Confronting Rising STIs in the Era of PrEP and Treatment as Prevention

Incidence of sexually transmitted infections and screening models among pre-exposure prophylaxis users

INTRODUCTION

There is discussion about the frequency of STI screening among pre-exposure prophylaxis (PrEP) users. The aim of this study was to analyse the incidence of STIs and to evaluate different screening models in order to optimise the follow-up.

METHODOLOGY

A prospective study was conducted between 2017 and 2023, including 138 PrEP users in a STI clinic. Participants were tested for STIs every three months. Unscheduled visits were performed for those with STI-related symptoms or for people who were notified for an STI by a sexual partner. We performed a survival analysis of repeated events, estimating the cumulative incidence (CI) and incidence rate (IR).

RESULTS

The overall CI by quarterly screening was 8.3 (95% CI: 7.6-9.1) infections per person over six years, with a decreasing trend. The most frequently diagnosed pathogen was Neisseria gonorrhoeae, with a IR of 0.76 (95% CI: 0.68-0.84). If the frequency of screening is reduced to every six months, the IR of STIs is reduced by (95% CI: 0.5-0.66) infections per user per year, and at 12 months by 0.82 (95% CI: 0.73-0.89). In the case of no pharyngeal or urethral screening, IR is reduced by 0.37 (95% CI: 0.32-0.42) infections per person per year and in those over 35 years of age by 0.33 (95% CI: 0.25-0.4). Eliminating unscheduled visits, the reduction in IR is 0.33 (95% CI: 0.24-0.42).

CONCLUSIONS

The incidence of STIs among PrEP users is high, especially in the rectum, but it does not increase over time. STI screening could be optimised reducing the frequency of pharyngeal and urethral testing, particularly in those over 35 years of age. It is essential to redistribute health resources for unscheduled visits, which have been shown to be the most cost-effective screening.

Acceptance and use of condoms among school-aged young people in Australia

BACKGROUND

Despite availability of vaccines or medical prophylaxis for some sexually transmissible infections (STIs), promoting condom use remains an important public health strategy for the prevention of STIs. Recent research shows that regular condom use among young people in Australia has declined over the past decade, while the rate of common STIs has increased.

METHOD

In this paper, we report findings from a large survey of school-aged young people in Australia (14-18years old) in which we looked at the association between condom use and positive feelings about sex, beliefs about social acceptability of condoms and confidence talking with partners about sex and condoms.

RESULTS

Communication and relational factors supported more consistent condom use. Participants were more likely to regularly use condoms if they discussed condom use with a sexual partner, perceived condom use to be easy (a measure that included perceived ease of discussing condoms with a partner) and perceived condom use to offer social or relational benefits, including perceiving condom use as a demonstration of care for a partner. Young men were more likely to report positive feelings about sex and regular condom use than young women. Young women were less likely than young men or trans and non-binary young people to report regular condom use.

CONCLUSIONS

The study shows the importance of supporting young people to build confidence expressing sexual needs and wants with partners. Public health approaches to STI prevention need to consider condom promotion in the context of young people's contemporary sexual, gendered and relationships cultures.

Questioning risk compensation: pre-exposure prophylaxis (PrEP) and sexually transmitted infections among men who have sex with men, capital region of Denmark, 2019 to 2022

BackgroundPre-exposure prophylaxis (PrEP) effectively prevents HIV, but its association with sexually transmitted infections (STIs) has raised concerns about risk compensation, potentially impacting the expansion of PrEP programmes.AimWe examined the relationship between PrEP and the incidence of chlamydia, gonorrhoea and syphilis.MethodsIn this prospective cohort study, we compared STI rates before and after PrEP initiation among users in the capital region of Denmark (2019-2022), calculating incidence rate ratios adjusted for age and testing frequency (aIRR). To pinpoint when increases began, we plotted weekly STI rates, adjusting the timeline to correspond with PrEP initiation.ResultsThe study included 1,326 PrEP users with a median age of 35 years. The STI incidence rate per 100,000 person-years rose from 35.3 before to 81.2 after PrEP start, with an aIRR of 1.35 (95% CI: 1.18-1.56). Notably, this increase preceded PrEP initiation by 10-20 weeks. Specific aIRR for chlamydia, gonorrhoea and syphilis were 1.23 (95% CI: 1.03-1.48), 1.24 (95% CI: 1.04-1.47) and 1.15 (95% CI: 0.76-1.72), respectively. In subanalyses for anatomical sites aIRR was 1.26 (95% CI: 1.01-1.56) for rectal chlamydia and 0.66 (95% CI: 0.45-0.96) for genital gonorrhoea.ConclusionWe found a 35% increase in STI incidence associated with PrEP use. It started before PrEP initiation, challenging the assumption that PrEP leads to risk compensation. Instead, the data suggest that individuals seek PrEP during periods of heightened sexual risk-taking. Consequently, PrEP programmes should include sexual health consultations, STI testing, treatment and prevention strategies to prevent HIV and improve sexual health.

Examination of Incidence of Sexually Transmitted Infections in the Ending the HIV Epidemic Priority Counties of the United States, 2005-2019

BACKGROUND

The incidence of sexually transmitted infections (STIs) has been increasing in the United States, and this trend has continued alongside expanding/changing human immunodeficiency virus (HIV) prevention strategies, moving from reliance solely on behavioral interventions like condoms to biomedical methods like oral and injectable antiretroviral preexposure prophylaxis (PrEP). In 2019, the Ending the HIV Epidemic (EHE) initiative was released to prioritize resource allocation to the 50 jurisdictions in the United States with the highest HIV incidence, providing an opportunity to monitor STI incidence in a national group of discrete, geographic units and identify trends and differences across jurisdictions.

OBJECTIVES AND DESIGN

Using existing data from the US CDC and Census Bureau, a retrospective analysis was conducted to examine the incidence of STIs in 49 of the 50 EHE priority counties between 2005 and 2019. This timeframe was divided into 2 periods representing a before and after entry into the biomedical era of HIV prevention: P1 (2005-2011) and P2 (2012-2019).

KEY RESULTS

A total of 49 EHE counties were included in this analysis, representing 27.4% of the total US population. Entry into the biomedical HIV prevention era was associated with an increase in STI incidence in 28 EHE counties and a decrease in 14 EHE counties. The greatest percent increase in total STI incidence was in the District of Columbia (+12.1%; incidence rate ratio = 1.121 [1.115, 1.127]; P < 0.001) and the greatest percent decrease was identified in Orleans Parish, LA (-8.7%; incidence rate ratio = 0.913 [0.908, 0.919]; P < 0.001).

CONCLUSIONS

Rising STI rates in the biomedical era of HIV prevention represent missed opportunities for comprehensive sexual and preventive healthcare. County-level data provide actionable insight for reducing STI incidence. The EHE counties that have experienced decreases in STI incidence while being in the biomedical era may provide models of best practice, which may be scaled in other jurisdictions.

Epidemiology of gonorrhoea: systematic review, meta-analyses, and meta-regressions, World Health Organization European Region, 1949 to 2021

BackgroundEpidemiology of Neisseria gonorrhoeae (NG) infection remains inadequately understood.AimWe aimed to characterise NG epidemiology in Europe.MethodsWe used Cochrane and PRISMA guidelines to systematically review, report, synthesise and analyse NG prevalence data from 1949 to 30 September 2021. Random-effects meta-analyses estimated pooled prevalence. Meta-regression analyses investigated associations and sources of heterogeneity.ResultsThe 844 included publications yielded 1,573 prevalence measures. Pooled prevalence of current urogenital infection was 1.0% (95% CI: 0.7-1.2%) among general populations, 3.2% (95% CI: 1.8-4.8%) among female sex workers, 4.9% (95% CI: 4.2-5.6%) among sexually transmitted infection clinic attendees and 12.1% (95% CI: 8.8-15.8%) among symptomatic men. Among men who have sex with men, pooled prevalence was 0.9% (95% CI: 0.5-1.4%), 5.6% (95% CI: 3.6-8.1%), and 3.8% (95% CI: 2.5-5.4%), respectively, for current urogenital, anorectal or oropharyngeal infection. Current urogenital, anorectal or oropharyngeal infection was 1.45-fold (95% CI: 1.19-1.77%), 2.75-fold (95% CI: 1.89-4.02%) and 2.64-fold (95% CI: 1.77-3.93%) higher among men than women. Current urogenital infection declined 0.97-fold (95% CI: 0.96-0.98%) yearly, but anorectal and oropharyngeal infection increased (1.02-fold; 95% CI: 1.01-1.04% and 1.02-fold; 95% CI: 1.00-1.04%), respectively.ConclusionsNeisseria gonorrhoeae epidemiology in Europe has distinct and contrasting epidemiologies for vaginal sex transmission in heterosexual sex networks vs anal and oral sex transmission in MSM sexual networks. Increased transmission may facilitate drug-resistant strain emergence. Europe is far from achieving the World Health Organization target of 90% incidence reduction by 2030.

Building gender-specific sexually transmitted infection risk prediction models using CatBoost algorithm and NHANES data

BACKGROUND AND AIMS

Sexually transmitted infections (STIs) are a significant global public health challenge due to their high incidence rate and potential for severe consequences when early intervention is neglected. Research shows an upward trend in absolute cases and DALY numbers of STIs, with syphilis, chlamydia, trichomoniasis, and genital herpes exhibiting an increasing trend in age-standardized rate (ASR) from 2010 to 2019. Machine learning (ML) presents significant advantages in disease prediction, with several studies exploring its potential for STI prediction. The objective of this study is to build males-based and females-based STI risk prediction models based on the CatBoost algorithm using data from the National Health and Nutrition Examination Survey (NHANES) for training and validation, with sub-group analysis performed on each STI. The female sub-group also includes human papilloma virus (HPV) infection.

METHODS

The study utilized data from the National Health and Nutrition Examination Survey (NHANES) program to build males-based and females-based STI risk prediction models using the CatBoost algorithm. Data was collected from 12,053 participants aged 18 to 59 years old, with general demographic characteristics and sexual behavior questionnaire responses included as features. The Adaptive Synthetic Sampling Approach (ADASYN) algorithm was used to address data imbalance, and 15 machine learning algorithms were evaluated before ultimately selecting the CatBoost algorithm. The SHAP method was employed to enhance interpretability by identifying feature importance in the model's STIs risk prediction.

RESULTS

The CatBoost classifier achieved AUC values of 0.9995, 0.9948, 0.9923, and 0.9996 and 0.9769 for predicting chlamydia, genital herpes, genital warts, gonorrhea, and overall STIs infections among males. The CatBoost classifier achieved AUC values of 0.9971, 0.972, 0.9765, 1, 0.9485 and 0.8819 for predicting chlamydia, genital herpes, genital warts, gonorrhea, HPV and overall STIs infections among females. The characteristics of having sex with new partner/year, times having sex without condom/year, and the number of female vaginal sex partners/lifetime have been identified as the top three significant predictors for the overall risk of male STIs. Similarly, ever having anal sex with a man, age and the number of male vaginal sex partners/lifetime have been identified as the top three significant predictors for the overall risk of female STIs.

CONCLUSIONS

This study demonstrated the effectiveness of the CatBoost classifier in predicting STI risks among both male and female populations. The SHAP algorithm revealed key predictors for each infection, highlighting consistent demographic characteristics and sexual behaviors across different STIs. These insights can guide targeted prevention strategies and interventions to alleviate the impact of STIs on public health.

LGBTQ+ health research guides: a multi-institutional analysis of usage patterns and user information needs

Objective

LGBTQ+ health research guides can strengthen the LGBTQ+ community through connecting people to quality health services and information, and previous studies have recommended that health sciences libraries create and maintain these guides. Little evidence exists, though, on how these guides are used and how well they meet the needs of LGBTQ+ users. Using retrospective data retrieved from multiple LGBTQ+ health research guides, we examined the categories of LGBTQ+ health information most used, as well as how often guides were accessed. Based on these results, we hope to find patterns which can lead to best practices for libraries.

Methods

Five North American academic health sciences libraries contributed select usage data from their LGBTQ+ health research guides, covering a three-year period (July 2018-June 2021). Data was analyzed in two ways. Firstly, the 20 most-clicked resources from each guide were categorized through open coding, to assess if certain information resource categories were more popular among guide users, allowing for inference of user needs. A time-series analysis was also conducted for two sites, using the Classical Seasonal Decomposition by Moving Averages method, to provide deeper insights into the data.

Results

Open coding data showed consumer health information resources were used more often than other health resource categories. Resources from more locally based organizations and those with provider and services information were heavily used, indicating that users may be looking for information connecting to local health services and providers. The time series analysis allowed the potential positive effect of guide promotion to be showcased in ways that would not have been clear from the raw data.

Conclusion

This study shows that people are accessing LGBTQ+ consumer health information through academic library research guides, with a preference for local information. Guide usage appears to be positively driven by outreach within one's institution and to the greater community. Locating external partners may increase guide impact and provide important links to local resources and services.

Partnership types and coital frequency as predictors of gonorrhea and chlamydia among young MSM and young transgender women

BACKGROUND

Sexually transmitted infections pose a major public health challenge in the United States and this burden is especially acute in subpopulations like young men who have sex with men (YMSM) and young transgender women (YTW). Yet, the direct behavioral antecedents of these infections are not well understood making it difficult to identify the cause of recent increases in incidence. This study examines how variations in partnership rates and the number of condomless sex acts are associated with STI infections among YMSM-YTW.

METHOD

This study leveraged 3 years of data from a large longitudinal cohort of YMSM-YTW. A series of generalized linear mixed models examined the association between the number of condomless anal sex acts, number of one-time partners, number of casual partners, and number of main partners and chlamydia, gonorrhea, or any STI.

RESULTS

Results indicated the number of casual partners was associated with gonorrhea [aOR = 1.17 (95% CI: 1.08, 1.26)], chlamydia [aOR = 1.12 (95% CI: 1.05, 1.20)], and any STI [aOR = 1.14 (95% CI: 1.08, 1.21)] while the number of one-time partners was only associated with gonorrhea [aOR = 1.13 (95% CI: 1.02, 1.26)]. The number of condomless anal sex acts was not associated with any outcome.

CONCLUSION

These findings suggest the number of casual partners is a consistent predictor of STI infection among YMSM-YTW. This may reflect the quick saturation of risk within partnerships making the number of partners, rather than the number of acts, the more relevant factor for STI risk.

Inadequate performance of a risk score to predict asymptomatic Neisseria gonorrhoeae and Chlamydia trachomatis infection among cisgender men who have sex with men

OBJECTIVES

Epidemiological treatment of persons who are sexual contacts to partners with Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) often results in treatment of uninfected persons, which may increase the risk of antibiotic-resistant infections. We sought to identify the predictors of NG and/or CT infections to develop a risk score that could be used to limit epidemiological treatment to persons most likely to have these infections.

METHODS

We included visits to the Public Health - Seattle & King County Sexual Health Clinic by asymptomatic cisgender men who have sex with men (MSM) aged ≥18 who presented as a sexual contact to partner(s) with CT or NG infection between 2011 and 2019. We used logistic regression to estimate the odds of CT and/or NG infections associated with demographic and clinical predictors, selecting the final set of predictors using the Akaike information criteria and obtaining score weights from model coefficients. We used a cross-validation approach to obtain average model discrimination from each of 10 models, leaving out 10% of the data, and evaluated sensitivity and specificity at various score cut-offs.

RESULTS

The final model for predicting NG or CT infection included seven predictors (age <35 years, HIV status, receptive oral sex in the prior 2 months, CT diagnosis, condomless receptive anal intercourse, condomless insertive anal intercourse and methamphetamine use in the prior 12 months). Model discrimination, as measured by the receiver operating curve, was 0.60 (95% CI 0.54 to 0.66). Sensitivity for detection of infection was ≥90% for scores ≥3, ≥5 and ≥7; specificity for these cut-offs was <16%. At scores ≥9, ≥12 and ≥14, specificity increased but sensitivity decreased to ≤76%.

CONCLUSIONS

Our risk score did not sufficiently discriminate between asymptomatic MSM with and without NG/CT infection. Additional studies evaluating epidemiological treatment as a standard of care in diverse populations are needed to guide best practices in the management of contacts to NG/CT infection.

Health Care Provider Discussions Regarding HIV/Sexually Transmitted Infection Risk Factors and Associations with HIV/Sexually Transmitted Infection Screening Among Men

Little is known regarding the specific discussions health care providers (HCP) have with their patients and how these discussions may increase rates of HIV/STI screening. The main objective of this study was to examine the content of HCP-patient discussions and associations with HIV/STI screening while adjusting for patient characteristics. Using the 2017-2019 National Survey of Family Growth data, seven survey-weighted multivariable multinomial/binary logistic regression models were analyzed in men ages 15-49 years old (N = 4260). Patients had significantly higher odds of a lifetime HIV test when their HCP asked about number of sexual partners (adjusted odds ratio [aOR] = 2.325; 95% CI 1.379-3.919) and discussed HIV/AIDS (aOR = 4.149; 95% CI 2.877-5.983). Odds of a recent STI screening were higher among patients with HCP that asked about: sexual orientation (aOR = 1.534; 95% CI 1.027-2.291), number of sexual partners (aOR = 2.123; 95% CI 1.314-3.430), use of condoms (aOR = 2.295 95% CI 1.484-3.548), type of sexual intercourse (aOR = 1.900; 95% CI 1.234-2.925), and discussed HIV/AIDS (aOR = 1.549; 95% CI 1.167-2.056). Results may provide insight on how HCPs may potentially promote HIV/AIDS and STI screening among men and which patient groups are more likely to receive a discussion of risks factors from their HCPs.

STI Testing among Medicaid Enrollees Initiating PrEP for HIV Prevention in Six Southern States

OBJECTIVES

The purpose of this study was to measure sexually transmitted infection (STI) testing among Medicaid enrollees initiating preexposure prophylaxis (PrEP) to prevent human immunodeficiency virus. Secondary data are in the form of Medicaid enrollment and claims data in six states in the US South.

METHODS

Research partnerships in six states in the US South developed a distributed research network to accomplish study aims. Each state identified all first-time PrEP users in fiscal year 2017-2018 (combined N = 990) and measured the presence of STI testing for chlamydia, syphilis, and gonorrhea through 2019. Each state calculated the percentage of individuals with at least one STI test during 3-, 6-, and 12-month follow-up periods.

RESULTS

The proportion of first-time PrEP users that received an STI test varied by state: 37% to 67% of all of the individuals in each state who initiated PrEP received a test within the first 6 months of PrEP treatment and 50% to 77% received a test within the first 12 months.

CONCLUSIONS

Although the Centers for Disease Control and Prevention recommends STI testing at least every 6 months for PrEP users, our analysis of Medicaid data suggests that STI testing occurs less frequently than recommended in populations at elevated risk of syphilis, gonorrhea, and chlamydia.

Temporal Changes in Sexually Transmitted Infections in a Cohort of Men Who Have Sex with Men Living with HIV: Sex Partner Seeking and Behavioral Correlates

With "undetectable equals untransmittable," continued engagement in condomless sex has prolonged STI risk in people living with HIV. This study examined the pattern and relationship between STI diagnosis and sex partner-seeking practice over time in a cohort of men who have sex with men (MSM) attending the HIV specialist clinic in Hong Kong. Participants' STI diagnosis record since HIV diagnosis was retrieved and their frequency of seeking sex partners (A) before, (B) after HIV diagnosis, and (C) following extended period (5-10 years), through eight different settings, was assessed in two rounds of survey, along with their risk behavioral profile. Multivariable regression models were employed to study the factors associated with STI diagnosis and partner-seeking frequency, while their temporal relationships over the three time points (A-C) were examined using cross-lagged panel model. Of 345 subjects recruited, STI incidence dropped from 252 to 187 cases/1000 person-years during 2015-2019. Totally 139/212 MSM (66%) had ≥ 1 episode of STI within the 10-year period after HIV diagnosis, giving an 11-20% annual prevalence. The reduced frequency of seeking sex partner was well preserved following diagnosis with a rebound specifically noted in the use of mobile application, the patrons of which were more likely to be co-infected with STI in 2019. Chemsex, concurrent partnership, and casual sex were risk factors shared between frequent partner-seeking practice and STI diagnosis. A robust autoregressive effect for partner-seeking frequency was also identified, and which significantly predicted STI risk in the long term. To enhance HIV care, the co-administration of STI/behavioral surveillance should be emphasized.

Persistently Elevated Risk of Syphilis Among Human Immunodeficiency Virus-Positive Men Receiving Care in a Status-Neutral Setting: A Retrospective Analysis

BACKGROUND

Over the past decade, the incidence of primary and secondary syphilis has increased dramatically in the United States and Western Europe. Men living with human immunodeficiency virus (HIV) and those at risk of HIV infection experience disproportionately high rates of early syphilis (ES). We compared the odds of ES among HIV-positive and HIV-negative men participating in a status-neutral comprehensive HIV prevention and treatment program (CHP).

METHODS

We conducted a retrospective analysis of men aged 18 to 65 years with ≥ 1 CHP visit and ≥2 rapid plasma reagin (RPR) tests performed between January 1, 2018, and December 31, 2021. Early syphilis was defined as newly reactive RPR with a minimum titer of ≥1:4 or a ≥ 4-fold increase in the RPR titer. Multiple logistic regression analyses were performed to determine predictors of ES.

RESULTS

A total of 2490 men met the inclusion criteria, of whom 1426 (57.3%) were HIV-positive and 1064 (42.7%) were HIV-negative. Of the 393 men with ES, 284 (72.3%) were HIV-positive and 109 (27.7%) were HIV-negative. Human immunodeficiency virus-positive men had higher adjusted odds of ES (adjusted odds ratio, 2.86; 95% confidence interval, 2.45-3.27) than HIV-negative men did. Chlamydia or gonorrhea infection did not differ according to HIV status (adjusted odds ratio, 0.93; 95% confidence interval, 0.82-1.04).

CONCLUSIONS

In our status-neutral care setting, HIV-positive status was associated with significantly higher odds of ES, but not chlamydia or gonorrhea. Our findings emphasize the vulnerability of HIV-positive men to syphilis in an era of effective HIV biomedical prevention.

Prevalence of Mycoplasma genitalium infection among HIV PrEP users: a systematic review and meta-analysis

OBJECTIVES

To summarise the prevalence of Mycoplasma genitalium (MG) and antibiotic-resistant MG infection among HIV pre-exposure prophylaxis (PrEP) users.

METHODS

We searched MEDLINE, Embase, Web of Science and Global Index Medicus up to 30 September 2022. We included studies reporting the prevalence of MG and/or antibiotic-resistant MG infection among PrEP users. Two reviewers independently searched for studies and extracted data. A systematic review with random-effects meta-analysis was performed to quantitatively summarise the results of included studies. The critical appraisal of included studies was conducted with the Joanna Briggs Institute checklist for prevalence studies and the quality of evidence was assessed with Grading of Recommendations Assessment, Development and Evaluation (GRADE).

RESULTS

A total of 15 studies were included in the systematic review, with 2341 individuals taking PrEP. Studies were conducted in high-income level countries between 2014 and 2019. Median age of participants varied from 23.5 to 40 years. The majority were men (85%) and among them, 93% were men who have sex with men. To identify MG, urine samples were analysed in 14 studies, rectal or anal swabs in 12 studies, oral or pharyngeal swabs in 9 studies, and urethral or vaginal in 3 studies. The pooled point prevalence of MG among PrEP users was 16.7% (95% CI 13.6% to 20.3%; 95% prediction interval (95% PI) 8.2% to 31.1%). The pooled point prevalence of macrolide-resistant infections was 82.6% (95% CI 70.1% to 90.6%; 95% PI 4.7% to 99.8%) and the prevalence of fluoroquinolone-resistant infections was 14.3% (95% CI 1.8% to 42.8%). Individuals taking PrEP have a higher chance of being infected with MG compared with those not taking PrEP (OR 2.30; 95% CI 1.6 to 3.4). The quality of evidence was very low to moderate.

CONCLUSION

We observed a high prevalence of MG and its macrolide resistance among PrEP users, highlighting the need to reinforce prevention strategies against sexually transmitted infections in this population.

PROSPERO REGISTRATION NUMBER

CRD42022310597.

Web-Based Harm Reduction Intervention for Chemsex in Men Who Have Sex With Men: Randomized Controlled Trial

BACKGROUND

Men who have sex with men (MSM) who practice chemsex have a higher likelihood of engaging in risky sexual behaviors and higher rates of HIV infection and other sexually transmitted infections (STIs) than those who do not.

OBJECTIVE

This trial aimed to evaluate the effectiveness of a web-based intervention in reducing the sexual harms of chemsex among MSM.

METHODS

The study was a 2-arm, assessor-blinded, randomized, parallel-group trial with a 3-month follow-up period. The study was conducted in the year 2021 in Hong Kong. Underpinned by the theory of planned behaviors and a harm reduction approach, the intervention consisted of interactive components and knowledge-based information about chemsex. Participants in the control group received brief information and content about sexual violence. The primary outcome was self-efficacy in refusing risky sexual behaviors and chemsex, as measured by the Condom Self-Efficacy Scale (CSES), Self-Efficacy for Sexual Safety (SESS) instrument, and Drug Avoidance Self-Efficacy Scale (DASES). The secondary outcomes included intentions to have chemsex, actual engagement in chemsex, HIV and other STI testing, and condom use in the last 3 months. All outcomes were self-reported. An online structured questionnaire was used to collect data.

RESULTS

In total, 316 MSM enrolled in the study. The intervention group demonstrated a significantly larger improvement in condom-use self-efficacy (as measured by CSES scores; time-by-group interaction: β=4.52, 95% CI 2.03-7.02; P<.001), self-efficacy for sexual safety (as measured by SESS scores; time-by-group interaction: β=2.11, 95% CI 0.66-3.56; P=.004), and drug avoidance self-efficacy (as measured by DASES scores; time-by-group interaction: β=6.98, 95% CI 1.75-12.22; P=.009). Regarding the secondary outcomes, participants in the intervention group demonstrated a significantly larger reduction in the likelihood of having engaged in chemsex in the last 3 months (time-by-group interaction: odds ratio [OR]=0.23, 95% CI 0.10-0.53; P=.001) and likelihood of having had the intention to engage in chemsex in the last 3 months (time-by-group interaction: OR=0.37, 95% CI 0.18-0.78; P=.009). Participants in the intervention group also showed a significantly larger increase in the likelihood of having undergone HIV testing in the last 3 months (time-by-group interaction: OR=3.08, 95% CI 1.72-5.54; P<.001).

CONCLUSIONS

This study suggests that a web-based intervention with a harm reduction approach can enhance the self-efficacy of MSM in refusing risky sexual behaviors and chemsex and improve the uptake of HIV testing. We also provide initial evidence that such interventions can reduce both the intention of MSM to engage in chemsex and their actual engagement in chemsex.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN20134522; https://www.isrctn.com/ISRCTN20134522.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s12889-021-10742-8.

Biological, Behavioral, and Demographic Drivers of Recent Syphilis Infection Among Emerging Adult Sexual Minority Men in New York City: The P18 Cohort Study

The rate of syphilis infections among sexual minority men (SMM) has continued to increase in recent decades. As such, this analysis sought to identify demographic, biological, and behavioral factors associated with recent syphilis infection in emerging adult SMM. Data were drawn from a 3-year cohort study of emerging adult SMM (n = 665), from July 2014 to March 2019. Biannual study assessments included rapid HIV testing and behavioral surveys. At baseline, and at the 18- and 36-month time points, participants underwent chlamydia, gonorrhea, and syphilis screening. Generalized estimating equations were used to generate four models of repeated syphilis screening. In this racially/ethnically and socioeconomically diverse sample of SMM, 5.0% of participants tested positive for syphilis at baseline and 9.0% had an infection at the subsequent time points. Across all models, racial/ethnic minority SMM had higher odds of syphilis. Higher odds of syphilis infection were also significantly associated with more frequent condomless anal sex, more frequent marijuana use, HIV seropositivity, not currently using pre-exposure prophylaxis (PrEP), and not receiving syphilis testing in the previous 6 months; lower odds were associated with more frequent oral sex and more frequent alcohol use. These findings support current screening guidelines based on SMM who may be at increased risk for sexually transmitted infection (STI) acquisition, such as people living with HIV or those who engage in condomless sex. Further, our findings of reduced syphilis incidence among those who are on PrEP and engaged in regular STI testing support existing efforts to increase the availability and accessibility of preventive sexual health care for SMM.

HIV awareness, pre-exposure prophylaxis perceptions and experiences among people who exchange sex: qualitative and community based participatory study

Background

People who exchange sex for money, favors, goods or services, combat higher risk of acquiring sexually transmitted diseases (STDs) and human immunodeficiency virus (HIV). Understanding barriers to STD and HIV related healthcare from the perspective of this stigmatized and marginalized community may improve access to sexual health services including pre-exposure prophylaxis (PrEP). 

Methods

We used community-partnered participatory and qualitative methods to conduct anonymous one-on-one interviews with people who exchange sex to understand their perspectives and experiences related to pre-exposure prophylaxis (PrEP) to prevent HIV acquisition. We conducted twenty-two interviews and coded them to perform thematic analysis. 

Results

We identified five themes: (1) Appreciation of HIV risk and prevention strategies grew from information accumulated over time. (2) PrEP information came from a variety of sources with mixed messages and uncertain credibility. (3) Decision-making about use of PrEP was relative to other behavioral decisions regarding exchange sex. (4) The multi-step process of obtaining PrEP presented multiple potential barriers. (5) Healthcare providers were seen as powerful facilitators to PrEP utilization.

Conclusions

Our findings suggest that PrEP education and care needs to be made more relevant and accessible to individuals who exchange sex.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14235-0.

Clinical Considerations in the Selection of Preexposure Prophylaxis for HIV Prevention in Canada

According to the Public Health Agency of Canada, approximately 62,050 people were living with HIV in Canada in 2018, and of those, 13% were undiagnosed. Currently, no single strategy provides complete protection or is universally effective across all demographic groups at risk for HIV. However, HIV preexposure prophylaxis (PrEP) is the newest HIV prevention strategy that shows promise. To date, two products have received an indication for PrEP by Health Canada: emtricitabine/tenofovir disoproxil fumarate (Truvada®; FTC/TDF) and emtricitabine/tenofovir alafenamide (Descovy®; FTC/TAF). Despite the high efficacy of these PrEP intervention methods, access to PrEP in Canada remains low. Identifying and addressing barriers to PrEP access, especially in high-risk groups, are necessary to reduce HIV transmission in Canada. While guidelines published by the Center for Disease Control and Prevention (CDC) include FTC/TAF information, the efficacy of FTC/TAF for PrEP has not yet been considered in Canada's clinical practice guidelines. Thus, the current paper reviews data regarding the use of FTC/TDF and FTC/TAF for PrEP, which may be useful for Canadian healthcare providers when counseling and implementing HIV prevention methods. The authors highlight these data in relation to various at-risk populations and review ongoing clinical trials investigating novel PrEP agents. Overall, FTC/TDF PrEP is effective for many populations, including men who have sex with men, transgender women, heterosexuals with partners living with HIV, and people who use drugs. While there is fewer data reported on the efficacy of FTC/TAF to date, recent clinical trials have demonstrated noninferiority of FTC/TAF in comparison to FTC/TDF. Notably, as studies have shown that FTC/TAF maintains renal function and bone mineral density to a greater extent than FTC/TDF, FTC/TAF may be a safer option for patients experiencing renal and/or bone dysfunction, for those at risk of renal and bone complications, and for those who develop FTC/TDF-related adverse events.

Variations in sexual network connectivity may explain dramatic variations in sexually transmitted infection prevalence between populations and over time: a selected four-country analysis

Background: The incidence of sexually transmitted infections (STIs) has been noted to vary dramatically between population groups and over time. Here, the hypothesis that changes in network connectivity underpin these changes is explored.

Methods: The incidence/prevalence estimates of HIV, herpes simplex virus-2, syphilis, chlamydia, and gonorrhoea, as well as two markers of sexual network connectivity (partner concurrency and multiple partnering) by ethnic group and sexual orientation in Kenya, South Africa, the United Kingdom (UK) and the United States (USA) were extracted from published studies. Pearson’s correlation was used to test the association between the markers of network connectivity and the incidence/prevalence of these five STIs. A literature review was performed to evaluate the possible causes of the increases and decreases in syphilis incidence over the past 60 years.

Results: In each country, the five STIs were found to cluster in particular ethnic groups and sexual orientations and to be positively associated with the two markers of network connectivity. Syphilis incidence in the UK and USA was found to increase dramatically in the 1960s/1970s, decline in the 1980s and again increase in the late 1990s. These changes took place predominantly in men who have sex with men, and were preceded by corresponding changes in network connectivity. The large decline in antenatal syphilis prevalence in Kenya and South Africa in the 1990s were likewise preceded by declines in network connectivity.

Conclusions: Although other explanatory variables are not controlled for, the present analysis is compatible with the hypothesis that differential network connectivity is a parsimonious explanation for variations in STI incidence over time and between populations.

Web-Based Risk Prediction Tool for an Individual's Risk of HIV and Sexually Transmitted Infections Using Machine Learning Algorithms: Development and External Validation Study

Background

HIV and sexually transmitted infections (STIs) are major global public health concerns. Over 1 million curable STIs occur every day among people aged 15 years to 49 years worldwide. Insufficient testing or screening substantially impedes the elimination of HIV and STI transmission.

Objective

The aim of our study was to develop an HIV and STI risk prediction tool using machine learning algorithms.

Methods

We used clinic consultations that tested for HIV and STIs at the Melbourne Sexual Health Centre between March 2, 2015, and December 31, 2018, as the development data set (training and testing data set). We also used 2 external validation data sets, including data from 2019 as external “validation data 1” and data from January 2020 and January 2021 as external “validation data 2.” We developed 34 machine learning models to assess the risk of acquiring HIV, syphilis, gonorrhea, and chlamydia. We created an online tool to generate an individual’s risk of HIV or an STI.

Results

The important predictors for HIV and STI risk were gender, age, men who reported having sex with men, number of casual sexual partners, and condom use. Our machine learning–based risk prediction tool, named MySTIRisk, performed at an acceptable or excellent level on testing data sets (area under the curve [AUC] for HIV=0.78; AUC for syphilis=0.84; AUC for gonorrhea=0.78; AUC for chlamydia=0.70) and had stable performance on both external validation data from 2019 (AUC for HIV=0.79; AUC for syphilis=0.85; AUC for gonorrhea=0.81; AUC for chlamydia=0.69) and data from 2020-2021 (AUC for HIV=0.71; AUC for syphilis=0.84; AUC for gonorrhea=0.79; AUC for chlamydia=0.69).

Conclusions

Our web-based risk prediction tool could accurately predict the risk of HIV and STIs for clinic attendees using simple self-reported questions. MySTIRisk could serve as an HIV and STI screening tool on clinic websites or digital health platforms to encourage individuals at risk of HIV or an STI to be tested or start HIV pre-exposure prophylaxis. The public can use this tool to assess their risk and then decide if they would attend a clinic for testing. Clinicians or public health workers can use this tool to identify high-risk individuals for further interventions.

Analysis of serological treatment response to doxycycline versus benzathine penicillin in syphilis infections, a retrospective single-center study

Doxycilicine is the second-line treatment of choice for infectious syphilis when treatment with penicillin G is not feasible. To date, difficulties in the penicillin supply chain make it necessary to evaluate and resort to antibiotic therapies which are currently considered a second-line choice. Moreover, systematic studies comparing the two treatments in affected patients are still few, and many do not consider late and indeterminate latent infections. The objective of this study was to assess the differences in the serological response of the treatment of syphilis infections with benzathine penicillin compared with doxycycline. We built an in-house database with all patients diagnosed with syphilis infection from January 2010 to January 2020 in the STD Centre of the S.Orsola-Malpighi Polyclinic of the University of Bologna, located in the North-east of Italy. We recorded all the principal independent (demographic, social status, reinfection rare, HIV infections, comorbidities, sexual behaviors, and initial TPHA values) and dependent variables (RPR values). We then extrapolated all patients treated with doxycycline (100 mg of doxycycline twice daily for 14 days for infections diagnosed within the first year and a 28 days course for infections older than 1 year or undetermined) and matched in 1:1 ratio numbers with a homogeneous group of patients treated with penicillin G (2.4 million units in a single dose intramuscularly for infections diagnosed within the first year and a cycle consisting in of 2.4 million units administered in a single dose per week for 3 weeks for infections older than 1 year or undetermined) We then analyzed the serological trends and outcomes in the primary, secondary and early latent groups versus late latent and undetermined infections. We retrieved 41 patients for each group with homogeneous initial characteristics. At the end of the 24-month observation period, a slight difference in a valid RPR reduction rate emerged, with a greater success rate emerged in patients receiving penicillin than those with doxycycline (26 vs. 22, p 0.615). Indeed, patients with latent or indeterminate syphilis treated with doxycycline appear to have a higher rate of serofast than those treated with penicillin. Linear regression analysis showed no strong correlation between the analyzed independent variables and the observed outcomes. Doxycycline had a slightly lower, though not statistically different, success rate when compared with penicillin in treating primary syphilis, but appeared to have a reduced success rate in attaining resolution in late and undetermined syphilis infection.

Possible Reactivation of Latent Anal Human Papillomavirus Associated with Markers of Immune Dysfunction in Gay and Bisexual Men

BACKGROUND

It is unknown whether reactivation of human papillomavirus (HPV) after latency occurs in the anus. We measured incidence and predictors of incident anal HPV in sexually inactive gay and bisexual men (GBM) as a surrogate of HPV reactivation.

METHODS

The Study of the Prevention of Anal Cancer collected data on sexual behavior, anal cytology, HPV DNA, histology and HPV serology. HPV incidence during periods when zero sexual partners were reported in the last six months at both the current and previous annual visit ("no sexual activity") was analyzed by Cox regression using the Wei-Lin-Weissfeld method to determine univariable predictors.

RESULTS

Of 617 men enrolled, 525 had results for ≥2 visits, of whom 58 (11%) had ≥ one period of "no sexual activity". During sexually inactive periods, there were 29 incident high risk HPV infections in 20 men, which occurred more commonly in older men (Ptrend = 0.010), HIV-positive men (HR = 3.12; 95% CI, 0.91-16.65), longer duration of HIV (Ptrend = 0.028), history of AIDS defining illness (P = 0.010), lower current (P = 0.010) and nadir CD4 count (P = 0.014). For 18 of 29 infections with available results, 12 men remained type-specific HRHPV L1 seronegative. None were consistently seropositive. A new diagnosis of HSIL occurred in only two men, caused by an HPV type other than the incident type.

CONCLUSIONS

Our findings suggest that in sexually inactive GBM, anal HRHPV incidence is relatively common, and is associated with increasing age and immune dysfunction, a pattern consistent with HPV reactivation.

IMPACT

Reactivation of anal HPV may occur.

A Machine-Learning-Based Risk-Prediction Tool for HIV and Sexually Transmitted Infections Acquisition over the Next 12 Months

Background: More than one million people acquire sexually transmitted infections (STIs) every day globally. It is possible that predicting an individual’s future risk of HIV/STIs could contribute to behaviour change or improve testing. We developed a series of machine learning models and a subsequent risk-prediction tool for predicting the risk of HIV/STIs over the next 12 months. Methods: Our data included individuals who were re-tested at the clinic for HIV (65,043 consultations), syphilis (56,889 consultations), gonorrhoea (60,598 consultations), and chlamydia (63,529 consultations) after initial consultations at the largest public sexual health centre in Melbourne from 2 March 2015 to 31 December 2019. We used the receiver operating characteristic (AUC) curve to evaluate the model’s performance. The HIV/STI risk-prediction tool was delivered via a web application. Results: Our risk-prediction tool had an acceptable performance on the testing datasets for predicting HIV (AUC = 0.72), syphilis (AUC = 0.75), gonorrhoea (AUC = 0.73), and chlamydia (AUC = 0.67) acquisition. Conclusions: Using machine learning techniques, our risk-prediction tool has acceptable reliability in predicting HIV/STI acquisition over the next 12 months. This tool may be used on clinic websites or digital health platforms to form part of an intervention tool to increase testing or reduce future HIV/STI risk.

Mindfulness for Reducing Minority Stress and Promoting Health Among Sexual Minority Men: Uncovering Intervention Principles and Techniques

Objectives

Tailored, evidence-based interventions are in high need for sexual minority men (gay, bisexual, and queer men who have sex with men) to address prevalent mental health issues and HIV/STI risk. This study describes the formative research that informed the development of Mindfulness-Based Queer Resilience (MBQR): a mindfulness-based intervention for health promotion among sexual minority men.

Methods

Guided by the ADAPT-ITT model, we conducted a series of interviews with community stakeholders, including sexual minority men with anxiety and depressive symptoms (n = 15) and mindfulness service providers with experience working with sexual minority men (n = 11). Thematic analysis was used for data analysis.

Results

Six intervention principles and seven key techniques/delivery considerations emerged relevant to intervention development. Principles included (a) reducing minority stress as a key theoretical guide, (b) affirming LGBTQ + identity and facilitating healthy identity development, (c) attending to intersectionality, (d) facilitating resilience and self-empowerment, (e) trauma sensitivity, and (f) promoting healthy relationships and a healthy community. Key techniques represent the pathways through which MBQR may address the adverse impacts of minority stress, including through attention control practice to facilitate agency and self-awareness, enhancing emotion regulation, reducing reactivity to minority stress-informed thoughts, self-compassion to increase self-acceptance, and reducing behavioral avoidance. Delivery considerations also included careful navigation regarding mindfulness and religion, as well as using modern technology to increase reach, access, and engagement.

Conclusions

If proven to be feasible and efficacious, MBQR may offer the potential to alleviate adverse impacts of minority stress and improve mental and sexual health of sexual minority men.

Repeat Syphilis Among HIV-Infected Men in Florida and Louisiana 2000-2018: Implications for Screening Recommendations

Syphilis rates have continued to rise in the United States. Florida and Louisiana consistently report high numbers of cases. We evaluated rates of reinfection to see if frequent rescreening might lead to earlier treatment and prevent infections. All syphilis records of all stages for males and females aged 15-70 years from the Florida and Louisiana Departments of Health surveillance databases 2000-2018 were evaluated. The first episode of syphilis during this period was considered the initial diagnosis for each person. Demographics of cases and repeaters (individuals reported with two or more cases of syphilis) were examined. Percentages of syphilis cases from repeaters by year were calculated as were percentages from HIV+ males. During 2000-2018, 124,827 syphilis cases were reported from 107,405 individuals: 73,811 (68.7%) males; 33,594 (31.3%) females. There were 12,545 individuals (repeaters) with two or more syphilis diagnoses (n = 17,422 cases; range, 2-10). From 2010 to 2018, repeaters accounted for steadily increasing percentage of all syphilis reported: 2010 (11%), 2013 (16%), 2015 (20%), and 2018 (26%). Among HIV+ male cases the percentage from repeaters also increased: 2010 (28%), 2013 (35%), 2015 (42%), and 2018 (50%). In 2018, 19% of all cases (n = 2455) were from HIV+ males who had a previous syphilis diagnosis. Among HIV+ males diagnosed with syphilis in 2015, 34% had a repeat syphilis diagnosis within 3 years. Most syphilis diagnosed in Florida and Louisiana was among persons infected for the first time. However, some subgroups could possibly benefit from more frequent screening. Males living with HIV who had a prior syphilis diagnosis were at very high risk of repeat infection.

HIV pre-exposure prophylaxis and sexually transmitted infections: intersection and opportunity

Pre-exposure prophylaxis (PrEP) has revolutionized HIV prevention, but PrEP does not protect against other sexually transmitted infections (STIs). Rates of STIs are rising worldwide, with notably high incidences among PrEP-using men who have sex with men in high-income countries; in low-income and middle-income countries, data are sparse, but results from a limited number of studies among African women initiating and taking PrEP have shown high STI prevalence and incidence. Efforts aimed at markedly reducing HIV in populations worldwide include a major focus on increasing PrEP use, along with improving HIV testing and treatment in order to eliminate HIV transmission. Together, these efforts could augment continued expansion of the global STI epidemic, but they could alternatively create an opportunity to improve STI control, including the development of comprehensive sexual health programmes and research to develop new STI prevention strategies. The introduction of PrEP globally has been characterized by challenges and many successes, and its role as part of a range of robust strategies to reduce HIV infections is clear. Looking ahead, understanding rising rates of curable STIs and their relationship to HIV prevention, and considering the future directions for synergies in PrEP and STI prevention will be integral to improving sexual health.

Genital Herpes Disclosure Attitudes Among Men Who Have Sex with Men

An abundance of literature interested in sexually transmitted infections-related disclosure attitudes among MSM (men who have sex with men) exists. However, comparatively few studies have examined these with respect to genital herpes. This cross-sectional study examined attitudes about herpes-related disclosure among Houston MSM. Convenience sampling at Houston-based MSM venues and events was conducted during December 2018 and January 2019 with 302 participants recruited. Participants were asked if an individual with genital herpes should disclose to others and if they would disclose to others if they had/have genital herpes. Factors associated with decreased belief that someone should disclose a genital herpes infection to others were history of genital herpes (OR 0.14, 95% CI [0.04, 0.55]) and race other than white, black, or Hispanic/Latino (OR 0.34, 95% CI [0.15, 0.77]). History of 0 to 1 sexual partner(s) in the past year was associated with increased belief that an individual should disclose (OR 2.43, 95% CI [1.19, 4.98]), while self-reported history of genital herpes was associated with decreased intent to disclose one's own infection to potential partners (OR 0.30, 95% CI [0.10, 0.91]). Self-reported history of genital herpes was associated with decreased belief that someone with genital herpes should tell others and with decreased likelihood to disclose one's own status. Lastly, race other than white, black, or Hispanic/Latino was associated with increased belief that someone with genital herpes should not tell others. Normalization of genital herpes could bolster intent to disclose genital herpes infection and improve sexual outcomes.

Countering the rise of syphilis: A role for doxycycline post-exposure prophylaxis?

Doxycycline post-exposure prophylaxis (PEP) holds the potential to mitigate increasing rates of syphilis among sexual minority men (SMM) in the US yet has received limited attention. Since evaluation of this intervention in actual populations is not currently feasible, we used agent-based models (ABM) to assess the population-level impact of this strategy. We adapted ABM of HIV and HPV transmission, representing a population of 10,230 SMM in Philadelphia, Pennsylvania, US. Parameter inputs were derived from the literature, and ABM outputs during the pre-intervention period were calibrated to local surveillance data. Intervention scenarios varied doxycycline uptake by 20, 40, 60, 80 and 100%, while assuming continued condom use and syphilis screening and treatment. Under each intervention scenario, we incorporated treatment adherence at the following levels: 0, 20, 40, 60, 80 and 100%. Long-term population impact of prophylactic doxycycline was measured using the cumulative incidence over the 10-year period and the percentage of infections prevented attributable to doxycycline at year 10. An uptake scenario of 20% with an adherence level of 80% would reduce the cumulative incidence of infections by 10% over the next decade, translating to 57 fewer cases per 1000 SMM. At year 10, under the same uptake and adherence level, 22% of infections would be prevented due to doxycycline PEP in the instances where condoms were not used or failed. Findings suggest that doxycycline PEP will have a modest impact on syphilis incidence when assuming a reasonable level of uptake and adherence. Doxycycline PEP may be most appropriate as a secondary prevention measure to condoms and enhanced syphilis screening for reducing infections among SMM.

Molecular screening in a longitudinal cohort of young men who have sex with men and young transgender women: associations with focus on the emerging sexually transmitted pathogen Mycoplasma genitalium

OBJECTIVES

This investigation sought to characterise risk factors associated with acquisition of traditional and emerging agents of sexually transmitted infection (STI) in a cohort of young men who have sex with men and transgender women.

METHODS

917 participants provided urine and rectal swab submissions assessed by transcription-mediated amplification (TMA)-based assays for Chlamydia trachomatis and Neisseria gonorrhoeae and by off-label TMA-based Trichomonas vaginalis and Mycoplasma genitalium testing. A subset provided specimens at 6-month and 12-month follow-up visits.

RESULTS

Prevalence of M. genitalium from rectal and urine specimens (21.7% and 8.9%, respectively) exceeded that of C. trachomatis (8.8% and 1.6%) and other STI agents. Black participants yielded higher prevalence of M. genitalium (30.6%) than non-black participants (17.0%; χ²=22.39; p<0.0001). M. genitalium prevalence from rectal specimens was 41.5% in HIV-positive participants vs 16.3% in HIV-negative participants (χ²=57.72; p<0.0001). Participant age, gender identity, condomless insertive anal/vaginal sexual practice and condomless receptive anal sexual practice were not associated with rectal C. trachomatis (p≥0.10), N. gonorrhoeae (p≥0.29), T. vaginalis (p≥0.18) or M. genitalium (p≥0.20) detection. While prevalence of T. vaginalis was calculated at ≤1.0%, baseline rectal and urine screening status was predictive of detection/non-detection at follow-up. A non-reactive M. genitalium baseline rectal or urine screening result was less predictive of non-reactive follow-up versus C. trachomatis, N. gonorrhoeae and T. vaginalis.

CONCLUSIONS

Rectal M. genitalium detection is associated with black race and HIV seropositivity. Baseline M. genitalium infection influences subsequent detection of the organism.

Evidence of changing sexual behaviours and clinical attendance patterns, alongside increasing diagnoses of STIs in MSM and TPSM

Background

Due to rising numbers of STI diagnosis and increasing prevalence of antimicrobial resistance, we explored trends in STI testing frequency and diagnoses, alongside sexual decision making and attitudes concerning condom use and HIV pre-exposure prophylaxis (PrEP) at a large urban UK sexual health clinic.

Methods

We examined 66 528 electronic patient records covering 40 321 attendees between 2016 and 2019, 3977 of whom were men who have sex with men or trans persons who have sex with men (MSM/TPSM). We also explored responses from MSM/TPSM attendees sent an electronic questionnaire between November 2018 and 2019 (n=1975) examining behaviours/attitudes towards PrEP. We measured trends in STI diagnoses and sexual behaviours including condomless anal intercourse (CAI), using linear and logistic regression analyses.

Results

Tests resulting in gonorrhoea, chlamydia or syphilis diagnoses increased among MSM/TPSM from 13.5% to 18.5% between 2016 and 2019 (p<0.001). The average MSM/TPSM STI testing frequency increased from 1.5/person/year to 2.1/person/year (p=0.017). Gay MSM/TPSM had the highest proportions of attendances resulting in diagnoses, increasing from 15.1% to 19.6% between 2016 and 2019 (p<0.001) compared with bisexual/other MSM/TPSM increasing from 6.9% to 14.5% (p<0.001), alongside smaller but significant increases in non-MSM/TPSM from 5.9% to 7.7% (p<0.001).

The proportion of MSM/TPSM clinic attendees reporting CAI in the previous 3 months prior to at least one appointment in a given year increased significantly from 40.6% to 45.5% between 2016 and 2019 (p<0.0001) and average number of partners from 3.8 to 4.5 (p=0.002). Of 617 eligible questionnaire responses, 339/578 (58.7%) HIV-negative and 29/39 (74.4%) HIV-positive MSM/TPSM indicated they would be more likely to have CAI with someone on PrEP versus not on PrEP. 358/578 (61.9%) HIV-negative respondents said that PrEP use would make them more likely to have CAI with HIV-negative partners.

Conclusion

Rising numbers of STI diagnoses among MSM/TPSM are not attributable to increased testing alone. Increased CAI and number of partners may be attributable to evolving sexual decision making among PrEP users and their partners. Proportionally, bisexual/other MSM/TPSM have the steepest increase in STI diagnoses.

"Shades of risk": Understanding current PrEP users' sexually transmitted infection perceptions

ABSTRACTPre-exposure prophylaxis (PrEP) is a safe and effective HIV prevention strategy. Given the possibility of increased sexual risk-taking and acquisition of other sexually transmitted infections (STIs) following PrEP initiation, it is important to explore STI risk perceptions both before and after PrEP initiation to understand the extent to which these perceptions inform decisions to engage in condomless sex. Semi-structured qualitative interviews were conducted with men who have sex with men currently using PrEP (n = 30). Prior to analysis, PrEP users were categorized into four subgroups based on condom use behavior post-PrEP initiation: (1) condom continuers (2) condomless sex continuers, (3) condomless sex increasers, and (4) condomless sex decreasers. Thematic analysis revealed two major themes that elucidated differences in (1) the appraisal of HIV risk relative to other STIs and (2) the importance of partner communication in determining STI risk perceptions by subgroup. Most PrEP users demonstrated no behavioral change after PrEP initiation. Those engaging in condomless sex prior to PrEP initiation also continued that behavior while taking PrEP. Results of this study support a tailored approach to PrEP counseling based on individual STI risk appraisal and motivations to initiate and continue PrEP.

Incidence of Sexually Transmitted Infections After Initiating HIV Pre-Exposure Prophylaxis Among MSM in Southern Denmark

Pre-exposure prophylaxis (PrEP) is a new preventive treatment for individuals at high-risk for HIV infection, such as men who has sex with men (MSM). Studies have confirmed the efficacy but concerns about the potential induction of risk compensation remains. We aimed to assess the incidence of sexually transmitted infections (STIs) after PrEP initiation as a proxy for sexual risk behavior.

This case-crossover study used data from medical records and from the Danish Microbiology Database from patients who initiated PrEP at the Region of Southern Denmark between 2017 and 2019. Poisson regression was used to assess STI incidence 6 months after PrEP initiation versus the 6 months before. To identify potential risk factors, we compared individuals with an increased STI incidence after PrEP initiation with those without, using logistic regression.

In total, 46 MSM initiated PrEP in the study period. We found a significant increase in the number of positive samples for STI after PrEP initiation (IRR 1.83; 95% CI [1.03, 3.26]) and a tendency for higher incidence of STI episodes (1.67; 95% CI [0.91, 3.13]). The increase was concentrated to a group of users, but no significant correlation was found between increasing incidence and the baseline factors examined.

We observed a degree of risk compensation after the implementation of PrEP among MSM, clustering to a group of users. Our results highlight the importance of frequent STI screening among MSM on PrEP as timely diagnosis could contribute to an overall decrease in STI incidence and incidence among MSM.

Pubic Hair Grooming and Sexually Transmitted Infections: A Clinic-Based Cross-Sectional Survey

BACKGROUND

Pubic hair grooming has been correlated with a self-reported history of sexually transmitted infections (STIs). We examined this relationship further in a cross-sectional survey of patients attending an urban STI clinic in San Francisco in 2018.

METHODS

Pubic hair grooming practices and detailed sexual histories were obtained. Sexually transmitted infections were confirmed via laboratory diagnosis or physical examination by a licensed provider.

RESULTS

A total of 314 individuals completed the survey. The median age of participants was 31 years. In total, there were 247 (80%) men, 58 (19%) women, and 5 (2%) transgender participants. Of the 247 men, 177 (72%) identified as gay or bisexual. Twenty-five (82%) of 314 patients reported pubic hair grooming within the past 3 months. Seventy-eight (25%) patients were diagnosed with a new STI during their visit. There were no significant associations between reporting any anal or genital grooming and being diagnosed with an STI. However, anal groomers were 3 times as likely to be diagnosed with a rectal STI after adjustment (adjusted odds ratio, 3.0; 95% confidence interval, 1.2-7.5) compared with genital only groomers and nongroomers. Participants who report removing all of their pubic hair more than 6 times within the past year had higher prevalence of genital STIs (33.3%, 6-10 times; 28.6%, >10 times) compared with participants who never groom all of their pubic hair (15.3%, P = 0.01).

CONCLUSIONS

We found no association between recent grooming and genital STIs. Anal grooming was associated with rectal STIs in gay and bisexual men.

To Pool or Not to Pool Samples for Sexually Transmitted Infections Detection in Men Who Have Sex With Men? An Evaluation of a New Pooling Method Using the GeneXpert Instrument in West Africa

BACKGROUND

Men who have sex with men (MSM) using preexposure prophylaxis (PrEP) are at risk for sexually transmitted infections (STIs). Therefore, PrEP services should include regular screening for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) at urethra, anorectum, and pharynx. However, financial and logistic challenges arise in low-resource settings. We assessed a new STI sample pooling method using the GeneXpert instrument among MSM initiating PrEP in West Africa.

METHODS

Urine, anorectal, and pharyngeal samples were pooled per individual for analysis. In case of an invalid result only (strategy 1) or a positive result of the pool (strategy 2), samples were analyzed individually to identify the infection's biological location. The results of 2 different pooling strategies were compared against the individual results obtained by a criterion standard.

RESULTS

We found a prevalence of 14.5% for chlamydia and 11.5% for gonorrhea, with a predominance of infections being extragenital (77.6%). The majority of infections were asymptomatic (88.2%). The pooling strategy 1, had a sensitivity, specificity and agreement for CT of 95.4%, 98.7%, and 0.93, respectively; and 92.3%, 99.2%, and 0.93 for pooling strategy 2. For NG, these figures were 88.9%, 97.7%, and 0.85 for strategy 1, and 88.9%, 96.7%, and 0.81 for strategy 2.

CONCLUSIONS

West African MSM have a high prevalence of extragenital and asymptomatic STIs. The GeneXpert method provides an opportunity to move from syndromic toward etiological STI diagnosis in low-income countries, as the platform is available in African countries for tuberculosis testing. Pooling will reduce costs of triple site testing.

"Far More than Just a Prescription": Focus Groups With U.S. Family Planning Providers and Staff About Integrating PrEP for HIV Prevention Into Their Work

BACKGROUND

Cisgender women in the United States use pre-exposure prophylaxis (PrEP) for HIV prevention at lower rates relative to other groups. Advocacy groups and patients identify family planning clinics as the preferred sites to lead PrEP implementation for women in the United States. However, limited qualitative exploration exists of U.S. family planning practitioners' attitudes toward integrating PrEP into their work.

METHODS

We conducted qualitative focus groups with a convenience sample of family planning clinicians, counselors, and clinic managers to explore barriers and facilitators to PrEP provision in U.S. family planning clinics.

RESULTS

We conducted six focus groups (total participants = 37) with respondents who worked in family planning clinics in San Francisco, California; Kansas City, Missouri; and Philadelphia, Pennsylvania. Key themes emerged highlighting how PrEP at times runs contrary to other family planning agendas, including efficient clinic visits, condom promotion, and long-acting reversible contraception counseling. Throughout these discussions, participants expressed discomfort with HIV vulnerabilities rooted in social and structural determinants of health.

CONCLUSIONS

Findings suggest that those seeking to implement PrEP for U.S. cisgender women may benefit from exploring 1) how to integrate patient/provider conversations about the structural determinants of health and their relationship to HIV and other sexual and reproductive health outcomes and 2) how to foster person-centered prevention conversations in the context of busy family planning visits.

Factors Predicting Uptake of Sexually Transmitted Infections Testing among Men Who Have Sex with Men Who Are "Pre-Exposure Prophylaxis Tourists"-An Observational Prospective Cohort Study

The term “Pre-exposure prophylaxis (PrEP) tourists” refers to individuals who obtain PrEP in other countries and use it in their home countries. A prospective observational cohort study was conducted among a group of men who have sex with men (MSM) who obtained PrEP in private clinics in Thailand and used it in Hong Kong. Participants completed two web-based self-administered surveys when obtaining PrEP in Thailand and three months afterwards. Out of 110 participants at baseline, 67 completed the follow-up. The prevalence of sexually transmitted infection (STI) testing was 47.8% during the follow-up period. Eleven participants received an STI diagnosis, and seven of them were incident infections in the past three months. Participants who perceived a higher chance for STI infection (adjusted odds ratios (AOR): 1.90, 95% CI: 1.00, 3.75) and reported higher intention to take up STI testing at baseline (AOR: 1.62, 95% CI: 1.05, 2.50) were more likely to receive STI testing during the follow-up period. Baseline perceptions that service providers would think they were having risky behaviors because of PrEP use was negatively associated with the dependent variable (AOR: 0.51, 95% CI: 0.31, 0.86). Service planning and health promotion related to STI testing is needed for MSM “PrEP tourists”.

Facing increased sexually transmitted infection incidence in HIV preexposure prophylaxis cohorts: what are the underlying determinants and what can be done?

PURPOSE OF REVIEW

The combined incidence of chlamydia, gonorrhoea and syphilis in MSM PrEP (preexposure prophylaxis) cohorts now frequently exceeds 100 per 100 person years. The efficacy of antiretroviral PrEP in reducing HIV transmission has led to efforts to find similar biomedical ways reduce sexually transmitted infection (STI) incidence. We review the recent evidence for these and other strategies.

RECENT FINDINGS

Doxycycline PrEP/postexposure prophylaxis has been shown to reduce the incidence of syphilis and chlamydia but not gonorrhoea. A meningococcal vaccine has been found to result in a lower incidence of gonorrhoea. Novel insights into the role of the pharynx in the transmission of gonorrhoea have led to clinical trials of oral antiseptics to reduce the spread of gonorrhoea. Intensified STI screening has been introduced in a number of clinics. Serious concerns have however been raised about the emergence of resistance to each of these strategies. This is particularly true for doxycycline PrEP which is not advocated by any guidelines we reviewed.

SUMMARY

Randomized controlled trials are urgently required to ascertain the benefits and risks of interventions to reduce STIs in MSM PrEP cohorts.

Comparison of Trends in Rates of Sexually Transmitted Infections Before vs After Initiation of HIV Preexposure Prophylaxis Among Men Who Have Sex With Men

IMPORTANCE

There have been concerns that HIV preexposure prophylaxis (PrEP) may be associated with increases in sexually transmitted infections (STIs) because of subsequent reductions in condom use and/or increases in sexual partners.

OBJECTIVE

To determine trends in STI test positivity among high-risk men who have sex with men (MSM) before and after the start of HIV PrEP.

DESIGN, SETTING, AND PARTICIPANTS

A before-after analysis was conducted using a subcohort of a single-group PrEP implementation study cohort in New South Wales, Australia (Expanded PreEP Implementation in Communities in New South Wales [EPIC-NSW]), from up to 1 year before enrollment if after January 1, 2015, and up to 2 years after enrollment and before December 31, 2018. STI testing data were extracted from a network of 54 sexual health clinics and 6 primary health care clinics Australia-wide, using software to deidentify, encrypt, and anonymously link participants between clinics. A cohort of MSM dispensed PrEP for the first time during the study, with 2 or more STI tests in the prior year and who tested during follow-up, were included from the EPIC-NSW cohort of HIV-negative participants with high-risk sexual behavior. Data analysis was performed from June to December 2019.

EXPOSURES

Participants were dispensed coformulated tenofovir disoproxil fumarate (300 mg) and emtricitabine (200 mg) as HIV PrEP.

MAIN OUTCOMES AND MEASURES

The main outcome was STI, measured using test positivity, defined as the proportion of participants testing positive for an STI at least once per quarter of follow-up. Outcomes were calculated for Chlamydia trachomatis and Neisseria gonorrhoea by site of infection (anorectal, pharyngeal, urethral, or any) and for syphilis.

RESULTS

Of the EPIC-NSW cohort of 9709 MSM, 2404 were included in the before-after analysis. The mean (SD) age of the participants was 36 (10.4) years, and 1192 (50%) were Australia-born. STI positivity was 52% in the year after PrEP (23.3% per quarter; 95% CI, 22.5%-24.2% per quarter) with no significant trend (mean rate ratio [RR] increase of 1.01 per quarter [95% CI, 0.99-1.02]; P = .29), compared with 50% positivity in the year prior to PrEP (20.0% per quarter [95% CI, 19.04%-20.95% per quarter]; RR for overall STI positivity, 1.17 [95% CI, 1.10-1.24]; P < .001), with an increase in quarterly STI positivity (mean RR of 1.08 per quarter, or an 8% increase per quarter [95% CI, 1.05-1.11]; P < .001; RR, 0.93 [95% CI, 0.90-0.96]; P < .001). Findings were similar when stratified by specific STIs and anatomical site.

CONCLUSIONS AND RELEVANCE

STI rates were high but stable among high-risk MSM while taking PrEP, compared with a high but increasing trend in STI positivity before commencing PrEP. These findings suggest the importance of considering trends in STIs when describing how PrEP use may be associated with STI incidence.

The past, present and future impact of HIV prevention and control on HPV and cervical disease in Tanzania: A modelling study

Background

Women with HIV have an elevated risk of HPV infection, and eventually, cervical cancer. Tanzania has a high burden of both HIV and cervical cancer, with an HIV prevalence of 5.5% in women in 2018, and a cervical cancer incidence rate among the highest globally, at 59.1 per 100,000 per year, and an estimated 9,772 cervical cancers diagnosed in 2018. We aimed to quantify the impact that interventions intended to control HIV have had and will have on cervical cancer in Tanzania over a period from 1995 to 2070.

Methods

A deterministic transmission-dynamic compartment model of HIV and HPV infection and natural history was used to simulate the impact of voluntary medical male circumcision (VMMC), anti-retroviral therapy (ART), and targeted pre-exposure prophylaxis (PrEP) on cervical cancer incidence and mortality from 1995–2070.

Findings

We estimate that VMMC has prevented 2,843 cervical cancer cases and 1,039 cervical cancer deaths from 1995–2020; by 2070 we predict that VMMC will have lowered cervical cancer incidence and mortality rates by 28% (55.11 cases per 100,000 women in 2070 without VMMC, compared to 39.93 with VMMC only) and 26% (37.31 deaths per 100,000 women in 2070 without VMMC compared to 27.72 with VMMC), respectively. We predict that ART will temporarily increase cervical cancer diagnoses and deaths, due to the removal of HIV death as a competing risk, but will ultimately further lower cervical cancer incidence and mortality rates by 7% (to 37.31 cases per 100,000 women in 2070) and 5% (to 26.44 deaths per 100,000 women in 2070), respectively, relative to a scenario with VMMC but no ART. A combination of ART and targeted PrEP use is anticipated to lower cervical cancer incidence and mortality rates to 35.82 and 25.35 cases and deaths, respectively, per 100,000 women in 2070.

Conclusions

HIV treatment and control measures in Tanzania will result in long-term reductions in cervical cancer incidence and mortality. Although, in the near term, the life-extending capability of ART will result in a temporary increase in cervical cancer rates, continued efforts towards HIV prevention will reduce cervical cancer incidence and mortality over the longer term. These findings are critical background to understanding the longer-term impact of achieving cervical cancer elimination targets in Tanzania.