Increases in sexually transmitted infections and sexual risk behaviour without a concurrent increase in HIV incidence among men who have sex with men in San Francisco: a suggestion of HIV serosorting?

Destination-Specific and Home Environment Condom Norms Influence Sexual Behavior During Travel

Travelers may adapt HIV risk-reduction practices based on perceived destination-specific norms. We examined the association between perceived condom norms and condomless anal sex (CAS) during international and domestic travel and in the home environment among men who have sex with men. Men who traveled internationally in the past 12 months were recruited by respondent-driven sampling (N = 501). Not knowing destination-specific condom norms was significantly associated with less CAS during international travel and in the home environment but not during domestic travel. Perceiving home environment condom norms to expect use of condoms was significantly associated with less CAS during domestic but not international travel. Men were less likely to engage in CAS during international travel when destination-specific condom norms were unknown. Unfamiliarity with the environment and culture may influence some men to refrain from higher-risk behaviors. During domestic travel, some men appeared to apply home environment condom norms, which may be erroneous in some situations and pose an HIV risk.

Association between rectal gonorrhoea and HIV incidence in men who have sex with men: a meta-analysis

BACKGROUND

Incidence of rectal gonorrhoea (GC) has been hypothesised as a correlate of HIV exposure in prevention trials of men who have sex with men (MSM). High rectal GC incidence in MSM trials of new biomedical prevention drugs may provide supportive evidence for ongoing HIV risk. Empirical evidence of correlation between rectal GC and HIV incidence is needed to assess whether high rectal GC rates reliably correlate with high risk of HIV.

METHODS

Rectal GC and HIV are routinely tested in sexual health clinics (SHCs) throughout England. Through routine surveillance data collected at visits to SHCs, we assessed HIV incidence and new rectal GC diagnoses in repeat visits by HIV-negative MSM between 2011 and 2018, predating widespread roll-out of pre-exposure prophylaxis. Meta-analysis regression assessed population-level association between HIV and rectal GC incidence over time.

FINDINGS

Between 2011 and 2018, HIV and rectal GC incidence was assessed in 541 056 HIV-negative MSM attending SHCs in England. HIV incidence among MSM attending SHCs fell from 1.26/100 person-years (PYs) in 2011 to 0.28/100 PYs in 2018. Rectal GC rates increased from 3.5/100 PYs to 11.1/100 PYs over the same period. The rate of HIV incidence decreased by 22.3% for each percent increase in rectal GC (95% CI -30.8 to -14.7, p<0.001).

INTERPRETATION

Among the population of MSM attending SHCs in England, rectal GC rates increased substantially while HIV incidence rates decreased between 2011 and 2018. HIV incidence likely decreased through expanded HIV testing, prompt antiretroviral treatment (ART) initiation and increased viral suppression in persons living with HIV, interventions that did not decrease rectal GC. Rectal GC may not be an ideal proxy for HIV incidence in trials, as HIV exposure risk is complex and context dependent, given effective HIV prevention interventions in MSM.

INTRODUCTION

Changing Patterns of Sexual Behavior and HIV/STI Among Men Who Have Sex With Men in Seattle, 2002 to 2018

BACKGROUND

The extent to which uptake of biomedical HIV prevention strategies have affected population-level sexual behavior and sexually transmitted infections (STIs) among men who have sex with men (MSM) is not well understood.

METHODS

We collected data as part of routine care from MSM attending the municipal STI clinic in Seattle, Washington, 2002-2018. MSM were asked about condom use in the previous 12 months. We classified behaviors into 4 mutually exclusive categories: no anal sex; consistent condom use for anal sex; serosorting [condomless anal sex (CAS) only with HIV-concordant partners]; and CAS with serodiscordant/unknown-status partners. STI/HIV testing was performed per routine clinic protocol.

RESULTS

There were 45,656 and 6987 visits by MSM without HIV and MSM with HIV, respectively. The use of antiretroviral therapy and preexposure prophylaxis increased substantially during the study period to 94% and 50%, respectively, by 2018. CAS with serodiscordant/unknown-status partners decreased through 2013 but increased thereafter (to 40% among MSM without HIV; 68% among MSM with HIV). Serosorting increased among MSM without HIV but declined after 2013 among MSM with HIV. Consistent condom use declined for all MSM (from 35% to 11% among MSM without HIV; from 20% to 5% among MSM with HIV). HIV test positivity declined substantially (3.5%-0.5%), whereas STI test positivity increased over time.

CONCLUSIONS

Since 2013, CAS with HIV-discordant/unknown-status partners increased substantially concurrent with declining HIV test positivity and increasing STI test positivity. This highlights the success of biomedical HIV prevention strategies to reduce HIV incidence while affirming the need for new approaches to STI prevention.

Temporal Variation in One-Time Partnership Rates Among Young Men Who Have Sex With Men and Transgender Women

BACKGROUND

Volatility in sexual contact rates has been recognized as an important factor influencing HIV transmission dynamics. One-time partnerships may be particularly important given the potential to quickly accumulate large number of contacts. Yet, empirical data documenting individual variation in contact rates remain rare. This study provides much needed data on temporal variation in one-time partners to better understand behavioral dynamics and improve the accuracy of transmission models.

METHODS

Data for this study were obtained from a longitudinal cohort study of young men who have sex with men and transgender women in Chicago. Participants provided sexual network data every 6 months for 2 years. A series of random effects models examined variation in one-time partnership rates and disaggregated within and between associations of exposure variables. Exposure variables included prior number of one-time partners, number of casual partners, and having a main partner.

RESULTS

Results indicated substantial between-person and within-person variation in one-time partners. Casual partnerships were positively associated and main partnerships negatively associated with one-time partnership rates. There remained a small positive association between prior one-time partnerships and the current number of one-time partnerships.

CONCLUSIONS

Despite the preponderance of a low number of one-time partners, substantial variation in one-time partnership rates exists among young men who have sex with men and transgender women. Accordingly, focusing on high contact rate individuals alone may be insufficient to identify periods of highest risk. Future studies should use these estimates to more accurately model how volatility impacts HIV transmission and better understand how this variation influences intervention effectiveness.

HIV Prevention Responsibility Beliefs Among Men Who Have Sex With Men in the PrEP Era

BACKGROUND

Beliefs regarding responsibility for preventing HIV transmission may differ between individuals and their sexual partners. We assessed HIV prevention responsibility beliefs among men who have sex with men (MSM) participating in the 2017 National HIV Behavioral Surveillance survey.

METHODS

MSM were recruited using time-location sampling at clubs, bars, and street locations in San Francisco. HIV prevention responsibility beliefs were assessed on a four-point scale (1 = strongly disagree to 4 = strongly agree). Associations were assessed using generalizing estimating equations to adjust for behaviors within multiple partnerships.

RESULTS

A total of 316 HIV-negative men and 76 HIV-positive men reported on 1336 partnerships. HIV-negative compared with HIV-positive men had higher endorsement of mutual responsibility (mean 3.7 vs. 3.5; P < 0.01). Both groups had similar levels of endorsing responsibility on the HIV-negative or HIV-positive partner. HIV-positive men endorsing equal responsibility were more likely to know their partner's HIV status (P < 0.01) and less likely to have serodiscordant condomless anal intercourse (CAI) (P < 0.01) than men who did not endorse equal responsibility. HIV-negative men in partnerships with pre-exposure prophylaxis (PrEP) use were more likely to know their partner's HIV status (P = 0.02) and have serodiscordant CAI (P = 0.04) than men not in partnerships with PrEP use.

CONCLUSIONS

HIV-negative and HIV-positive men accept responsibility for preventing HIV. The finding that HIV-negative men in partnerships with PrEP use who engage in serodiscordant CAI is concerning because they are still at risk for other sexually transmitted infections, which are presently at elevated levels in San Francisco and other US cities.

Syphilis among men who have sex with men attending a large HIV clinic in Trinidad

A chart review study was conducted to determine the prevalence of syphilis and explore the associated risk factors among men who have sex with men (MSM) who attended a large HIV clinic in Trinidad during the period January-December 2019. Patients were routinely screened for syphilis annually, and demographic, clinical, and laboratory data were extracted from the medical records. Descriptive and bivariate analyses were performed, and factors significantly associated with a syphilis diagnosis were assessed using multivariate logistic regression. During the period, 218 MSM were seen, age range 19-67 years, and median age 34.0 years. The prevalence of syphilis was 41.3% (90/218), and 71.1% (64//90) of these infections were asymptomatic. Multivariate analysis using logistic regression showed that MSM living with HIV in the 30-34 years old-age group (OR, 4.32; 95% CI, 1.04-18.02), and those with a previous history of treated syphilis (OR, 10.18; 95% CI, 4.60-22.53) were more likely to be diagnosed with syphilis. The prevalence of syphilis is high among MSM attending the HIV clinic in Trinidad, and most of these infections were asymptomatic; hence, targeted and sustained interventions to reduce syphilis transmission are urgently required. Repeat episodes of syphilis may play a role in the transmission dynamics of syphilis in MSM.

The Estimated Number and Lifetime Medical Cost of HIV Infections Attributable to Sexually Transmitted Infections Acquired in the United States in 2018: A Compilation of Published Modeling Results

BACKGROUND

The purpose of this study was to estimate the number and lifetime medical cost of HIV infections attributable to incident sexually transmitted infections (STIs) in the United States in 2018.

METHODS

We combined data from published models regarding the number or percentage of HIV infections attributable to STIs with updated estimates of the lifetime medical cost per HIV infection. We used 2 distinct calculation methods. Our first calculation used recent estimates of the percentage of HIV infections in men who have sex with men (MSM) attributable to gonorrhea and chlamydia. Our second calculation, based on older studies, used estimates of the expected number of STI-attributable HIV infections per new STI infection, for gonorrhea, chlamydia, syphilis, and trichomoniasis.

RESULTS

Our first calculation method suggested that 2489 (25th-75th percentiles, 1895-3000) HIV infections in 2018 among MSM could be attributed to gonorrhea and chlamydia, at an estimated lifetime medical cost of $1.05 billion (25th-75th percentiles, $0.79-$1.26 billion). Our second calculation method suggested that 2349 (25th-75th percentiles, 1948-2744) HIV infections in the general population (including MSM) could be attributed to chlamydia, gonorrhea, syphilis, and trichomoniasis acquired in 2018, at an estimated lifetime medical cost of $0.99 billion (25th-75th percentiles, $0.80-$1.16 billion).

CONCLUSIONS

Despite ambiguity regarding the degree to which STIs affect HIV transmission, our combination of data from published STI/HIV transmission models and an HIV lifetime medical cost model can help to quantify the estimated burden of STI-attributable HIV infections in the United States.

Detecting Spatial Cores and Temporal Trends of Repeat STIs to Plan Pre-exposure Prophylaxis (PrEP) Scale-up in DC

BACKGROUND

Repeat sexually transmitted infections (STIs) in DC primarily results from untreated sexual partners. This analysis aims to identify high-risk areas and temporal trends of repeat STIs for pre-exposure prophylaxis scale-up and STI mitigation in DC.

METHODS

We identified repeat infections in the DC Department of Health STI and HIV data management systems, diagnosed from 2014 to 2018. The cases were geocoded and aggregated by census tracts. Poisson discrete scan statistic was implemented in SaTScan software to find clusters. Weighted moving average was used to compare temporal trends of repeat STIs. We used χ analysis to identify association with demographic variables.

RESULTS

We identified 8535 repeat STIs from 2014 to 2018. Of these, 61.84% were among men, most cases were among blacks (34.75%) and 47.45% represented gonorrhea cases. The high-risk spatial clusters were identified as those tracts that had relative risk (relative risk > 1; P-value < 0.001). We identified one significant radius of risk covering tracts of wards 7 and 8 and parts of wards 5 and 6. We spotted positive temporal trends in cluster 1 and outside the cluster. We found significant associations of repeat STIs with gender (χ = 317.27, P < 0.001), age (χ = 539.26, P < 0.001), HIV coinfections (χ = 352.06, P < 0.001), and year of diagnoses (χ = 1.5, P < 0.01).

CONCLUSIONS

Our findings indicate spatial disparities in DC for repeat STIs. This analysis is critical for pre-exposure prophylaxis planning, STI prevention strategies such as expedited partner therapies and condom distribution strategies in DC should prioritize the high-risk spatial cores.

Brief Report: Seroadaptive Behaviors Varied Among Geographically Diverse iPrEx Participants

BACKGROUND

Seroadaptive behaviors refer to a wide range of harm reduction practices to decrease HIV transmission risk. Effective implementation of seroadaptive behaviors is dependent on knowledge of one's own serostatus and that of one's sexual partners. Partner-level and environmental-level attributes may affect seroadaptation practices. We assessed factors associated with seroadaptive behaviors.

METHODS

Men who have sex with men and transgender women were recruited from an HIV pre-exposure prophylaxis clinical trial (iPrEx) with study sites in the US, Peru, Ecuador, Brazil, Thailand, and South Africa. Partnership-level data were collected at the baseline visit for the 3 most recent partners. Participants were considered to have practiced seroadaptive behaviors if: (1) they believed their partner to be HIV-negative, that is, serosorting; or (2) no condomless receptive sex occurred with an HIV-positive or unknown status partner, that is, seropositioning.

RESULTS

Of 2331 participants, 41% always practiced seroadaptive behaviors, 36% sometimes did, and 23% never did. Participants enrolled at study sites in the US (P < 0.001) and Peru/Ecuador (P < 0.001) were more likely to practice seroadaptive behaviors, whereas transgender women were less likely to do so (P < 0.001). Seroadaptive behaviors were more likely to occur in relationships with steady partners (P = 0.005) and emotionally close relationships (P = 0.013).

CONCLUSIONS

Seroadaptive behaviors were more frequently observed among iPrEx participants from the US, Peru, and Ecuador study sites and among participants in relationships with partners who they were more committed to and felt emotionally close to. Our findings suggest that seroadaptive behaviors may be influenced by social norms that vary geographically and culturally.

Magnitude of risky sexual practice and associated factors among big construction site daily laborers in Bahir Dar city, Amhara Region, Ethiopia

BACKGROUND

Young person's susceptibility to sexually transmitted infection has been consistently linked to intractable work places. In Ethiopia, different behavior related interventions had carried out to raise awareness of risky sexual behaviors and their consequences. However, there is still limited information on risky sexual practices.

METHODS

A cross-sectional study was conducted among the big construction site daily laborers from April 1, 2019 to May 30, 2019. A pre-tested questionnaire was used for data collection, and data were entered into Epidata and transported to SPSS for analysis. Independent variables with p < 0.05 in the multivariate analysis were considered to have a statistically significant association with risky sexual practice.

RESULT

Among 627 sample respondents, the magnitude of risky sexual practice was found to be 24.2%. Labor workers who had a history of an STIs (AOR = 4.29; 95% CI: 2.56, 7.19), those who enjoy in the nightclubs (AOR = 2.33; 95% CI: 1.34, 4.08), those who started sex by peer pressure (AOR = 3.42; 95% CI: 2.06, 5.68), substance users (AOR = 2.03; 95% CI: 1.08, 3.82), those who were unable to read and write (AOR = 3.65; 95% CI: 1.41, 9.67), living independently (AOR = 3.71; 95% CI: 1.78, 7.77) and living with relatives (AOR = 3.12; 95% CI: 1.06, 9.20) were statistically associated with risky sexual practice.

CONCLUSION

The magnitude of risky sexual practice among big constriction daily laborers was high in Bahir Dar City likely to increase their vulnerability to HIV. The findings of this study show the need of targeted HIV prevention plan to give due attention for daily laborers who had a history of an STI, enjoy in the night clubs, peer pressure, substance users, educational status and living arrangement. The Amhara Education Bureau and the city education department have to design ways to deliver at least a high school education.

Optimizing Screening for HIV

BACKGROUND

The HIV epidemic is unevenly distributed throughout the United States, even within neighborhoods. This study evaluated how effectively current testing approaches reached persons at risk for HIV infection across San Diego (SD) County, California.

METHODS

HIV case and testing data, sexually transmitted infection (STI) data, and sociodemographic data for SD County were collected from the SD Health and Human Services Agency and the "Early Test" community-based HIV screening program between 1998 and 2016. Relationships between HIV diagnoses, HIV prevalence, and STI diagnoses with screening at the ZIP code level were evaluated.

RESULTS

Overall, 379 074 HIV tests were performed. The numbers of HIV tests performed on persons residing in a ZIP code or region overall strongly correlated with prevalent HIV cases (R 2 = .714), new HIV diagnoses (R 2 = .798), and STI diagnoses (R 2 = .768 [chlamydia], .836 [gonorrhea], .655 [syphilis]) in those regions. ZIP codes with the highest HIV prevalence had the highest number of tests per resident and fewest number of tests per diagnosis. Even though most screening tests occurred at fixed venues located in high-prevalence areas, screening of residents from lower-prevalence areas was mostly proportional to the prevalence of HIV and rates of new HIV and STI diagnoses in those locales.

CONCLUSIONS

This study supported the ability of a small number of standalone testing centers to reach at-risk populations dispersed across SD County. These methods can also be used to highlight geographic areas or demographic segments that may benefit from more intensive screening.

Transcriptional Profiling Reveals the Regulatory Role of CXCL8 in Promoting Colorectal Cancer

C-X-C motif chemokine ligand 8 (CXCL8) is involved in tumor proliferation, migration, and invasion. However, the function of CXCL8 in colorectal cancer (CRC) is controversial. Here, we analyzed RNA-sequencing (RNA-seq) data to identify differentially expressed genes and pathways according to gene ontology (GO) enrichment and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways associated with CRC. The levels of the mRNA encoding CXCL8 were significantly increased in early and advanced stages of CRC, as well as in metastases and nonmetastasis cases using RNA-seq analysis (n = 91). These findings were consistent with immunohistochemical analysis of CXCL8 expression (n = 87). Protein-protein interaction (PPI) prediction combined with transcriptional profiling data revealed that CXCL8 levels positively correlated with cAMP responsive element binding protein 1 (CREB1)/ribosomal protein S6 kinase B1 (RPS6KB1) expression, which promotes cell proliferation and differentiation in high expression, while inversely correlated with the expression of Bcl2 associated agonist of cell death (BAD) protein to inhibit apoptosis during the progression of CRC. These findings provide compelling clinical and molecular evidence to support the conclusion that CXCL8 contributes to the genesis and progression of CRC.

Risk Factors and Incidence of Syphilis in Human Immunodeficiency Virus (HIV)-Infected Persons: The HIV Outpatient Study, 1999-2015

Background

Since 2000, the incidence of syphilis has been increasing, especially among gay, bisexual, and other men who have sex with men (MSM) in the United States. We assessed temporal trends and associated risk factors for newly diagnosed syphilis infections among human immunodeficiency virus (HIV)-infected patients during a 16-year period.

Methods

We analyzed data from the HIV Outpatient Study (HOPS) cohort participants at 10 US HIV clinics during 1999-2015. New syphilis cases were defined based on laboratory parameters and clinical diagnoses. We performed Cox proportional hazards regression analyses of sociodemographic, clinical, and behavioral risk factors for new syphilis infections.

Results

We studied 6888 HIV-infected participants; 641 had 1 or more new syphilis diagnoses during a median follow-up of 5.2 years. Most participants were male (78%), aged 31-50 years, and 57% were MSM. The overall incidence was 1.8 (95% confidence interval [CI], 1.6-1.9) per 100 person-years (PY) and it increased from 0.4 (95% CI, .2-.8) to 2.2 (95% CI, 1.4-3.5) per 100 PY during 1999-2015. In multivariable analyses adjusting for calendar year, risk factors for syphilis included age 18-30 years (hazard ratio [HR], 1.3 [95% CI, 1.1-1.6]) vs 31-40 years, being MSM (HR, 3.1 [95% CI, 2.4-4.1]) vs heterosexual male, and being non-Hispanic black (HR, 1.6 [95% CI, 1.4-1.9]) vs non-Hispanic white.

Conclusions

The increases in the syphilis incidence rate through 2015 reflect ongoing sexual risk and highlight the need for enhanced prevention interventions among HIV-infected patients in care.

Multilevel elements associated with HIV serosorting for sexual encounters: a scoping literature review

A scoping literature review to identify the multilevel HIV serosorting related elements was developed. Articles from EBSCO, PubMed, PsyNET and Science Direct with serosort* or serosorting at the tittle or abstract, written in English or Spanish were included. No restriction in type of population or design were applied. 239 records were retrieved after duplicates removed, but 181 references were extracted for full-text review. Individual level: HIV knowledge, serostatus, risk perceptions, abilities to disclose and for condom use negotiation, motivations, use of drugs, stigma, attitudes toward condom use, and perceptions/beliefs about the HIV and related treatments, HIV infection rates/testing and behavioral factors. Interpersonal level: social networks, abilities (sexual behavior negotiation, and communication). Community level: stigma, social norms, access to HIV related services. Structural level: political context, HIV related funding and public policies. HIV Serosorting is not solely an interpersonal behavior it involves multilevel elements that must be acknowledged by professionals and stakeholders.

Risk factors of syphilis co-infection among HIVinfected men who have sex with men in Tel-Aviv, Israel

Syphilis incidence in Israel and other industrialized countries has increased in the past decade, mainly among men who have sex with men (MSM) who were co-infected with HIV. This study aimed to assess the demographic characteristics and behavioral risk factors for syphilis infection among HIV-infected MSM in the Tel-Aviv region, Israel. This cross-sectional study compared HIV-infected MSM who were co-infected with syphilis since 2005 with HIV-infected MSM without syphilis, using an anonymous self-administered questionnaire distributed at the AIDS treatment clinic in central Israel in 2016. This study included 75 HIV-infected MSM who were diagnosed with syphilis after their HIV diagnosis and 99 HIV-infected MSM without syphilis. Variables associated with syphilis infection included inadequate adherence to antiretroviral therapy (ART) (OR = 1.8 [1.2-2.4]), frequent unprotected receptive anal intercourse (UAI) with casual sex partners (OR = 2.2 [1.5-8.2]), especially with HIV-infected partner (OR = 3.2 [1.1-7.9]). In conclusion, HIV and syphilis co-infection were associated with frequent UAI with casual sex partners, inadequate adherence to ART and limited partner notification. In order to minimize syphilis transmission among HIV-infected MSM, AIDS clinics should encourage HIV-infected MSM to use condoms, ensure that patients perform periodic syphilis serology testing and improve partner notifications.

Epidemiology and prevention of sexually transmitted infections in men who have sex with men at risk of HIV

Since 2012, the increasingly widespread promotion and uptake of HIV treatment as prevention and pre-exposure prophylaxis in men who have sex with men has been associated with increased sexually transmitted infections (STIs). However, numbers of STI cases have been rising for more than 20 years and the introduction of biomedical HIV interventions cannot explain the majority of the rises in STIs. The increases appear to have occurred mostly because of gradual changes in behaviour over many years, coupled in some settings with more condomless anal intercourse, and as a result of the increased screening for previously undetected asymptomatic infections. If control of STIs is to be improved, then a far greater emphasis on increased use of existing effective STI control strategies will be required, in addition to the investigation of new interventions. Central to effective STI control is accessible clinical care and screening services, which are currently inadequate in most settings. Insufficient action carries a risk of increased STI epidemics, including of newly resistant organisms.

Effects of Sexual Network Connectivity and Antimicrobial Drug Use on Antimicrobial Resistance in Neisseria gonorrhoeae

Contemporary strategies to curtail the emergence of antimicrobial resistance in Neisseria gonorrhoeae include screening for and treating asymptomatic infections in high-prevalence populations in whom antimicrobial drug–resistant infections have typically emerged. We argue that antimicrobial resistance in these groups is driven by a combination of dense sexual network connectivity and antimicrobial drug exposure (for example, through screen-and-treat strategies for asymptomatic N. gonorrhoeae infection). Sexual network connectivity sustains a high-equilibrium prevalence of N. gonorrhoeae and increases likelihood of reinfection, whereas antimicrobial drug exposure results in selection pressure for reinfecting N. gonorrhoeae strains to acquire antimicrobial resistance genes from commensal pharyngeal or rectal flora. We propose study designs to test this hypothesis.

Total Lifetime and Cancer-related Costs for Elderly Patients Diagnosed With Anal Cancer in the United States

OBJECTIVE

To determine the lifetime and phase-specific cost of anal cancer management and the economic burden of anal cancer care in elderly (66 y and older) patients in the United States.

PATIENTS AND METHODS

For this study, we used Surveillance Epidemiology and End Results-Medicare linked database (1992 to 2009). We matched newly diagnosed anal cancer patients (by age and sex) to noncancer controls. We estimated survival time from the date of diagnosis until death. Lifetime and average annual cost by stage and age at diagnosis were estimated by combining survival data with Medicare claims. The average lifetime cost, proportion of patients who were elderly, and the number of incident cases were used to estimate the economic burden.

RESULTS

The average lifetime cost for patients with anal cancer was US$50,150 (N=2227) (2014 US dollars). The average annual cost in men and women was US$8025 and US$5124, respectively. The overall survival after the diagnosis of cancer was 8.42 years. As the age and stage at diagnosis increased, so did the cost of cancer-related care. The anal cancer-related lifetime economic burden in Medicare patients in the United States was US$112 million.

CONCLUSIONS

Although the prevalence of anal cancer among the elderly in the United States is small, its economic burden is considerable.

Differences in Partner Services Outcomes for Men Who Have Sex With Men Diagnosed With Primary and Secondary Syphilis by HIV Serostatus

BACKGROUND

Differences in partner services outcomes in men who have sex with men (MSM) by HIV serostatus have not been explored as a potential driver of differential early syphilis (ES) burden in this population.

METHODS

We compared partner services outcomes (number of partners named, notified, tested, diagnosed, and treated) between HIV-positive and HIV-negative MSM initiated for ES partner services in Texas from 2013 to 2016 using logistic regression and Wilcoxon-Mann-Whitney tests. Logistic regression was used to assess the relationship between HIV serostatus and having a no-partner-initiated (NPI) partner services interview controlling for demographic characteristics, prior partner services interactions, and geosocial phone application use.

RESULTS

A total of 4161 HIV-positive MSM and 5254 HIV-negative MSM were initiated for ES partner services. HIV-positive MSM named fewer partners than did HIV-negative MSM (mean, 1.2 vs. 1.9; P < 0.001) and had lower indices of partners notified, tested, diagnosed, and treated. HIV seropositivity was significantly associated with NPI. However, this association was not significant when limited to MSM with previous partner services interviews (adjusted risk ratio [aRR] 1.06; P = 0.38); in this subset of MSM, using geosocial phone application was negatively associated with having an NPI interview (aRR, 0.90), and having 1 (aRR, 1.33) or more than 1 previous NPI interview (aRR, 1.57) was associated with an NPI interview during the study period.

CONCLUSIONS

Suboptimal outcomes for syphilis partner service may result in missed opportunities for testing and treatment of sexual contacts, which could allow for propagation of syphilis. Implementation of innovative protocols is needed to ensure that partner services continue to be an effective and acceptable method of syphilis disease intervention in MSM.

"Losing the Phobia:" Understanding How HIV Pre-exposure Prophylaxis Facilitates Bridging the Serodivide Among Men Who Have Sex With Men

The use of HIV serostatus information has played a pivotal role in partner selection norms. A phenomenon known as serosorting is the practice of selecting a partner based on a perception that they are of the same HIV status in order to avoid transmission from one partner to the other. An understudied aspect of serosorting is that it has a divisive effect-one accepts or rejects a potential partner based on a singular characteristic, the partner's HIV status, and thus excludes all others. This division has been formally referred to as the HIV serodivide. In this study, we explored partner selection strategies among a group of HIV-negative, young men who have sex with men (n = 29) enrolled in a PrEP demonstration project in Northern California. We found that trends in serosorting were in fact shifting, and that a new and opposite phenomenon was emerging, something we labeled "seromixing" and that PrEP use played a part in why norms were changing. We present three orientations in this regard: (1) maintaining the phobia: in which men justified the continued vigilance and exclusion of people living with HIV as viable sex or romantic partners, (2) loosening/relaxation of phobia: among men who were reflecting on their stance on serosorting and its implications for future sexual and/or romantic partnerships, and (3) losing the phobia: among men letting go of serosorting practices and reducing sentiments of HIV-related stigma. The majority of participants spoke of changing or changed attitudes about intentionally accepting rather than rejecting a person living with HIV as a sex partner. For those who maintained strict serosorting practices, their understandings of HIV risk were not erased as a result of PrEP use. These overarching themes help explain how PrEP use is contributing to a closing of the HIV serodivide.

Old Pathogen, New Challenges: A Narrative Review of the Multilevel Drivers of Syphilis Increasing in American Men Who Have Sex With Men

Since the turn of the current century, syphilis incidence and prevalence have been increasing more rapidly among men who have sex with men (MSM) than any other US subpopulation, exceeding their previously high rates in the 1970s and 1980s, before the AIDS epidemic. The reasons for these trends are multifactorial and complex, involving individual behavioral, sociocultural, structural, and biological factors, which will be reviewed in this article. Men who have sex with men tend to have more sexual partners than heterosexuals, and engage in practices (e.g., anal sex) that are highly efficient for syphilis transmission and nondetection of primary chancres. In the era of highly active antiretroviral therapy rendering adherent patients noninfectious and the use of preexposure prophylaxis, there is substantially less concern about HIV transmission and acquisition among MSM, resulting in higher levels of condomless sex. The increased concentration of syphilis among black MSM is partially related to assortative mixing, that is, black MSM being more likely to have other black sex partners, as well as decreased access to preventive services and treatment due to economic marginalization, Societal rejection and discrimination may also potentiate factors that may increase sexual risks resulting in syphilis, for example, depression and substance use. The anticipation of experiencing homophobic discrimination in health care settings may lead many sexually active MSM to delay needed screening and treatment, thus being infectious to partners for longer periods than other populations. To effectively control the syphilis epidemic among MSM, scaling up a combination of programs, ranging from enhanced community education to training clinicians and health care systems to provide culturally competent care, will be necessary.

Prevalence of and Factors Associated with the Use of HIV Serosorting and Other Biomedical Prevention Strategies Among Men Who Have Sex with Men in a US Nationwide Survey

PrEP and treatment-as-prevention (TasP) are biomedical strategies to reduce HIV transmission. Some men who have sex with men (MSM) are combining biomedical strategies with HIV serosorting-termed "biomed matching" when both partners are either on PrEP or TasP, or "biomed sorting" when one partner is using PrEP and the other TasP. Nevertheless, there is limited data on the extent of biomed matching/sorting in large geographically diverse samples. In 2016-2017, 5021 MSM from across the US were surveyed about their HIV status and HIV viral load/PrEP use, as well as that of their recent casual male partners. For each participant, we calculated the proportion of his partners who were (1) HIV-positive and undetectable, (2) HIV-positive and detectable/unknown, (3) HIV unknown/undiscussed, (4) HIV-negative on PrEP, (5) HIV-negative, not on PrEP. In total, 66.6% (n = 3346) of participants were HIV-negative and not on PrEP, 11.9% (n = 599) on PrEP, 14.1% (n = 707) HIV-positive and undetectable, 1.1% (n = 55) HIV-positive and viral load detectable/unknown, and 6.2% (n = 313) HIV unsure/unknown. A participant's own HIV and PrEP status/was significantly associated with that of his partners (all p < 0.001), evincing evidence of both serosorting and biomed matching. Among men on PrEP and those who were HIV-undetectable, there was also some evidence to suggest these participants dually engaged in biomed matching as well as biomed sorting. We found evidence of biomed matching and sorting, which may compound its effectiveness for those using it (i.e., both partners bring biomedical protection). Unintended consequences of biomed matching/sorting include that men not using a biomedical strategy may be less likely to benefit from a partner's use of the strategy-potentially further driving disparities in HIV infections. Public health campaigns might be well served to highlight not only the benefits that biomedical HIV prevention strategies provide for their users (e.g., "being on PrEP protects me from getting HIV"), but also the benefits that a user brings to his partners (e.g., "my use of PrEP means my partners won't get HIV"), and the benefits of being with a partner who is using a biomedical strategy (e.g., "my partner's use of PrEP/TasP protects me from HIV").

Correlates of Serosorting and Knowledge of Sexual Partner's HIV Status Among Men Who have Sex with Men in Ukraine

Ukraine has among the highest rates of newly diagnosed HIV infections in the WHO European region. Men who have sex with men (MSM) is the least studied group in the context of the HIV epidemics in Ukraine. The present paper aims to estimate the prevalence and correlates of knowledge of sexual partner's HIV status and potentially discordant anal intercourse (failure to serosort) among MSM. Data of the cross-sectional study among 8100 MSM in Ukraine in 2013 were used for this analysis. Less than half of the participants (42.5%) reported that they knew the HIV serostatus of their most recent male sexual partner, and about 13% of participants reported failure to serosort during their most recent anal sexual intercourse with a male partner. Targeted interventions can be implemented to increase knowledge about sexual partner's HIV status, both among HIV-negative and HIV-positive MSM, to reduce the risk of HIV acquisition and transmission.

Increased Syphilis Testing of Men Who Have Sex With Men: Greater Detection of Asymptomatic Early Syphilis and Relative Reduction in Secondary Syphilis

Background

Syphilis rates have increased markedly among men who have sex with men (MSM) internationally. We examined trends in syphilis testing and detection of early syphilis among MSM in Australia.

Methods

Serial cross-sectional analyses on syphilis testing and diagnoses among MSM attending a national sentinel network of 46 clinics in Australia between 2007 and 2014.

Results

359313 clinic visits were included. The proportion of MSM serologically tested for syphilis annually increased in HIV-negative (48% to 91%; Ptrend < .0001) and HIV-positive MSM (42% to 77%; Ptrend < .0001). The mean number of tests per man per year increased from 1.3 to 1.6 in HIV-negative MSM (Ptrend < .0001) and from 1.6 to 2.3 in HIV-positive MSM (Ptrend < .0001). 2799 and 1032 syphilis cases were detected in HIV-negative and HIV-positive MSM, respectively. Among HIV-negative MSM, the proportion of infections that were early latent increased from 27% to 44% (Ptrend < .0001), while the proportion that were secondary decreased from 24% to 19% (Ptrend = .030). Among HIV-positive MSM, early latent infections increased from 23% to 45% (Ptrend < .0001), while secondary infections decreased from 45% to 26% (Ptrend = .0003). Among HIV-positive MSM, decreasing secondary syphilis correlated with increasing testing coverage (r = -0.87; P = .005) or frequency (r = -0.93; P = .001).

Conclusions

Increases in syphilis screening were associated with increased detection of asymptomatic infectious syphilis and relative falls in secondary syphilis for both HIV-positive and HIV-negative MSM nationally, suggesting interruption of syphilis progression.

Factors associated with repeat diagnosis of syphilis in genitourinary medicine (GUM) clinic attendees in the North East of England, 2002-2014

This study aimed to identify factors associated with repeat syphilis infection in North East England, in order to inform local prevention and control opportunities. We undertook a case-case study comparing individuals diagnosed with single or multiple episodes of syphilis infection within genitourinary medicine (GUM) clinics in NE England (12 clinics serving a population of 2.5 million). Study cases were verified as having had true re-infection by a GUM clinician (using serological and/or clinical parameters) and control cases (3 per case) frequency matched to cases by age and year of presentation. The odds of exposure to sexual behavioural and clinical factors were compared for cases and control cases using stepwise multivariable logistic regression. We included 66 cases and 235 control cases. The majority of cases (62/66) and control cases (165/235) were men who had sex with men (MSM). Data were missing for 0-64% of cases across different variables. Following multivariable analysis HIV seropositivity (OR 23.3, 95% CI 4.32-125.9), failure to attend follow-up (OR 4.63, 95% CI 1.11-19.31), stage of infection and deprivation were associated with re-infection ( p < 0.001). In this study, HIV seropositivity and failure to attend follow-up were associated with re-infection with syphilis. Actions targeted at these groups may help to reduce ongoing transmission.

Sexually Transmitted Disease Testing of Human Immunodeficiency Virus-Infected Men Who Have Sex With Men: Room for Improvement

BACKGROUND

In the United States, sexually transmitted infection (STI) testing is recommended at least annually for sexually active men who have sex with men (MSM). We evaluated human immunodeficiency virus (HIV) providers' STI testing practices and frequency of positive test results.

METHODS

We analyzed data from HIV Outpatient Study (HOPS) participants who, from 2007 to 2014, completed a confidential survey about risk behaviors. Using medical records data, we assessed the frequency of gonorrhea, chlamydia, and syphilis testing and positive results during the year after the survey for MSM who reported sex without a condom in the prior 6 months. We compared testing frequency and positivity for men having 1, 2 to 3, and 4 or more sexual partners. Correlates of STI testing were assessed using general linear model to derive relative risks (RR) with associated 95% confidence intervals (CI).

RESULTS

Among 719 MSM, testing frequency was 74.5%, 74.3%, and 82.9% for gonorrhea, chlamydia, and syphilis, respectively, and was higher in those men who reported more sexual partners (P < 0.001 for all). In multivariable analysis, testing for gonorrhea was significantly more likely among non-Hispanic black versus white men (RR, 1.17; 95% CI, 1.03-1.33), among men seen in private versus public clinics (RR, 1.16; 95% CI, 1.05-1.28), and among men with 2 to 3 and 4 or more sexual partners versus 1 partner (RR, 1.12; 95% CI, 1.02-1.23, and RR, 1.18; 95% CI, 1.08-1.30, respectively). Correlates of chlamydia and syphilis testing were similar. Test positivity was higher among men with more sexual partners: for gonorrhea 0.0%, 3.0%, and 6.7% for men with 1, 2 to 3, and 4 or more partners, respectively (P < 0.001, syphilis 3.7%, 3.8% and 12.5%, P < 0.001).

CONCLUSIONS

Among HIV-infected MSM patients in HIV care who reported sex without a condom, subsequent testing was not documented in clinic records during the following year for up to a quarter of patients. Exploring why STI testing did not occur may improve patient care.

Prevalence of asymptomatic sexually transmitted infections in HIV-positive men who have sex with men in Germany: results of a multicentre cross-sectional study

PURPOSE

Sexually transmitted infections (STIs) occur frequently in risk populations. Hereby, the role of screening-programmes remains controversial. Our study aimed to determine the prevalence of STI infections in HIV-positive men-who-have-sex-with-men (MSM).

METHODS

We enrolled asymptomatic, HIV-MSM in a prospective cross-sectional study from February to August 2016 at seven German HIV-centres. All subjects were screened for Treponema-pallidum (TP) and hepatitis-B/C-infection. HIV RNA and screening for oral, rectal and urethral colonisation by Chlamydia-trachomatis (CT) and/or Neisseria-gonorrhoeae (NG) was performed. All subjects were asked to complete a sexual-risk-behaviour-questionnaire.

RESULTS

In total, 296 subjects with a median age of 43.2 (36.2-49.5) years were enrolled; 99.3% were on ART for 5.5 (2.3-11.2) years. HIV RNA was < 50 copies/mL in 93.6%. Active syphilis infection was found in 5.0% of all patients, whereas 55.4% had history of infection. HCV seropositivity was found in 33 patients (13.2%) and positive HCV RNA was available in 39.4%. 66/294 (22.5%) showed negative anti-HBs-antibodies, indicating lack of immunity. Overall, 40/296 (13.5%) had positive CT/NG swabs (CT in 8.8%; 7.3% anorectal, 1.7% oropharyngeal, 1.0% urethral and NG in 6.8%; 4.5% anal, 2.0% oropharyngeal, 1.4% urethral). Time since HIV infection < 7 years (OR 2.6 (1.2-5.5); p = 0.012), the use of inhalative nitrites ("poppers") (OR 2.8 (1.3-5.9; p = 0.008) and reporting unprotected intercourse with > 20 partners within the last 6 months [OR 3.0 (1.2-7.8); p = 0.003] were significantly associated in multivariate analysis.

CONCLUSION

We found high numbers of asymptomatic syphilis, hepatitis-C and CT/NG infections in HIV-MSM, remarkably in patients with shorter duration of HIV-infection with more sexual partners within last 6 months.

Infectious and congenital syphilis in Canada, 2010-2015

BACKGROUND

Syphilis is the third most commonly reported notifiable sexually transmitted infection (STI) in Canada, following chlamydia and gonorrhea, respectively. Rates of this STI have been rising rapidly in Canada since 2001.

OBJECTIVE

To summarize trends observed in syphilis rates for 2010 to 2015 in Canada.

METHODS

Laboratory-confirmed cases of infectious syphilis and early congenital syphilis were reported to the Public Health Agency of Canada by all of the Canadian provinces and territories. National infectious syphilis rates were computed, as were rates per sex, age group and province/territory. Rates of congenital syphilis were also calculated.

RESULTS

From 2010 to 2015, the rate of infectious syphilis in Canada increased by 85.6%, from 5.0 to 9.3 cases per 100,000 population. In 2015, a total of 3,321 cases of infectious syphilis were reported, mainly in males (93.7%), among whom the rate was 17.5 cases per 100,000 males versus 1.2 per 100,000 females. The rate also rose faster among males in 2010-2015, a 90.2% increase versus 27.8% among females. Individuals aged 20-39 years had the highest rates. Across the provinces and territories, the highest rates of infectious syphilis were in Nunavut, British Columbia and Manitoba.​: The rate of congenital syphilis decreased from 2010 to 2014 (1.6 to 0.3 cases per 100,000 live births) before increasing to 1.5 cases per 100,000 live births in 2015, which corresponds to six reported cases.

CONCLUSION

Rates of syphilis continue to rise in Canada, especially among young men, and this is consistent with trends in the United States of America and European Union. Based on data from Canada and from these regions, the sexual behaviour of men who have sex with men (MSM) is thought to be a major risk factor for syphilis.

HIV Serodisclosure and Sexual Behavior During International Travel

When traveling internationally, HIV serodisclosure and knowledge of partners' serostatus were hampered by the lack of a common language. Condomless anal intercourse was less likely to occur in partnerships where HIV serostatus was not disclosed or known. Taken together, these observations suggest that language barriers may affect sexual decision making.

Unsafe Sexual Behavior Among Gay/Bisexual Men in the Era of Combination Antiretroviral Therapy (cART)

The aim of this study was to determine the association between psychosocial determinants of unprotected receptive anal intercourse (URAI) and unprotected insertive anal intercourse (UIAI). Data from 417 HIV positive men who have sex with men (MSM) in the Multicenter AIDS Cohort Study from April 1999 to March 2012 were analyzed and adjusted odds were calculated. It was found that 66% (n = 277) and 72% (n = 299) reported any UIAI or URAI over follow-up, respectively. Cumulative cART-years (median = 5.30 years) was associated with 33 and 47% increases in UIAI and URAI, respectively. Not having reduced concern about HIV transmission (UIAI: OR 0.37, p-value = 0.0004; URAI: OR 0.57, p-value = 0.04), increased safe sex fatigue (UIAI: OR 2.32, 95% p-value = 0.0002; URAI: OR 1.94, p-value = 0.003), and sexual sensation seeking (UIAI: OR 1.76, p-value = 0.002; URAI: OR 1.56, p-value = 0.02) were associated with UIAI and URAI. Serosorting was associated with UIAI (OR 6.11, p-value < 0.0001) and URAI (OR 6.80, p-value < 0.0001). Findings suggest that negative attitudes about HIV transmission are sustained among older men who have sex with men.

A double-edged sword: does highly active antiretroviral therapy contribute to syphilis incidence by impairing immunity to Treponema pallidum?

BACKGROUND AND HYPOTHESIS

Recently, the world has experienced a rapidly escalating outbreak of infectious syphilis primarily affecting men who have sex with men (MSM); many are taking highly active antiretroviral therapy (HAART) for HIV-1 infection. The prevailing hypothesis is that HAART availability and effectiveness have led to the perception among both individuals who are HIV-1 infected and those who are uninfected that HIV-1 transmission has become much less likely, and the effects of HIV-1 infection less deadly. This is expected to result in increased sexual risk-taking, especially unprotected anal intercourse, leading to more non-HIV-1 STDs, including gonorrhoea, chlamydia and syphilis. However, syphilis incidence has increased more rapidly than other STDs. We hypothesise that HAART downregulates the innate and acquired immune responses to Treponema pallidum and that this biological explanation plays an important role in the syphilis epidemic.

METHODS

We performed a literature search and developed a mathematical model of HIV-1 and T. pallidum confection in a population with two risk groups with assortative mixing to explore the consequence on syphilis prevalence of HAART-induced changes in behaviour versus HAART-induced biological effects.

CONCLUSIONS AND IMPLICATIONS

Since rising syphilis incidence appears to have outpaced gonorrhoea and chlamydia, predominantly affecting HIV-1 positive MSM, behavioural factors alone may be insufficient to explain the unique, sharp increase in syphilis incidence. HAART agents have the potential to alter the innate and acquired immune responses in ways that may enhance susceptibility to T. pallidum. This raises the possibility that therapeutic and preventative HAART may inadvertently increase the incidence of syphilis, a situation that would have significant and global public health implications. We propose that additional studies investigating the interplay between HAART and enhanced T. pallidum susceptibility are needed. If our hypothesis is correct, HAART should be combined with enhanced patient management including frequent monitoring for pathogens such as T. pallidum.

Toward a Realistic Modeling of Epidemic Spreading with Activity Driven Networks

Models of epidemic spreading are widely used to predict the evolution of an outbreak, test specific intervention scenarios, and steer interventions in the field. Compartmental models are the most common class of models. They are very effective for qualitative analysis, but they rely on simplifying assumptions, such as homogeneous mixing and time scale separation. On the other end of the spectrum, detailed agent-based models, based on realistic mobility pattern models, provide extremely accurate predictions. However, these models require significant computing power and are not suitable for analytical treatment. Our research aims at bridging the gap between these two approaches, toward time-varying network models that are sufficiently accurate to make predictions for real-world applications, while being computationally affordable and amenable to analytical treatment. We leverage the novel paradigm of activity driven networks (ADNs), a particular type of time-varying network that accounts for inherent inhomogeinities within a population. Starting from the basic incarnation of ADNs, we expand on the framework to include behavioral factors triggered by health status and spreading awareness. The enriched paradigm is then utilized to model the 2014–2015 Ebola Virus Disease (EVD) spreading in Liberia, and perform a what-if analysis on the timely application of sanitary interventions in the field. Finally, we propose a new formulation, which is amenable to analytical treatment, beyond the mere computation of the epidemic threshold.

MSW student perceptions of sexual health as relevant to the profession: Do social work educational experiences matter?

Many social work clients are at an increased risk for negative outcomes related to sexual behavior, including unwanted pregnancies and sexually transmitted infections (STIs). However, there is a dearth of literature on social work student experiences with these topics in social work classrooms and their perceptions about the topic's relevance to their practice. The purpose of this study is to explore relationships between experiences with STIs and contraception as topics in social work education and practica experiences on student perceptions toward sexual health as a relevant topic for social work. Among a national sample of MSW students (N = 443), experiences with STIs and contraception as topics in practica was significantly related to perceptions toward sexual health's relevance to social work. Findings and implications are discussed.

Syphilis Trends among Men Who Have Sex with Men in the United States and Western Europe: A Systematic Review of Trend Studies Published between 2004 and 2015

Globally, men who have sex with men (MSM) are disproportionately burdened with syphilis. This review describes the published literature on trends in syphilis infections among MSM in the US and Western Europe from 1998, the period with the fewest syphilis infections in both geographical areas, onwards. We also describe disparities in syphilis trends among various sub-populations of MSM. We searched electronic databases (Medline, Embase, Global Health, PsychInfo, CAB Abstracts, CINAHL, Sociological Abstracts, Web of Science, Cochrane Library, and LILACS) for peer-reviewed journal articles that were published between January 2004 and June 2015 and reported on syphilis cases among MSM at multiple time points from 1998 onwards. Ten articles (12 syphilis trend studies/reports) from the US and eight articles (12 syphilis trend studies/reports) from Western Europe were identified and included in this review. Taken together, our findings indicate an increase in the numbers and rates (per 100,000) of syphilis infections among MSM in the US and Western Europe since 1998. Disparities in the syphilis trends among MSM were also noted, with greater increases observed among HIV-positive MSM than HIV-negative MSM in both the US and Western Europe. In the US, racial minority MSM and MSM between 20 and 29 years accounted for the greatest increases in syphilis infections over time whereas White MSM accounted for most syphilis infections over time in Western Europe. Multiple strategies, including strengthening and targeting current syphilis screening and testing programs, and the prompt treatment of syphilis cases are warranted to address the increase in syphilis infections among all MSM in the US and Western Europe, but particularly among HIV-infected MSM, racial minority MSM, and young MSM in the US.

Anorectal pathology amongst HIV infected patients attending the Douala General Hospital: a cross-sectional study

While gastrointestinal disease is common among HIV infected individuals, the prevalence and distribution of ano-rectal pathology has not been well studied in our setting. The objective of this study therefore was to determine the prevalence and determinants of ano-rectal pathology in HIV infected patients attending the Douala General Hospital HIV treatment centre. A hospital-based cross-sectional study was undertaken. We collected socio-demographic, clinical and laboratory data using a structured questionnaire and patients' files. Each study participant had a full physical and ano-rectal examination. We further studied factors associated with having at least one ano-rectal lesion by logistic regression reporting odds ratios (ORs) and their 95% confidence intervals (CI). We included 390 HIV infected patients. The mean age was 41 (SD: 8) years and 48% were men. Median duration since HIV diagnosis was 3 (interquartile range: 2-5) years and median CD4 cell count was 411 (interquartile range: 234-601) cells/mm³. Prevalence of ano-rectal pathology was 22.8% (95% CI: 18.7-27.3). Hemorrhoids and proctitis were most common lesions found; each in 10% of patients. From multivariate logistic regression, factors associated with ano-rectal pathology were CD4 < 350 cells/ml (OR: 2.1, 95% CI: 1.1-4.2), not on highly active antiretroviral therapy (OR: 2.2, 95% CI: 1.1-4.6), inpatient (OR: 2.3, 95% CI: 1.2-4.3), ano-rectal intercourse (OR: 5.0, 95% CI: 1.7-15.1), and more than one sexual partner (OR: 2.4, 95% CI: 1.3-4.2). Ano-rectal pathology is common amongst HIV infected patients. Care givers should actively investigate and treat them as this will improve the quality of life of people living with HIV/AIDS.

Trends in Serosorting and the Association With HIV/STI Risk Over Time Among Men Who Have Sex With Men

BACKGROUND

Serosorting among men who have sex with men (MSM) is common, but recent data to describe trends in serosorting are limited. How serosorting affects population-level trends in HIV and other sexually transmitted infection (STI) risk is largely unknown.

METHODS

We collected data as part of routine care from MSM attending a sexually transmitted disease clinic (2002-2013) and a community-based HIV/sexually transmitted disease testing center (2004-2013) in Seattle, WA. MSM were asked about condom use with HIV-positive, HIV-negative, and unknown-status partners in the prior 12 months. We classified behaviors into 4 mutually exclusive categories: no anal intercourse (AI); consistent condom use (always used condoms for AI); serosorting [condom-less anal intercourse (CAI) only with HIV-concordant partners]; and nonconcordant CAI (CAI with HIV-discordant/unknown-status partners; NCCAI).

RESULTS

Behavioral data were complete for 49,912 clinic visits. Serosorting increased significantly among both HIV-positive and HIV-negative men over the study period. This increase in serosorting was concurrent with a decrease in NCCAI among HIV-negative MSM, but a decrease in consistent condom use among HIV-positive MSM. Adjusting for time since last negative HIV test, the risk of testing HIV positive during the study period decreased among MSM who reported NCCAI (7.1%-2.8%; P= 0.02), serosorting (2.4%-1.3%; P = 0.17), and no CAI (1.5%-0.7%; P = 0.01). Serosorting was associated with a 47% lower risk of testing HIV positive compared with NCCAI (adjusted prevalence ratio = 0.53; 95% confidence interval: 0.45 to 0.62).

CONCLUSIONS

Between 2002 and 2013, serosorting increased and NCCAI decreased among Seattle MSM. These changes paralleled a decline in HIV test positivity among MSM.

Randomized Controlled Trial of an Internet Application to Reduce HIV Transmission Behavior Among HIV Infected Men Who have Sex with Men

We conducted a prospective, randomized controlled trial of an internet-based safer-sex intervention to reduce HIV transmission risk behaviors. HIV-infected men who have sex with men (n = 179) were randomized to receive a monthly internet survey alone or a monthly survey plus tailored risk reduction messages over 12 months. The primary outcome was the cumulative sexually transmitted infection (STI) incidence over 12 months. Secondary outcomes included self-reported unprotected sex with an at risk partner and disclosure of HIV status to partners. In a modified intent to treat analysis, there was no difference in 12-month STI incidence between the intervention and control arms (30 vs. 25 %, respectively; p = 0.5). Unprotected sex decreased and disclosure increased over time in both study arms. These improvements suggest that addition of the risk-reduction messages provided little benefit beyond the self-monitoring of risky behavior via regular self-report risk behavior assessments (as was done in both study arms).

A case-control study evaluating the role of internet meet-up sites and mobile telephone applications in influencing a syphilis outbreak: Multnomah County, Oregon, USA 2014

OBJECTIVES

Early syphilis in Multnomah County, Oregon, USA, increased 16-fold during 2007-2013. Cases predominantly occurred among men who have sex with men (MSM); 55% were HIV coinfected. We conducted a case-control study to evaluate the association between meeting sex partners online and early syphilis.

METHODS

Cases subjects (cases) were Multnomah County resident, English speaking, MSM, aged ≥18 years with laboratory-confirmed early syphilis reported 1 January to 31 December 2013. We recruited two MSM controls subjects (controls) per case, frequency matched by HIV status and age. Participants completed self-administered questionnaires. We performed multivariable logistic regression.

RESULTS

Seventy per cent (40/57) of cases and 42% (50/119) of controls met partners online (p<0.001). Cases more frequently met partners online (adjusted OR (aOR)=3.0; 95% CI 1.2 to 6.7), controlling for presumptive confounders. Cases reported more partners than controls (medians 5, 2; p<0.001). When including number of partners, aOR decreased to 1.4 (95% CI 0.5 to 3.9).

CONCLUSIONS

Early syphilis was associated with meeting partners online. We believe this association may be related to number of sex partners acting as an intermediate variable between use of online resources to meet sex partners and early syphilis. Online meet-up sites might represent areas for public health interventions targeting at-risk individuals.

Sexually transmitted infections and pre-exposure prophylaxis: challenges and opportunities among men who have sex with men in the US

Pre-Exposure Prophylaxis (PrEP) has shown high efficacy in preventing human immunodeficiency virus (HIV) infection among men who have sex with men (MSM) in several large clinical trials, and more recently in “real world” reports of clinical implementation and a PrEP demonstration project. Those studies also demonstrated high bacterial sexually transmitted infection (STI) incidence and raised the discussion of how PrEP may impact STI control efforts, especially in the setting of increasing Neisseria gonorrhoeae antimicrobial resistance and the increase in syphilis cases among MSM. Here, we discuss STIs as a driver of HIV transmission risk among MSM, and the potential opportunities and challenges for STI control afforded by expanded PrEP implementation among high-risk MSM.

What people want from sex and preexposure prophylaxis

PURPOSE OF REVIEW

As demand for preexposure prophylaxis (PrEP) increases, we are learning more about what people want from sex and PrEP.

RECENT FINDINGS

PrEP demand has reached a tipping point in the USA and is increasing rapidly. Although the primary benefit of PrEP use is biological, to reduce risk of HIV infection, PrEP users often express an alternative set of social and emotional benefits that are provided by PrEP. These collateral benefits of PrEP have salience, affect, and are experienced in the present, which are compelling drivers of human behavior. PrEP use has been associated with feeling safe during sex, usually in contrast to ruminations related to fear of HIV or intimate partner violence or control. PrEP can create empowerment, or agency, defined as the capacity and autonomy to act on one's own behalf, because it provides control over one's vulnerability to HIV and relief to women and men who may otherwise worry about whether their partners will use a condom, take antiretroviral therapy, or disclose their HIV status accurately. Planning for sexual and social goals in calm moments is also empowering. These highly desired collateral benefits of PrEP could be undermined, or eliminated, if PrEP is implemented in ways that are coercive or that foment fear of sexual risk compensation, drug resistance, toxicity, or moral judgment.

SUMMARY

Current PrEP implementation provides direct and indirect benefits that are highly desired.

Sexual Behavior and Network Characteristics and Their Association with Bacterial Sexually Transmitted Infections among Black Men Who Have Sex with Men in the United States

Background

Black men who have sex with men (MSM) have a high prevalence of bacterial sexually transmitted infections (STIs), and individual risk behavior does not fully explain the higher prevalence when compared with other MSM. Using the social-ecological framework, we evaluated individual, social and sexual network, and structural factors and their association with prevalent STIs among Black MSM.

Methods

The HIV Prevention Trials Network 061 was a multi-site cohort study designed to determine the feasibility and acceptability of a multi-component intervention for Black MSM in six US cities. Baseline assessments included demographics, risk behavior, and social and sexual network questions collected information about the size, nature and connectedness of their sexual network. Logistic regression was used to estimate the odds of having any prevalent sexually transmitted infection (gonorrhea, chlamydia, or syphilis).

Results

A total of 1,553 Black MSM were enrolled in this study. In multivariate analysis, older age (aOR = 0.57; 95% CI 0.49–0.66, p<0.001) was associated with a lower odds of having a prevalent STI. Compared with reporting one male sexual partner, having 2–3 partners (aOR = 1.74; 95% CI 1.08–2.81, p<0.024) or more than 4 partners (aOR = 2.29; 95% CI 1.43–3.66, p<0.001) was associated with prevalent STIs. Having both Black and non-Black sexual partners (aOR = 0.67; 95% CI 0.45–0.99, p = 0.042) was the only sexual network factor associated with prevalent STIs.

Conclusions

Age and the number and racial composition of sexual partners were associated with prevalent STIs among Black MSM, while other sexual network factors were not. Further studies are needed to evaluate the effects of the individual, network, and structural factors on prevalent STIs among Black MSM to inform combination interventions to reduce STIs among these men.

Emerging trends and persistent challenges in the management of adult syphilis

There are an estimated 10.6 million incident cases of syphilis worldwide each year. We highlight some persistent challenges and emerging trends in the clinical management of syphilis with a particular focus on therapy, serology, diagnostics, and prevention. Decades after the introduction of penicillin, the optimal management of early syphilis continues to be a controversial topic, particularly in the setting of HIV co-infection. Similarly, the need for routine lumbar puncture in HIV co-infected asymptomatic persons is an unanswered question. Despite advances in both automation and point-of-care diagnostics, we continue to rely on indirect measures of disease activity to manage this infection. As syphilis rates in some populations continue to rise, novel and effective prevention strategies are needed.

Chlamydia trachomatis, Neisseria gonorrhoeae and syphilis among men who have sex with men in Brazil

BACKGROUND

Sexually transmitted diseases (STD) are frequently asymptomatic and increase the likelihood of transmitting and acquiring HIV. In Brazil, the guidelines for STDs diagnosis and treatment are based on the syndromic approach. Nucleic acid amplification tests (NAAT) has been recommended as routine STDs screening in some countries, especially for men who have sex with men (MSM). Limited data are available about how to best define target groups for routine screening by NAATs within this population. We aimed to assess the prevalence of rectal and urethral Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections and syphilis, and the factors associated with having at least one STD among HIV-infected and uninfected MSM in Rio de Janeiro, Brazil.

METHODS

From August 2010 to June 2012, 391 MSM were enrolled into the Evandro Chagas National Institute of Infectious Diseases-INI-Fiocruz cohort, and 292 MSM (HIV-infected:211 and HIV-uninfected:81) were included in this study. NAATs were performed on the rectal swabs and urine for CT and NG. The rapid plasma reagin test and microhemagglutination assay for Treponema pallidum were performed for syphilis diagnosis.

RESULTS

The overall prevalence of STD was 20.0% (95%CI:15.7-25.1): 10% anorectal chlamydia; syphilis 9.9%; anorectal gonorrheae 2.5%; and urethral chlamydia 2.2%; no case of urethral gonorrheae was detected. The proportion of HIV-positive MSM who had at least one STD was nearly two times that of HIV-negative MSM (22.6% vs 13.2%; P = 0.09). The frequency of each STD, except for anorectal NG (1.5% vs.5.2%), was higher among HIV-positive than HIV-negative individuals. Among the 211 asymptomatic participants, 17.5% (n = 37) were identified as having at least one STD; 10.4% (n = 22/211) tested positive for anorectal chlamydia. Sixty five percent of HIV-positive MSM were asymptomatic at the time of the STD diagnosis, while 100.0% of the HIV-negative MSM. Age (APR = 0.78; 95%CI:0.60-1.00 for each additional ten years) and a positive-HIV serostatus (APR = 2.05; 95%CI:1.03-4.08) were significantly associated with STD diagnosis.

CONCLUSION

An overall high STD-prevalence rate was observed, especially among HIV-infected and in younger individuals, and the majority of STDs were asymptomatic. STD screening using NAATs among asymptomatic MSM is a potentially cost-effective intervention for the prevention of HIV infection among MSM.

Gay and bisexual men engage in fewer risky sexual behaviors while traveling internationally: a cross-sectional study in San Francisco

BACKGROUND

International travel poses potential challenges to HIV prevention. A number of studies have observed an association between travel and behavioural disinhibition. In the present study, we assessed differences in sexual behaviour while travelling internationally and within the USA, compared with being in the home environment.

METHODS

A probability-based sample of men who have sex with men (MSM) from the San Francisco Bay Area who had travelled internationally in the previous 12 months was recruited through an adapted respondent-driven sampling methodology (N=501). Participants completed interviewer-administered, computer-assisted surveys.

RESULTS

Detailed partner-by-partner behavioural data by destination type were collected on 2925 sexual partnerships: 1028 while travelling internationally, 665 while travelling within the USA and 1232 while staying in the San Francisco Bay Area. The proportion of partnerships during international travel that involved unprotected anal intercourse (UAI) was lower compared with during domestic travel and staying locally. International travel was associated with decreased odds of receptive UAI (AOR=0.65, p=0.02) compared with staying locally and there was a trend towards decreased odds of insertive UAI (AOR=0.70, p=0.07).

CONCLUSIONS

MSM engaged in proportionately fewer sexual activities which present a high HIV transmission risk when travelling internationally, namely unprotected receptive and insertive anal intercourse and particularly with HIV serodiscordant partners. The lower sexual risk-taking during international travel was robust to controlling for many factors, including self-reported HIV serostatus, age, relationship status and type of partnership. These findings suggest that when travelling internationally, MSM may experience behavioural disinhibition to a lesser extent than had been described previously.

Clinical and epidemiological characteristics of patients with early syphilis from three academic centres in Poland, Germany and Ireland: initial findings from the POETS study

OBJECTIVES

Syphilis recognition in HIV-positive patients has important implications. Initial data from this study, established in June 2012 to better understand the natural history of syphilis and treatment response, examine the characteristics of patients including sexual behaviour, rates of concurrent sexually transmitted infections (STI) and type of treatment given.

METHODS

Patients were recruited from Ireland, Poland and Germany. Data gathered included demographics, method of syphilis acquisition, stage of syphilis infection, HIV status, nadir and current CD4 counts and HIV viral suppression rates. Data were then subanalysed into HIV-positive and HIV-negative groups.

RESULTS

Of 175 patients recruited, 68% were HIV-positive and 86.3% were men who have sex with men. Most HIV-positive patients presented with secondary syphilis (55.7% vs 13.2%) (p=0.0001) while the majority of HIV-negative patients had primary syphilis noted at the time of recruitment (47.2% vs18.9%, p=0.0002). Approximately half of all patients had a HIV RNA viral load <40 copies/mL (55%). Previous syphilis infection occurred more frequently in HIV-positive than HIV-negative patients (p=0.0001). Concurrent STIs at the time of syphilis diagnosis were found in 26.8%, of whom 31 (25.4%) were HIV-positive (p=0.64). HIV-positive patients received doxycycline more frequently than their HIV-negative counterparts (33.6% vs 1.9%, p=0.0001) while HIV-negative patients were treated with long-acting penicillin in 88.7% of cases vs 58% of HIV-positive patients (p=0.0002).

CONCLUSIONS

A 40% rate of unsuppressed viraemia, high levels of STIs and varying treatment regimens represent a public health risk for Europe, suggesting the model of sexual healthcare delivery in HIV-positive patients requires further evaluation.

Daily associations between alcohol use and unprotected anal sex among heavy drinking HIV-positive men who have sex with men

Men who have sex with men (MSM) account for the largest proportion of new HIV infections in the United States. Alcohol may facilitate HIV transmission by increasing unprotected anal sex, but few studies have focused on transmission behaviors in HIV-positive MSM. This study explored daily associations between alcohol use and sexual behavior among heavy drinking HIV-positive MSM using a 30-day Timeline Followback interview. Results of generalized estimating equations indicated that greater alcohol consumption on a given day was associated with a linear increase in the odds of having unprotected anal sex with partners of any HIV status. However, the odds of reporting unprotected anal sex with HIV-negative or HIV-status unknown partners increased in a curvilinear fashion, occurring primarily at very heavy levels of use (12+ drinks). Results suggest that very heavy drinking increases the risk of engaging in sexual behavior that has the potential for transmitting HIV to other men.

Serosorting Sexual Partners by Gay and Bisexual Men to Prevent HIV Infection: Implications for Public Health Clinicians

The most recent Centers for Disease Control and Prevention epidemiological statistics in the United States demonstrate that gay and bisexual men are at most risk for acquiring new HIV infections. While public health campaigns aimed at gay and bisexual males have resulted in improved HIV screening and greater awareness of the need for safer sex practices, barebacking has become a practice of increasing incidence. This act carries the highest risk of HIV transmission and acquisition; and data suggest HIV disease burden is higher among ethnic minorities. Serosorting-purposely seeking HIV serocordant partners--to help lower risk of HIV infection is common. While this can be a positive step in preventing the spread of HIV, it carries serious threats that must be acknowledged. The purpose of this article was to explore the positive and negative aspects of serosorting in the prevention of HIV, describe ways in which health care providers can approach the topic with clients, provide clinical practice implications, and suggest some direction for future research.