagnosed-but-underserved-trans-health-survey\\u003c/li\\u003e\\n\\u003cli\\u003eWang, H., Kolstee, J., Casalini, J. L., Hakim, S., Zimmermann, H. M., \\u0026amp; Jonas, K. J. (2024). Likelihood of HIV and recent bacterial sexually transmitted infections among transgender and non-binary individuals in 20 European countries, October 2023 to April 2024. \\u003cem\\u003eEuro Surveill, 29\\u003c/em\\u003e(48). https://doi.org/10.2807/1560-7917.ES.2024.29.48.2400347\\u003c/li\\u003e\\n\\u003cli\\u003eWare, J. E., Jr., Keller, S. D., Gandek, B., Brazier, J. E., \\u0026amp; Sullivan, M. (1995). Evaluating translations of health status questionnaires. Methods from the IQOLA project. International Quality of Life Assessment. \\u003cem\\u003eInt J Technol Assess Health Care, 11\\u003c/em\\u003e(3), 525-551. https://doi.org/10.1017/s0266462300008710\\u003c/li\\u003e\\n\\u003cli\\u003eWeatherburn, P., Hickson, F., Reid, D. S., Marcus, U., \\u0026amp; Schmidt, A. J. (2020). European Men-Who-Have-Sex-With-Men Internet Survey (EMIS-2017): Design and Methods. \\u003cem\\u003eSexuality Research and Social Policy, 17\\u003c/em\\u003e(4), 543-557. https://doi.org/10.1007/s13178-019-00413-0\\u003c/li\\u003e\\n\\u003cli\\u003eWeatherburn, P., Schmidt, A. J., Hickson, F., Reid, D., Berg, R. C., Hospers, H. J., Marcus, U., \\u0026amp; The EMIS network. (2013). The European Men-who-have-sex-with-men Internet Survey (EMIS): Design and Methods. \\u003cem\\u003eSex Res Social Policy, 10\\u003c/em\\u003e( 4), 243-257. http://link.springer.com/article/10.1007%2Fs13178-013-0119-4\\u003c/li\\u003e\\n\\u003cli\\u003eWinter, S., Diamond, M., Green, J., Karasic, D., Reed, T., Whittle, S., \\u0026amp; Wylie, K. (2016). Transgender people: health at the margins of society. \\u003cem\\u003eLancet, 388\\u003c/em\\u003e(10042), 390-400. https://doi.org/10.1016/S0140-6736(16)00683-8\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":true,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":true,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Sexual Health, Mental Health, Epidemiology, HIV, Sexually Transmitted Infections, MSM, Transgender\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-6991809/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-6991809/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003eMen who have sex with men (MSM), as well as transgender and non-binary individuals, continue to face a disproportionate burden of stigma, mental health challenges, HIV, and other sexually transmitted infections. To address their needs, public health planners require reliable and comparable data. Monitoring behaviours in these populations also supports the evaluation of health policies.\\u003c/p\\u003e\\u003cp\\u003eThe European MSM Internet Survey (EMIS-2024) builds on our international surveys conducted in 2010 and 2017, expanding its scope to include transgender women and non-binary people explicitly. It provides much-needed data for planning interventions, promoting health, and harmonising behavioural surveillance. A key strength of EMIS-2024 is the use of a shared sampling frame and core questionnaire across all participating countries. This approach allows meaningful cross-national comparisons, unlike many national surveys with varying methods.\\u003c/p\\u003e\\u003cp\\u003eThe three core consortium partners led the EMIS-2017 questionnaire\\u0026rsquo;s revision, with broader but less partner involvement in content development being more limited than in previous rounds. Over 60 partners from 40 countries played a key role in the survey\\u0026rsquo;s success, providing high-quality translations in 35 languages and actively promoting the survey. National partners ensured the survey\\u0026rsquo;s visibility, credibility, and relevance, once dating app advertisements or invitations appeared.\\u003c/p\\u003e\\u003cp\\u003eThe survey ran online during the first half of 2024. Overall, 165,380 responses were received, of which 50,330 qualified for the analytic sample. EMIS-2024 demonstrates that large-scale, multi-country sexual health surveys are feasible with public funding. A harmonised questionnaire, shared sampling strategy, and meaningful community involvement were key to generating robust, comparable data across Europe.\\u003c/p\\u003e\",\"manuscriptTitle\":\"European Men-Who-Have-Sex-With-Men and Trans People Internet Survey (EMIS-2024): Design and Methods\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-07-18 16:00:35\",\"doi\":\"10.21203/rs.3.rs-6991809/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"6bd1734f-5b89-4bc2-8c14-15ccd22e7e08\",\"owner\":[],\"postedDate\":\"July 18th, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"posted\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-03-23T16:00:56+00:00\",\"versionOfRecord\":{\"articleIdentity\":\"rs-6991809\",\"link\":\"https://doi.org/10.1007/s13178-026-01288-8\",\"journal\":{\"identity\":\"sexuality-research-and-social-policy\",\"isVorOnly\":false,\"title\":\"Sexuality Research and Social Policy\"},\"publishedOn\":\"2026-03-19 15:58:04\",\"publishedOnDateReadable\":\"March 19th, 2026\"},\"versionCreatedAt\":\"2025-07-18 16:00:35\",\"video\":\"\",\"vorDoi\":\"10.1007/s13178-026-01288-8\",\"vorDoiUrl\":\"https://doi.org/10.1007/s13178-026-01288-8\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-6991809\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-6991809\",\"identity\":\"rs-6991809\",\"version\":[\"v1\"]},\"buildId\":\"8U1c8b4HqxoKbykW_rLl7\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}