WHO guidelines for HIV/STI prevention and care among MSM and transgender people: implications for policy and practice

Extragenital Sexually Transmitted Infection Testing Among Louisiana Parish Health Units, 2016-2019

BACKGROUND

The Centers for Disease Control and Prevention recommends that men who have sex with men (MSM) get tested annually for urethral and rectal chlamydia (CT) and gonorrhea (NG), and pharyngeal NG. There are no national recommendations to screen women and heterosexual men at extragenital sites. We assessed extragenital CT/NG screening among men and women at Louisiana's Parish Health Units (PHU).

METHODS

The Louisiana STD/HIV/Hepatitis Program piloted extragenital screening at 4 PHUs in February 2016 and expanded to 11 PHUs in 2017. Sexual histories were used to identify gender of sex partners and exposed sites. Because of billing restrictions, up to 2 anatomical sites were tested for CT/NG.

RESULTS

From February 2016 to June 2019, 70,895 urogenital and extragenital specimens (56,086 urogenital, 13,797 pharyngeal, and 1,012 rectal) were collected from 56,086 patients. Pharyngeal CT positivity was 160 of 7,868 (2.0%) among women, 54 of 4,838 (1.1%) among men who have sex with women (MSW) and 33 of 1,091 (3.0%) among MSM. Rectal CT positivity was 51 of 439 (11.6%) among women and 95 of 573 (16.6%) among MSM. Pharyngeal NG positivity was 299 of 7,868 (3.8%) among women, 222 of 4,838 (4.6%) among MSW, and 97 of 1,091 (8.9%) among MSM. Rectal NG positivity was 20 of 439 (4.6%) among women and 134 of 573 (23.4%) among MSM.Urogenital-only screening would have missed: among women, 173 of 3,923 (4.4%) CT and 227 of 1,480 (15.3%) NG infections; among MSW, 26 of 2,667 (1%) CT and 149 of 1,709 (8.7%) NG infections; and among MSM, 116 of 336 (34.5%) CT and 127 of 413 (42.1%) NG infections.

CONCLUSIONS

Many CT/NG infections would have been missed with urogenital-only screening. Men who have sex with men had much higher extragenital infection rates than women and MSW.

Cross-sectional assessment of determinants of STIs among men who have sex with men and transgender women in Kigali, Rwanda

BACKGROUND

STIs among men who have sex with men (MSM) and transgender women (TGW) continue to increase. In Rwanda, STI management relies on syndromic management with limited empirical data characterising the burden of specific STIs among MSM/TGW. This study evaluated the prevalence of syphilis, Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) and associated factors among MSM/TGW in Kigali.

METHODS

From March to August 2018, 737 MSM/TGW >18 years were enrolled using respondent-driven sampling (RDS). Structured interviews and HIV/STI screening were conducted. Syphilis was screened with rapid plasma reagin confirmed by Treponema pallidum hemagglutination assay. CT/NG were tested by Cepheid GeneXpert. RDS-adjusted multivariable Poisson regression models with robust variance estimation were used to evaluate factors associated with any STI, and determinants of urethral and rectal STIs separately.

RESULTS

Prevalence of any STI was 20% (RDS adjusted: 16.7% (95% CI: 13.2% to 20.2%)). Syphilis was 5.7% (RDS adjusted: 6.8% (95% CI: 4.3% to 9.4%)). CT was 9.1% (RDS adjusted: 6.1% (95% CI: 3.9% to 8.4%)) and NG was 8.8% (RDS adjusted: 7.1% (95% CI: 4.9% to 9.2%)). STIs were more common among older MSM and those with HIV (p<0.05). Of CT infections, 67% were urethral, 27% rectal and 6% were dual site. For NG infections, 52% were rectal, 29% urethral and 19% were dual site. Overall, 25.8% (23 of 89) of those with confirmed STI and returned for their results were symptomatic at time of testing.STI symptoms in the previous year (adjusted prevalence ratio (aPR): 1.94 (95% CI: 1.26 to 2.98)) were positively associated with any STI. Being circumcised was negatively associated with any STI (aPR: 0.47 (95% CI: 0.31 to 0.73)). HIV was positively associated with rectal STIs (aPR: 3.50 (95% CI: 1.09 to 11.21)) but negatively associated with urethral STIs.

CONCLUSION

MSM/TGW, especially those living with HIV, are at high risk of STIs in Rwanda with the vast majority being asymptomatic. These data suggest the potential utility of active STI surveillance strategies using highly sensitive laboratory methods among those at high risk given the anatomical distribution and limited symptomatology of STIs observed among Rwandan MSM/TGW.

HIV incidence and risk factors among transgender women and cisgender men who have sex with men in two cities of China: a prospective cohort study

Background

HIV epidemic among men who have sex with men (MSM) remains a major public health concern in China. Despite a growing body of research on transgender women worldwide, little is known about Chinese transgender women within MSM. We sought to estimate HIV incidence and distinguish risk factors of HIV acquisition among them from that among cisgener (non-transgender) MSM (cis-MSM).

Methods

We conducted an open cohort study among Chinese MSM, including those who were identified as transgender in Shanghai and Tianjin. Participants were initially recruited by local community-based organizations from January to June, 2016, and were followed up approximately every 6 months until June 2018. At each visit, a structured questionnaire was used to gather information on demographics, sexual risk behaviors, and HIV status. HIV incidence was calculated as the number of seroconversions divided by total number of person-years of follow-up among HIV-negatives at baseline. Risk factors of HIV acquisition were assessed by univariate and multivariate Cox regression models with time-dependent variables.

Results

A total of 1056 participants contributed 1260.53 person-years (PYs) of follow-up, 33 HIV seroconversions occurred during the follow-up period, yielding an estimated HIV incidence of 2.62 (95% CI 1.80–3.68) per 100 PYs. HIV incidence among transgender women was 4.42 per 100 PYs, which was significantly higher than that of 1.35 per 100 PYs among cis-MSM, demonstrating a threefold higher odds of HIV infection than cis-MSM. For transgender women, those lived locally ≤ 2 years (adjusted hazard ratio [aHR] = 1.76, 95% CI 1.13–2.76) and unprotected anal sex last time (aHR = 4.22, 95% CI 1.82–9.79) were more likely to acquire HIV. For cis-MSM, factors associated with HIV acquisition were frequency of anal sex ≥ 3 times in past one month (aHR = 4.19, 95% CI 1.06–16.47) and unprotected anal sex last time (aHR = 5.33, 95% CI 1.52–18.73).

Conclusions

Compared to cis-MSM, transgender women were at higher risk of HIV acquisition, highlighting an urgent need of tailored prevention. Future HIV program should consider to include them to ensure that this population in China are not left behind.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s40249-022-00947-3.

Prevalence of bacterial sexually transmitted infections and coinfection with HIV among men who have sex with men and transgender women in Tijuana, Mexico

We estimated the prevalence of syphilis and Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections, as well as human immunodeficiency virus (HIV) coinfection among cisgender men who have sex with cisgender men (MSM) and transgender women (TW) in Tijuana, Mexico. MSM and TW (N = 212) recruited via respondent-driven and venue-based sampling for HIV testing underwent sexually transmitted infection (STI) testing and completed interviewer-administered surveys in this study (2017-2018). Treponemal rapid tests were used at the point-of-care with positives undergoing confirmatory testing following the reverse syphilis-testing algorithm. Nucleic acid amplification testing of urine and swabs (rectal and pharyngeal) was used to detect CT/NG at three anatomic sites. Chi-squared tests were used to compare STI prevalence by HIV status. Sexually transmitted infection prevalence was 39.6% overall but higher for newly diagnosed HIV-positive (55.7%; N = 88) than HIV-negative (28.2%; N = 124) participants (p-value < 0.0001). Among newly diagnosed HIV-positive participants, the prevalence of syphilis was 35.2% (31/88), CT infection was 27.3% (24/88; nine urethral; 16 rectal; four pharyngeal), and NG infection was 26.1% (23/88; six urethral; 19 rectal; nine pharyngeal). Among HIV-negative participants, the prevalence of syphilis was 12.1% (15/124), CT infection was 13.7% (17/124; seven urethral; nine rectal; two pharyngeal), and NG infection was 9.7% (12/124; three urethral; seven rectal; seven pharyngeal). Over 60% of all CT (25/41) and NG (26/35) infections in the full sample occurred extragenitally in the absence of urethral infections, and over 80% of rectal (30/37) and pharyngeal (16/18) infections were asymptomatic. The high prevalence of syphilis, CT, and NG infections among MSM and TW in Tijuana suggests STI screening that includes extragenital tests, particularly at HIV diagnosis, may help curb HIV/STI transmission.

Optimizing screening for anorectal, pharyngeal, and urogenital C. trachomatis and N. gonorrhoeae infections in at risk adolescents and young adults in New Orleans, Louisiana and Los Angeles, California, USA

BACKGROUND

Public health organizations have inconsistent recommendations for screening adolescents and young adults for Chlamydia trachomatis (C. trachomatis) and Neisseria gonorrhoeae (N. gonorrhoeae) infections. Guidelines suggest different combinations of anorectal, pharyngeal, and urogenital testing based on age, sex, and sexual activity. Further evaluation of how identity and behaviors impact the anatomic distribution of C. trachomatis and N. gonorrhoeae infection is needed to optimize future screening practices.

METHODS

We assessed the positivity of C. trachomatis and N. gonorrhoeae infections at different anatomic sites in a cohort of at-risk sexually active adolescents and young adults between 12-24 years old in New Orleans, Louisiana and Los Angeles, California. Participants were tested for C. trachomatis and N. gonorrhoeae at three sites (anorectum, pharynx, and urethral/cervix) every four months using self-collected swabs. We stratified anatomic distributions of infection into four gender and sexual behavior categories: (i) cisgender men who have sex with men and transgender women (MSMTW), (ii) cis-heterosexual males, (iii) cis-heterosexual females, and (iv) gender minorities assigned female at birth.

RESULTS

While three-site testing detected all infections, two-site (anorectum and urethra/cervix) testing identified 92-100% of C. trachomatis or N. gonorrhoeae infections in participants assigned female at birth and cis-heterosexual males. For MSMTW, two site anorectal and pharyngeal testing versus single site anorectal testing increased the proportion of individuals with either infection from 74 to 93%.

CONCLUSION

Sexual behavioral and gender identity factors may influence detection of C. trachomatis and N. gonorrhoeae infections at specific anatomic testing sites. Testing guidelines should incorporate sexual behavior and gender identity.

Pilot implementation of a home-care programme with chlamydia, gonorrhoea, hepatitis B, and syphilis self-sampling in HIV-positive men who have sex with men

Background

Not all men who have sex with men (MSM) at risk for sexually transmitted infections (STIs) and human immunodeficiency virus (HIV) infection currently receive sexual healthcare. To increase the coverage of high-quality HIV/STI care for MSM, we developed a home-care programme, as extended STI clinic care. This programme included home sampling for testing, combined with treatment and sexual health counselling. Here, we pilot implemented the programme in a hospital setting (HIV-positive MSM) to determine the factors for the successful implementation of STI home sampling strategies.

Methods

Healthcare providers from the HIV hospital treatment centre (Maastricht) were invited to offer free STI sampling kits (syphilis, hepatitis B, [extra]genital chlamydia and gonorrhoea laboratory testing) to their HIV-positive MSM patients (March to May 2018). To evaluate implementation of the program, quantitative and qualitative data were collected to assess adoption (HIV care providers offered sampling kits to MSM), participation (MSM accepted the sampling kits) and sampling-kit return, STI diagnoses, and implementation experiences.

Results

Adoption was 85.3% (110/129), participation was 58.2% (64/110), and sampling-kit return was 43.8% (28/64). Of the tested MSM, 64.3% (18/28) did not recently (< 3 months) undergo a STI test; during the programme, 17.9% (5/28) were diagnosed with an STI. Of tested MSM, 64.3% (18/28) was vaccinated against hepatitis B. MSM reported that the sampling kits were easily and conveniently used. Care providers (hospital and STI clinic) considered the programme acceptable and feasible, with some logistical challenges. All (100%) self-taken chlamydia and gonorrhoea samples were adequate for testing, and 82.1% (23/28) of MSM provided sufficient self-taken blood samples for syphilis screening. However, full syphilis diagnostic work-up required for MSM with a history of syphilis (18/28) was not possible in 44.4% (8/18) of MSM because of insufficient blood sampled.

Conclusion

The home sampling programme increased STI test uptake and was acceptable and feasible for MSM and their care providers. Return of sampling kits should be further improved. The home-care programme is a promising extension of regular STI care to deliver comprehensive STI care to the home setting for MSM. Yet, in an HIV-positive population, syphilis diagnosis may be challenging when using self-taken blood samples.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-020-05658-4.

Factors associated with sexually transmissible infection testing practices among men who have sex with men in Jamaica: results from a cross-sectional, tablet-based survey

Background Men who have sex with men (MSM) are at elevated risk for sexually transmissible infection (STI) acquisition globally. Yet, limited research has explored STI testing practices among MSM in contexts where same-sex practices are criminalised, such as in Jamaica.

METHODS

A cross-sectional, tablet-based survey with MSM in Kingston, Ocho Rios and Montego Bay, Jamaica, was conducted. Multivariable logistic regression analyses were conducted to determine the adjusted risk ratio for lifetime STI testing and lifetime STI diagnosis. Multinomial logistic regression analyses were conducted to determine the relative odds of having had an STI test 3-5 months ago and 6-12 months ago in comparison with <3 months ago.

RESULTS

Three-quarters (74.8%) of the 556 participants reported receiving an STI test (44% <3 months ago; 32% 3-5 months ago; 13% 6-12 months ago; 10% >12 months ago); 12.1% reported ever receiving an STI diagnosis. In adjusted multivariable analyses, STI testing was associated with sociodemographic (education, location), individual (depression, perceived risk), social (relationship status, sexual stigma) and structural (healthcare provider access) factors. In multinomial analysis, reporting a less recent STI test (>3 months ago) versus <3 months ago was associated with increased likelihood of sexual stigma and food insecurity. Lifetime STI diagnosis was associated with sociodemographic (location), individual (HIV infection) and social (lower social support) factors.

CONCLUSIONS

Findings document associations between structural factors and delayed timing of STI testing. Further research is necessary to explore how to address social ecological factors in sexual health interventions with MSM in Jamaica.

A Systematic Review of eHealth Interventions Addressing HIV/STI Prevention Among Men Who Have Sex With Men

A systematic review was conducted to summarize and appraise the eHealth interventions addressing HIV/STI prevention among men who have sex with men (MSM), and characterize features of successful eHealth interventions. Fifty-five articles (17 pilots and 38 full efficacy trials) were included with the predominance of web-based interventions in the United States-based settings. Intervention modalities include web-based, short message service (SMS)/text messges/email reminder, online video-based, computer-assisted, multimedia-based, social network, live chat and chat room, virtual simulation intervention, and smartphone applications. Forty-nine eHealth interventions achieved a short-term behaviour change among participants. Four studies were conducted with 12-month follow-ups; and only one of them could maintain the behaviour change over this longer time period which could be due to the lack of booster interventions. Our study suggests that eHealth interventions can achieve short term behaviour change among MSM, however limited interventions could maintain behaviour change over 12 months. Further eHealth intervention strategies to promote HIV prevention among MSM should be conducted and rigorously evaluated.

HIV-related care for transgender people: A systematic review of studies from around the world

RATIONALE

Transgender people face unique challenges, such as structural, interpersonal, and individual vulnerabilities to chronic diseases. Stigma and prejudice may hamper their access to health care and prevent their inclusion in the labor market, as well as cause exposition to violence. Labor market exclusion contributes to engagement in survival sex work, which increases HIV infection vulnerability. HIV continuum of care combines HIV prevention (including antiretroviral pre-exposure prophylaxis (PrEP), antiretroviral post-exposure prophylaxis (PEP) and HIV testing) with linkage to care (that is, initiating, maintaining and monitoring antiretroviral therapy). Currently, many studies evaluate the access barriers and facilitators to HIV care for transgender people.

OBJECTIVE

The present systematic review aimed to provide a clear summary of the current literature on HIV-related care for transgender men, transgender women and gender diverse people.

METHOD

Inclusion criteria were peer-reviewed quantitative studies, published through April 04, 2018, concerning transgender women, transgender men and gender diverse people and HIV-related care, which was any intervention aiming to prevent, treat or alleviate the impact of HIV on these populations.

RESULTS

From 6,585 references, 62 articles were included: Three articles had results on PEP, 18 on PrEP, 29 on HIV-testing, 17 on access to health care, and 13 on adherence to treatment.

CONCLUSIONS

The present study is the first systematic review evaluating HIV-related care for transgender people. Data collection is still scarce regarding transgender men and gender diverse people. Worldwide, testing for HIV infection does not necessarily enable access to the HIV continuum of care for transgender populations or even guarantee awareness of HIV seropositivity.

Factors Associated With Syphilis Testing and a History of Syphilis Infection Among a Sample of Transgender Women in Jamaica

BACKGROUND

Globally, social inequalities contribute to elevated sexually transmitted infections (STIs) rates among transgender women. High syphilis prevalence has been documented among transgender women in Latin America. Little is known, however, of syphilis testing uptake among transgender women in Jamaica, where homosexuality is criminalized. The study objective was to understand factors associated with opting-in for syphilis testing and a syphilis infection history among transgender women in Jamaica.

METHODS

We conducted a cross-sectional tablet-based survey of 137 transgender women between March and November 2015 in Jamaica. Bivariate analyses were used to assess differences across sociodemographic, intrapersonal, interpersonal, and structural factors based on syphilis infection history. We conducted univariable and multivariable logistic regression to determine the odds ratio for opting-in for syphilis testing for all factors associated with testing uptake at a P value of less than 0.05 in bivariate analyses, controlling for sociodemographic characteristics.

RESULTS

Among 137 participants, 83 (60.6%) opted in for syphilis screening and 8 (9.6%) had positive rapid test results. One quarter of participants (n = 26; 25.2%) reported being HIV positive. Opting-in for syphilis testing was associated with the following: 1 health (HIV-positive serostatus: adjusted odds ratio [AOR], 4.33; 95% confidence interval [CI], 1.31-14.26), 1 intrapersonal (perceived STI risk: AOR, 1.58; 95% CI, 1.04-2.40), 1 interpersonal (childhood sexual abuse: AOR, 2.80; 95% CI, 1.03-7.62), and 1 structural (incarceration: AOR, 0.27; 95% CI, 0.11-0.71) factor.

CONCLUSIONS

This study identified factors (HIV-positive serostatus, perceived STI risk, childhood sexual abuse, no incarceration history) associated with syphilis testing uptake among transgender women. Findings can inform multilevel STI testing, prevention, and care strategies tailored for transgender women in Jamaica.

Does pre-exposure prophylaxis for HIV prevention in men who have sex with men change risk behaviour? A systematic review

AIMS AND OBJECTIVES

To review the literature regarding PrEP and sexual behaviour change in MSM.

BACKGROUND

Pre-exposure prophylaxis for HIV has been available since 2012. Even so, pre-exposure prophylaxis has not been widely accepted among healthcare providers and men who have sex with men some of whom are convinced that pre-exposure prophylaxis decreases condom use and increases sexually transmitted infections.

DESIGN

A systematic review of the state of the evidence regarding the association of pre-exposure prophylaxis with condom use, sexually transmitted infection incidence and change in sexual risk behaviours in men who have sex with men. A structured search of databases resulted in 142 potential citations, but only 10 publications met inclusion criteria and underwent data abstraction and critical appraisal.

METHODS

An adapted Cochrane Collaboration domain-based assessment tool was used to critically appraise the methodological components of each quantitative study, and the Mixed Methods Appraisal Tool was used to critically appraise qualitative and mixed-methods studies.

RESULTS

Condom use in men who have sex with men using pre-exposure prophylaxis is influenced by multiple factors. Studies indicate rates of sexually transmitted infections in treatment and placebo groups were high. Pre-exposure prophylaxis did not significantly change sexually transmitted infection rates between baseline and follow-up. Reporting of sexual risk improved when questionnaires were completed in private by clients. Our review found that pre-exposure prophylaxis may provide an opportunity for men who have sex with men to access sexual health care, testing, treatment and counselling services. We did not find any conclusive evidence that pre-exposure prophylaxis users increase sexual risk behaviours.

CONCLUSION

The perception among healthcare providers that pre-exposure prophylaxis leads to increased sexual risk behaviours has yet to be confirmed. In order to provide effective sexual health services, clinicians need to be knowledgeable about pre-exposure prophylaxis as an HIV prevention tool.

RELEVANCE TO CLINICAL PRACTICE

In an era where HIV prevention methods are rapidly improving, strategies for sexually transmitted infection testing, treatment, counselling and prevention remain vital to improve health. All healthcare providers are uniquely positioned to promote sexual health through the dissemination of accurate information.

Determinants of frequent and infrequent STI testing and STI diagnosis related to test frequency among men who have sex with men in the eastern part of the Netherlands: a 6-year retrospective study

OBJECTIVE

Men who have sex with men (MSM) remain vulnerable to sexually transmitted infections (STIs) and are advised to be tested at least twice a year. The aim of this study was to assess the determinants of test frequency and their associations with an STI diagnosis.

DESIGN

A 6-year retrospective study.

SETTING

5 STI clinics in the eastern part of the Netherlands.

PARTICIPANTS

MSM whose mean test interval was 6 months or more were grouped as 'infrequently tested' (n=953), and those with a mean test interval less than 6 months were grouped as 'frequently tested' (n=658).

PRIMARY AND SECONDARY OUTCOME MEASURES

Test frequency and STI diagnosis and determinants.

RESULTS

MSM who were ever diagnosed with an STI (OR=1.4, 95% CI 1.1 to 1.7), MSM who had never had STI symptoms (OR=0.8, 95% CI 0.6 to 1.0), and MSM who had ever had sex with both men and women (OR=0.6, 95% CI 0.5 to 0.8) were more often frequently tested. Moreover, in both groups, MSM who had ever been notified by a partner (OR=2.2, 95% CI 1.7 to 2.9 infrequently tested; OR=2.0, 95% CI 1.4 to 2.9 frequently tested), MSM who had ever had STI symptoms (OR=1.6, 95% CI 1.2 to 2.1 infrequently tested; OR=1.8, 95% CI 1.3 to 2.6 frequently tested) and MSM who were ever diagnosed with HIV (OR=2.7, 95% CI 1.5 to 4.6 infrequently tested; OR=6.8, 95% CI 2.6 to 17.5 frequently tested) were more likely to be diagnosed with an STI.

CONCLUSIONS

Among MSM visiting STI clinics, those who were ever diagnosed with HIV were more often diagnosed with an STI, but did not visit STI clinics more frequently than HIV-negative MSM. This highlights the necessity of encouraging MSM who are diagnosed with HIV to have STI tests more frequently.

General Practitioners' views and experiences on the barriers and facilitators that men who have sex with men have when accessing primary care for HIV testing and sexual health screening

Aim This study's objectives were to collate General Practitioners' (GPs) views and experiences on the barriers and facilitators for providing HIV and sexual health screening in primary care to men who have sex with men.

BACKGROUND

Men who have sex with men (MSM) are disproportionately effected by sexually transmitted infections and HIV. Some MSM may not attend for testing and primary care may come in contact with this group. There may be varying barriers for MSM accessing services. Primary care can provide an opportunity to offer testing but with limited GPs views on this topic, it is important to understand the potential barriers and facilitators.

METHOD

A structured online survey was used to gather data and the survey link was emailed to all General Practices in the City of Edinburgh. The total available sample of GPs was 485. The survey used a combination of multiple choice questions and Likert scales rating from 1 to 5. Friedman's two-way analysis of variation rank was used for data analysis. Findings In total, 62 GPs from the City of Edinburgh completed the survey with the majority of the sample having over 10 years' experience in primary care. The most significant barrier was patient preference to access specialist services. The highest rated method to promote HIV and sexual health screening was the use of external promotion.

Social-ecological factors associated with HIV infection among men who have sex with men in Jamaica

In Jamaica, where homosexuality is criminalized, scant research has examined associations between sexual stigma and HIV infection. The study objective was to examine correlates of HIV infection among men who have sex with men (MSM) in Jamaica. We conducted a cross-sectional tablet-based survey with MSM in Jamaica using chain referral sampling. We assessed socio-demographic, individual, social, and structural factors associated with HIV infection. A logit-link model, fit using backwards-stepwise regression, was used to estimate a final multivariable model. Among 498 participants (median age: 24, interquartile range: 22-28), 67 (13.5%) were HIV-positive. In the multivariable model, HIV infection was associated with increased odds of socio-demographic (older age, odds ratio [OR]: 1.05, 95% confidence interval [CI]: 1.00-1.10]; residing in Kingston versus Ocho Rios [OR: 6.99, 95% CI 2.54-19.26]), individual (poor/fair versus excellent/good self-rated health [OR: 4.55, 95% CI: 1.81-11.42], sexually transmitted infection [STI] history [OR: 3.67, 95% CI: 1.61-8.38]), and structural (enacted sexual stigma [OR: 1.08, 95% CI: 1.01-1.15], having a health care provider [OR: 2.23, 95% CI: 1.06-4.66]) factors. This is among the first studies to demonstrate associations between sexual stigma and HIV infection in Jamaica. Findings underscore the need to integrate STI testing in the HIV care continuum and to address stigma and regional differences among MSM in Jamaica.

Barriers and facilitators to HIV testing among young men who have sex with men and transgender women in Kingston, Jamaica: a qualitative study

Introduction: Young men who have sex with men (MSM) in Jamaica have the highest HIV prevalence in the Caribbean. There is little information about HIV among transgender women in Jamaica, who are also overrepresented in the Caribbean epidemic. HIV-related stigma is a barrier to HIV testing among Jamaica’s general population, yet little is known of MSM and transgender women’s HIV testing experiences in Jamaica. We explored perceived barriers and facilitators to HIV testing among young MSM and transgender women in Kingston, Jamaica.

Methods: We implemented a community-based research project in collaboration with HIV and lesbian, gay, bisexual and transgender (LGBT) agencies in Kingston. We held two focus groups, one with young (aged 18–30 years) transgender women (n = 8) and one with young MSM (n = 10). We conducted 53 in-depth individual semi-structured interviews focused on HIV testing experiences with young MSM (n = 20), transgender women (n = 20), and community-based key informants (n = 13). We conducted thematic analysis to identify, analyze, and report themes.

Results: Participant narratives revealed social-ecological barriers and facilitators to HIV testing. Barriers included healthcare provider mistreatment, confidentiality breaches, and HIV-related stigma: these spanned interpersonal, community and structural levels. Healthcare provider discrimination and judgment in HIV testing provision presented barriers to accessing HIV services (e.g. treatment), and resulted in participants hiding their sexual orientation and/or gender identity. Confidentiality concerns included: clinic physical arrangements that segregated HIV testing from other health services, fear that healthcare providers would publicly disclose their status, and concerns at LGBT-friendly clinics that peers would discover they were getting tested. HIV-related stigma contributed to fear of testing HIV-positive; this intersected with the stigma of HIV as a “gay” disease. Participants also anticipated healthcare provider mistreatment if they tested HIV positive. Participants identified individual (belief in benefits of knowing one’s HIV status), social (social support) and structural (accessible testing) factors that can increase HIV testing uptake.

Conclusions: Findings suggest the need for policy and practice changes to enhance confidentiality and reduce discrimination in Jamaica. Interventions to challenge HIV-related and LGBT stigma in community and healthcare settings can enhance access to the HIV prevention cascade among MSM and transgender youth in Jamaica.

Prevalence of hepatitis C virus infection among HIV+ men who have sex with men: a systematic review and meta-analysis

Since 2000, an increase in hepatitis C virus infection among HIV-infected (HIV+) men who have sex with men has been observed. Evidence points to blood exposure during sex as the medium of hepatitis C virus transmission. Hepatitis C virus prevalence among HIV + MSM overall and in relation to injection drug use is poorly characterized. In this study, a systematic review and meta-analysis examining global hepatitis C virus antibody prevalence and estimating active hepatitis C virus prevalence among HIV + MSM were conducted; 42 reports provided anti-hepatitis C virus prevalence data among HIV + MSM. Pooled prevalence produced an overall anti-hepatitis C virus prevalence among HIV + MSM of 8.1%; active HCV prevalence estimate was 5.3%-7.3%. Anti-hepatitis C virus prevalence among injection drug use and non-injection drug use HIV + MSM was 40.0% and 6.7%, respectively. Among HIV + MSM, hepatitis C virus prevalence increased significantly over time among the overall and non-injection drug use groups, and decreased significantly among injection drug use HIV + MSM. We identified a moderate prevalence of hepatitis C virus among all HIV + MSM and among non-injection drug use HIV + MSM; for both, prevalence was observed to be increasing slightly. Pooled prevalence of hepatitis C virus among HIV + MSM was higher than that observed in the 1945-1965 US birth cohort. The modest but rising hepatitis C virus prevalence among HIV + MSM suggests an opportunity to control HCV among HIV + MSM; this combined with data demonstrating a rising hepatitis C virus incidence highlights the temporal urgency to do so.

Factors associated with previously undiagnosed human immunodeficiency virus infection in a population of men who have sex with men and male-to-female transgender women in Lima, Peru

The aim of the study was to identify factors associated with undiagnosed human immunodeficiency virus (HIV) infection among men who have sex with men (MSM) and male-to-female transgender women in Lima, Peru.We analyzed characteristics of 378 MSM and transgender women recruited from 2 sexually transmitted infection (STI) clinics in Lima, Peru. Descriptive analyses compared: (A) HIV-uninfected, (B) previously undiagnosed HIV-infected, and (C) previously diagnosed HIV-infected participants. Multivariable logistic regression models identified: (1) correlates of previously undiagnosed HIV-infection among participants thought to be HIV-uninfected (B vs A); and (2) correlates of previously undiagnosed HIV-infection among HIV-infected participants (B vs C). Subanalysis identified correlates of frequent HIV testing among participants thought to be HIV-uninfected.Among participants, 31.0% were HIV-infected; of those, 35.0% were previously undiagnosed. Among participants thought to be HIV-uninfected (model 1), recent condomless receptive anal intercourse and last HIV test being over 1-year ago (compared to within the last 6-months) were associated with increased odds of being previously undiagnosed HIV-infected (adjusted odds ratio [aOR] = 2.43, 95% confidence interval [95%CI] = 1.10-5.36; aOR = 2.87, 95%CI = 1.10-7.53, respectively). Among HIV-infected participants (model 2), recent condomless receptive anal intercourse was again associated with previously undiagnosed HIV-infection (aOR = 2.54, 95%CI = 1.04-6.23). Achieving post-secondary education and prior syphilis infection were associated with lower odds of having previously undiagnosed HIV-infection (aOR = 0.35, 95%CI = 0.15-0.81; aOR = 0.32, 95%CI = 0.14-0.75, respectively).Reporting semiannual testing was associated with higher educational attainment, identifying as a transgender woman, or reporting a history of syphilis (aOR = 1.94, 95%CI = 1.11-3.37; aOR = 2.40, 95%CI = 1.23-4.70; aOR = 2.76, 95%CI = 1.62-4.71, respectively). Lower odds of semiannual testing were associated with recent condomless insertive anal intercourse or reporting a moderate or high self-perceived risk of acquiring HIV (aOR = 0.56, 95%CI = 0.33-0.96; aOR = 0.32, 95%CI = 0.18-0.59 and aOR = 0.43, 95%CI = 0.21-0.86, respectively).In our study, undiagnosed HIV-infection was associated with recent condomless receptive anal intercourse, infrequent HIV testing, lower education, and absence of prior syphilis diagnosis. Infrequent HIV testing was associated with lower education, not identifying as transgender, recent condomless insertive anal intercourse, absence of prior syphilis diagnosis, and higher self-perceived risk of HIV. Further efforts to decrease HIV transmission and increase HIV-serostatus awareness should be directed towards effectively promoting condom use and frequent HIV testing, integrated with STI management.

Prevalence and Correlates of HIV Infection and HIV Testing Among Transgender Women in Jamaica

Transgender women are overrepresented in the Caribbean HIV epidemic. The study objective was to examine correlates of HIV infection and HIV testing among transgender women in Jamaica. We implemented a cross-sectional survey with transgender women in Kingston and Ocho Rios, Jamaica. We conducted multivariable logistic regression to identify factors associated with HIV testing and HIV infection. Among 137 transgender women [mean age 24.0; standard deviation (SD) 5.5], three-quarters (n = 103, 75.7%) had received an HIV test. Of these, one-quarter (n = 26, 25.2%) were HIV positive. In multivariable analyses, HIV testing was associated with: perceived HIV risk [adjusted odds ratio (AOR) 2.42, confidence interval (CI) 1.36-4.28], depression (AOR 1.34, CI 1.01-1.77), forced sex (AOR 3.83, CI 1.42-10.35), physical abuse (AOR 4.11, CI 1.44-11.72), perceived transgender stigma (AOR 1.23, 1.06-1.42), having a healthcare provider (AOR 5.89, CI 1.46-23.77), and lower HIV-related stigma (AOR 0.96, CI 0.92-0.99), incarceration (AOR 0.28, CI 0.10-0.78), and drug use (AOR 0.74, CI 0.58-0.95). HIV infection was associated with the following: homelessness (AOR 5.94, CI 1.27-27.74), perceived HIV risk (AOR 1.67, CI 1.02-2.72), depression (AOR 1.39, CI 1.06-1.82), STI history (AOR 56.79, CI 5.12-630.33), perceived (AOR 1.26, CI 1.06-1.51) and enacted (AOR 1.16, CI 1.04-1.29) transgender stigma, forced sex (AOR 4.14, CI 1.49-11.51), physical abuse (AOR 3.75, CI 1.39-10.12), and lower self-rated health (AOR 0.55, CI 0.30-0.98) and social support (AOR 0.79, CI 0.64-0.97). Transgender women in Jamaica experience high HIV infection rates and suboptimal HIV testing. Combination HIV prevention approaches should address transgender women's social and structural vulnerabilities.

High prevalence of extra-genital chlamydial or gonococcal infections among men who have sex with men and transgender women in Lima, Peru

Chlamydia trachomatis and Neisseria gonorrhoeae are among the most common sexually transmitted bacterial infections in the world. Data are limited, however, on the burden of extra-genital chlamydial and gonococcal infections among men who have sex with men and transgender women in Lima, Peru. Data were gathered from self-collected anal or pharyngeal swabs from participants in Lima, Peru, and analyzed via cross-sectional methods. Prevalence ratios for the association between extra-genital infection with socio-demographic and sexual behaviors were determined. Overall, 127 (32.8%) participants had anal or pharyngeal infections. On multivariate modeling, anal infection was positively associated with practicing both receptive and insertive anal sex, when compared to insertive alone (PR = 2.49; 95% CI = 1.32-4.71), and negatively associated with any antibiotic use in the prior three months (PR = 0.60; 95% CI = 0.39-0.91). Pharyngeal infection was negatively associated with age greater than 30 years compared to 18-30 years (PR = 0.54; 95% CI = 0.30-0.96), and positively associated with gender identity of transgender women (PR = 2.12; 95% CI = 1.20-3.73). This study demonstrates considerable burden of extra-genital chlamydial and gonococcal infections among men who have sex with men and transgender women in Lima, Peru.

Recorded gonorrhoea rates in Denmark, 1900-2010: the impact of clinical testing activity and laboratory diagnostic procedures

OBJECTIVES

Assessment of the relations between recorded gonorrhoea rates and clinical testing activity and disposable diagnostic tests.

METHODS

In Denmark, two sources of information on the epidemiology of gonorrhoea are available: (1) a mandatory clinical notification system (since 1867) comprising summary information about geographic distribution, season, age group and gender; in 1994, more detailed anonymous individualised epidemiological information was included; (2) a voluntary countrywide laboratory surveillance system for culture-confirmed cases (since 1957) comprising information about patient's age and gender, infected anatomical sites and medical setting attended.

RESULTS

Both surveillance systems showed marked simultaneous changes in gonorrhoea rates, although periodically considerable under-reporting or under-diagnosing was demonstrated. The annual incidence of notified cases peaked in 1919 (474/100,000), in 1944 (583/100,000) and in 1972 (344/100,000). Since 1995, the incidence has been at a low endemic level (1.5-10/100,000) and the total male/female incidence ratios were from 3 to 7 times higher than previously recorded. Among approximately 2 million persons tested during 1974-1988 78,213 men and 63,143 women with culture-confirmed gonorrhoea were identified. During this period, pharyngeal sampling was performed in 36% of men and 25% of women with gonorrhoea; pharyngeal gonorrhoea was found in 10% and 16%, respectively; 40% and 30% of these patients had no concomitant urogenital gonorrhoea. Among men with gonorrhoea, 34% were sampled from the rectum; 9% had rectal gonorrhoea, among whom the rectum was the only infected site in 67%.

CONCLUSIONS

Crucial factors for case finding are clinical sampling tradition and appropriate laboratory diagnostic facilities. When case finding is insufficient, a reservoir of asymptomatic rectal or pharyngeal gonorrhoea remains unrecognised.

Sexual health promotion for young people delivered via digital media: a scoping review

Background

Young people are at risk of poor sexual health and are, therefore, in need of comprehensive, effective sexual health education. Young people are confident and constant users of digital technology, such as the internet and mobile phones, and there are many innovative possibilities for sexual health education involving these technologies.

Objectives

To summarise evidence on effectiveness, cost-effectiveness and mechanism of action of interactive digital interventions (IDIs) for sexual health; optimal practice for intervention development; contexts for successful implementation; research methods for digital intervention evaluation; and the future potential of sexual health promotion via digital media.

Design

Literature review of evidence on digital interventions for sexual health for young people, integrating the findings with the views of young people, parents and experts in digital media/sexual health. IDIs are defined as digital media programmes that provide health information and tailored decision support, behaviour-change support and/or emotional support. We focus on sexual well-being for young people aged 13–24 years in the UK.

Results

There are many imaginative IDIs for sexual health promotion, but few interventions address issues that are important to young people, such as sexual pleasure and relationships. It is vital to collaborate with young people and to use Behaviour-Change Theory in designing interventions. We located 19 randomised controlled trials of IDIs for sexual health promotion for young people, finding a moderate effect on sexual health knowledge [standardised mean difference (SMD) 0.54, 95% confidence interval (CI) 0.17 to 0.92], a small effect on confidence (self-efficacy) (SMD 0.11, 95% CI 0.02 to 0.20) and a positive effect on sexual behaviour (odds ratio 1.28, 95% CI 1.01 to 1.61), but no significant effects on safer sex intention or biological outcomes. One study suggests that IDIs may be as good as face-to-face interventions for sexual health knowledge and safer sex intention. There are no existing data on the cost-effectiveness of IDIs for sexual health promotion. The impact of an IDI will be determined by the proportion of the target population reached, intervention efficacy, adoption in a setting, how well it is delivered and maintenance/sustainability. All of these elements must be addressed for IDIs to be successful. More collaboration is needed to capitalise on the knowledge of users and stakeholders, the design and software skills of the commercial sector and the theoretical expertise and evaluation skills of academia.

Conclusions

IDIs are effective for knowledge acquisition and sexual behaviour, and could usefully contribute to sexual health education in schools, in clinic settings and online; however, there are obstacles to overcome, such as access to information technology and ensuring the quality and safety of interventions.

Future work

More evidence is needed on the best designs for interventions (e.g. choice of behaviour-change mechanisms and interactive features) and the best models of delivery (e.g. setting, modes of delivery, methods of facilitation and support for engagement) to improve sexual behaviour, biological outcomes and sexual well-being in a cost-effective way.

Funding

The National Institute for Health Research Public Health Research programme.