From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection

A global meta-analysis of gonorrhoea and chlamydia prevalence among men who have sex with men from 2000 to 2022

IntroductionWe conducted a global systematic review and meta-analysis of gonorrhoea and chlamydia among men who have sex with men (MSM) from 2000 to 2022.MethodsWe searched four databases to identify studies conducted between 1 January 2000 and 19 April 2022 that reported prevalence from aetiological assays. We extracted data, calculated point estimates, corrected and then pooled them using random-effects models. We stratified results by United Nations regions and conducted subgroup analyses established apriori.Results172 studies met our inclusion criteria, providing 387 prevalence data points from 57 countries. The overall pooled prevalence for gonorrhoea was 7.2% [95% CI: 6.0 to 8.5; 188 data points; n = 347,253] and for chlamydia was 9.9% (95% CI: 8.8 to 11.0; 190 data points; n = 342,799). For gonorrhoea, pooled prevalence between 2000 and 2010 was 5.0% (95% CI: 3.7 to 6.5; 89 data points; n = 78,557) compared to 9.3% (7.7-11.1; 99 data points; n = 268,696) between 2011 and 2022, p < 0.001. For chlamydia, pooled prevalence between 2000 to 2010 was 6.6% (95% CI: 5.4 to 7.9; 95 data points; n = 91,015) compared to 13.6% (12.0-15.2; 95 data points; n = 251,784) between 2011 and 2022, p < 0.001.ConclusionA holistic approach is needed to reduce the curable STIs burden among MSM.

Genetic characterization of Haemophilus ducreyi from non-genital skin lesions in Cameroon

BACKGROUND

Haemophilus ducreyi, traditionally recognized as the etiological agent of chancroid, a genital ulcer disease, is increasingly being identified as a significant cause of cutaneous ulcers in yaws-endemic regions across the South Pacific, Southeast Asia, and Sub-Saharan Africa. Despite its clinical relevance, this pathogen remains poorly characterized, and comprehensive genetic tools for analyzing isolate relationships are still lacking.

METHODS

In this study, we present a follow-up of our previous research and developed a multilocus sequence typing (MLST) approach based on six of the seven loci from the Haemophilus influenzae MLST scheme and applied it to 82 primary clinical samples, previously confirmed to contain H. ducreyi, without culture. We also performed whole-genome sequencing (WGS) and antibiotic susceptibility testing on four cultured isolates obtained from cutaneous ulcers in yaws endemic health districts of Cameroon.

RESULTS

Antibiotic susceptibility testing of H. ducreyi cultured isolates revealed sensitivity to all tested antibiotics, including ceftriaxone, azithromycin, and ciprofloxacin. MLST analysis, using data extracted from WGS and directly from clinical samples, identified 38 complete profiles across the six loci (34 from direct samples and four from cultured isolates), identifying 14 distinct sequence types (STs). BURST analysis of the six MLST genes grouped the STs into two distinct clonal complexes. An additional, polymorphism was observed in the ftsI gene, which encodes the penicillin-binding protein 3.

CONCLUSIONS

This study highlights the need for genetic typing of H. ducreyi strains circulating in the yaws-endemic regions of Cameroon. The developed MLST scheme offered effective strain discrimination and provided valuable insights into their genetic relationships in these areas.

Enhanced Chlamydia trachomatis and Neisseria gonorrhoeae Sexually Transmitted Infections and Associated Risk Factors in Fiji Following the Coronavirus Disease 2019 Pandemic

Background

The coronavirus disease 2019 pandemic impact on sexually transmitted infections in countries practicing syndromic management remains unknown. We conducted cross-sectional surveys in Fiji to assess increases and risk factors for Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) infections pre- and postpandemic.

Methods

We enrolled women, men who have sex only with women (MSW), and men who have sex with men (MSM) aged 18-40 years, collected sociodemographic/behavioral data, and tested vaginal, urethral, and rectal samples using Xpert-CT/NG. Risk factors were evaluated using regression models.

Results

Of 1955 participants, 6.4% (95% confidence interval [CI], 5.4%-7.6%) had gonorrhea, increasing significantly postpandemic >2-fold among women aged 25-40 years and >4-fold among MSM, MSW, and men aged 18-24 and 25-40 years; 20.0% (95% CI, 18.3%-21.8%) had chlamydia, increasing significantly postpandemic among younger women and approximately 2- to 4-fold among MSW and younger and older men. Increases were driven by urethral/vaginal infections. Coinfections increased significantly postpandemic among older women. Postpandemic gonorrhea was associated with difficulty obtaining condoms (adjusted relative risk [aRR], 2.7 [95% CI, 1.0-8.0]) and ≥2 partners (aRR, 2.6 [95% CI, 1.0-7.1]) among younger women, and iTaukei ethnicity (aRR, 4.7 [95% CI, 1.4-16.5]) and heavy alcohol use (aRR, 7.1 [95% CI, 2.5-19.7]) among older women. Postpandemic chlamydia was associated with having a casual sex partner among younger (aRR, 1.7 [95% CI, 1.0-2.9]) and older (aRR, 1.9 [95% CI, 1.1-3.4]) women and with being unmarried (aRR, 1.7 [95% CI, 1.0-2.7]). iTaukei men had increased risk postpandemic for gonorrhea (aRR, 3.7 [95% CI, 1.3-10.6]) and chlamydia (aRR, 2.5 [95% CI, 1.3-4.9]). More than 50% of infected participants did not meet syndromic treatment criteria and would have remained untreated.

Conclusions

Postpandemic increases in gonorrhea and chlamydia-with risk factors varying by pathogen, gender, and age-require immediate interventions to reduce infection and transmission in Fiji.

Gonorrhea and Early Syphilis Treatment Practices Among Community Health Care Providers in Baltimore City, Maryland

BACKGROUND

Ensuring patients receive appropriate (Centers for Disease Control and Prevention-recommended) and prompt (≤14 days of specimen collection) treatment is critical to decrease gonorrhea and early syphilis (ES) incidence. The objectives were to (1) quantify treatment performance among community health care providers (CHPs), (2) compare CHP treatment performance to local health department goals, and (3) describe variation in treatment performance by CHP characteristics in Baltimore City, Maryland.

METHODS

Surveillance data for gonorrhea and ES diagnoses reported between January 2018 and December 2019 were used. Treatment performance measures were calculated for each CHP (gonorrhea: 171 CHPs; ES: 122 CHPs). Measures were (1) percent treated among all diagnoses (goal: ≥90%), (2) percent appropriately treated among diagnoses treated (goal: ≥90% gonorrhea, ≥95% ES), and (3) percent promptly treated among diagnoses appropriately treated (goal: ≥85%). Treatment performance measures and achievement of goals were compared across CHP characteristics.

RESULTS

For gonorrhea, median percent treated, appropriately treated, and promptly treated were 71.4%, 95.0%, and 100.0%, respectively; 29.8% met treated goals. The majority achieved appropriately treated (62.9%) and promptly treated (76.8%) goals. Community health care practices reporting high (vs. low) volume of gonorrhea diagnoses less frequently achieved percent-treated goals (12.2% vs. 35.4%, P = 0.008). Median value for all ES treatment performance measures was 100.0%. Most achieved treated (90.2%) and appropriately treated (95.9%) goals. Less than half (49.2%) achieved the promptly treated goal. Community health care practices reporting high (vs. low) volumes of ES less frequently achieved promptly treated goals (33.3% vs. 54.4%, P = 0.045).

CONCLUSIONS

Substantial gaps in reporting gonorrhea treatment and prompt ES treatment were observed. Practice-level interventions to facilitate reporting gonorrhea treatment and provide prompt ES treatment are needed.

DoxyPEP Implementation Preferences for Bacterial STD Prevention Among Gay, Bisexual, and Other Men Who Have Sex with Men Living With and Without HIV in Los Angeles: A Mixed-Methods Approach

Bacterial sexually transmitted diseases (STDs) remain prominent in the United States among gay, bisexual, and other men who have sex with men (GBMSM). Doxycycline for post-exposure prophylaxis (DoxyPEP) is a regimen by which the antibiotic doxycycline is taken after sex to prevent bacterial STDs, such as, chlamydia, gonorrhea, and syphilis. Despite this, this study was conducted because there are a limited number of publications that describe GBMSM's knowledge of, and interest in, taking DoxyPEP and preferences regarding its implementation. We conducted a mixed-methods study between November 2023 and March 2024. Participants (N = 21) completed a semi-structured interview and survey and were eligible if they were a cisgender man who reported having anal sex with another man in the past year and lived in the greater Los Angeles area. Interviews were recorded and transcribed and were analyzed using thematic content analysis. The majority of participants identified as gay (90%) and a racial/ethnic minority (86%); 33% were living with HIV and 43% had been diagnosed with an STD in the prior year. Participants' mean age was 40 years (standard deviation [SD] = 15) and they reported an average of 4.5 (SD = 2.27) sexual partners in the past year. Interviews revealed that knowledge of DoxyPEP was low (28%), but most (81%) were interested in using DoxyPEP after learning about its potential. The vast majority were willing to pay $10-$20 for a 1-month supply but preferred that it be free or covered by insurance. Most preferred to get DoxyPEP from a medical provider or over-the-counter at a pharmacy. Others suggested sexualized venues, such as private sex parties, bathhouses, sex clubs, etc. The greatest concerns about its use included possible side effects, antibiotic resistance, or that it would lead to decreased condom use and increased number of sex partners. A common misconception was that DoxyPEP could prevent both a bacterial STD and HIV. DoxyPEP has strong potential as a widely accepted STD prevention method, but its successful adoption will require proactive strategies to increase GBMSM's knowledge. Implementation programs might consider nontraditional venues where sex between men is regularly occurring.

Immunization Against Chlamydia trachomatis Polymorphic Membrane Protein D Tetrapeptide Motifs Limits Early Female Reproductive Tract Infection in a Mouse Model

Background/Objectives: Chlamydia trachomatis (Ct) is a common pathogen causing urogenital, anal, oral, and ocular infections. Although extensive vaccine efforts have been underway for decades, there is no licensed vaccine available to prevent human Ct infection. Polymorphic membrane protein D (PmpD) is a highly conserved protein present on the surface of Ct elementary bodies, suggesting an important role Ct biology. Repetitive tetrapeptide motifs GGA(I,L,V) and FxxN are conserved across Pmps and are important for adhesion in the related Chlamydia pneumoniae Pmp21. Methods: Using bioinformatics approaches, we identified amino acids 270 to 294 of PmpD that included two GGA(I,L,V) motifs and an FxxN motif as vaccine targets. Synthetic peptides corresponding to these regions were chemically conjugated separately via the carboxy (C)- or amino (N)-terminus (FxxN 1.1 and FxxN 1.2) to the surface of Qβ virus-like particles (VLPs) and were tested for immunogenicity and protective capacity in mice. Results: Female mice immunized three times with a mixture of Qβ-FxxN 1.1 and Qβ-FxxN 1.2 vaccines without exogenous adjuvant elicited geometric-mean endpoint dilution titers near 104. Further, mice showed decreased infection at early time points when challenged vaginally with luciferase-expressing Chlamydia muridarum over 9 days and a faster time to undetectable infection compared to controls. Immunization with individual vaccines (Qβ-FxxN 1.1 or Qβ-FxxN 1.2) did not show the same degree of reduction. Conclusions: Vaccination against PmpD tetrapeptide motifs is a novel and promising approach for limiting initial Chlamydia infection and warrants further investigation to characterize the mechanism of protection.

Peer Education Intervention Reduced Sexually Transmitted Infections Among Male Tajik Labor Migrants Who Inject Drugs: Results of a Cluster-randomized Controlled Trial

Background

In a cluster-randomized controlled trial, the "Migrants' Approached Self-Learning Intervention in HIV/AIDS for Tajiks" (MASLIHAT) reduced intervention participants' sexual risk behaviour including any condomless sex, condomless sex with female sex workers, and multiple sexual partners. This analysis investigates if observed changes in sexual risk behaviors translated into fewer reported STIs among participants over 12-month follow-up.

Methods

The MASLIHAT intervention was tested in a cluster-randomized controlled trial with sites assigned to either the MASLIHAT intervention or comparison health education training (TANSIHAT). Participants and network members (n=420) were interviewed at baseline and 3-month intervals for one year to assess HIV/STI sex and drug risk behaviour. We conducted mixed effects robust Poisson regression analyses to test for differences between conditions in self-reported STIs during 12 months of follow-up, and to test the contribution of sexual risk behaviours to STI acquisition. We then tested the mediating effects of sexual behaviours during the first six months following the intervention on STIs reported at the 9 and 12-month follow-up interviews.

Results

Participants in the MASLIHAT condition were significantly less likely to report an STI during follow-up (IRR=0.27, 95% CI 0.13-0.58). Condomless sex with a non-main (casual or commercial) partner was significantly associated with STI acquisition (IRR=2.30, 95% CI 1.26-4.21). Adjusting for condomless sex with a non-main partner, the effect of MASLIHAT intervention participation was reduced (IRR=0.36, 95% CI 0.16-0.80), signalling possible mediation. Causal mediation analysis indicated that the intervention's effect on reported STI was partially mediated by reductions among MASLIHAT participants in condomless sex with a non-main partner.

Conclusions

The MASLIHAT peer-education intervention reduced reported STIs among Tajik labour migrants partly through reduced condomless sex with casual and commercial partners.

Clinical trial registration

ClinicalTrials.gov, 2021-04-16, NCT04853394.

Prevalence of human papilloma virus infection and anal dysplasia among men with HIV in Lebanon: a cross-sectional study

BACKGROUND

Oncogenic human papillomavirus (HPV) types are linked to anal cancer, with elevated risk among men who have sex with men (MSM), especially men with HIV. Data on HPV-related malignancies in the Middle East and North Africa (MENA) region is scarce. This study aims to assess anal HPV strains, dysplasia, and sexually transmitted infections (STIs) among asymptomatic MSM with HIV in Lebanon.

METHODS

We conducted a cross-sectional study with 38 participants who completed questionnaires on socio-demographics, HIV-related data, and STI history. Anoscopy, anal Pap smears, and PCR for HPV and STIs were performed.

RESULTS

HPV was detected in 34 of 38 samples (89%), with 91% having multiple strains. HPV16 was the most common strain (56%). Eighteen percent had a concomitant bacterial anal STI. Most participants lacked awareness of anal dysplasia and cancer risk, with only 29% vaccinated against HPV.

CONCLUSION

This study highlights high HPV prevalence and low awareness among men with HIV in Lebanon. The findings underscore the need for improved HPV education, vaccination, and routine screening in this population. Further research is needed to address barriers to comprehensive HIV and STI care in the region.

Risk factors for curable sexually transmitted infections among youth: findings from the STICH population survey in Zimbabwe

OBJECTIVES

Youth are at high risk of sexually transmitted infections (STIs) in Africa. We aimed to determine the risk factors for curable STIs in youth in Zimbabwe.

METHODS

A population-based survey was conducted among randomly selected 18-24 year-olds in 16 communities across two provinces in Zimbabwe to ascertain outcomes for a cluster randomised trial investigating the impact of community-based STI screening for youth on population prevalence of STIs. Participants underwent an interviewer-administered questionnaire, HIV testing and screening for Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and Trichomonas vaginalis (TV). Risk factors for curable STIs were explored through multivariable logistic regression.

RESULTS

Of the 5601 participants, 62.5% (n=3500) were female, and the median age was 20 (IQR 19-22) years. HIV prevalence was 6.3% (351/5556), and 55.4% (1939/3501) reported condomless sex at last intercourse. Only 7.2% (401/5599) reported STI symptoms, but CT/NG/TV prevalence was 19.8% (1107/5601). On multivariable analysis, factors associated with STI diagnosis included being aged 21-24 years (adjusted OR (aOR) 1.37, 95% CI 1.17 to 1.61); female sex (aOR 2.11, 95% CI 1.76 to 2.53); being unemployed/informally employed (compared with in education/formal employment) (aOR 1.35, 95% CI 1.13 to 1.61); increasing number of sexual partners in the preceding 12 months (one partner: aOR 2.23, 95% CI 1.73 to 2.88; two partners: aOR 2.39, 95% CI 1.69 to 3.39); living with HIV (aOR 1.44, 95% CI 1.07 to 1.94); and previous attempted suicide (aOR 1.58, 95% CI 1.08 to 2.32).

CONCLUSIONS

The prevalence of STIs among youth in Zimbabwe is high, particularly among those with HIV. In addition to moving away from syndromic STI management and strengthening implementation of existing prevention tools, there is a need for a more holistic focus on broader risk factors such as mental health and employment opportunities, and of integration of HIV and STI programming.

TRIAL REGISTRATION NUMBER

ISRCTN15013425, NCT03719521.

The effect of protecting women against economic shocks to fight HIV in Cameroon, Africa: The POWER randomised controlled trial

BACKGROUND

Women in sub-Saharan Africa are disproportionately affected by the HIV epidemic. Young women are twice as likely to be living with HIV as men of the same age and account for 64% of new HIV infections among young people. Many studies suggest that financial needs, alongside biological susceptibility, are a leading cause of the gender disparity in HIV acquisition. New robust evidence suggests women adopt risky sexual behaviours to cope with economic shocks, the sudden decreases in household's income or consumption power, enhancing our understanding of the link between poverty and HIV. We investigated if health insurance protects against economic shocks, reducing the need for vulnerable women to engage in risky sexual behaviours and reducing HIV and sexually transmitted infection (STI) incidence.

METHOD AND FINDINGS

We conducted a randomised controlled trial to test the effectiveness of a formal shock coping strategy to prevent HIV among women at high risk of HIV (registration number: ISRCTN 22516548). Between June and August 2021, we recruited 1,508 adolescent girls and women over age 15 years who were involved in transactional sex (n = 753) or commercial sex (n = 755), using snowball sampling. Participants were randomly assigned (1:1) to receive free health insurance for themselves and their economic dependents for 12 months either at the beginning of the study (intervention; n = 579; commercial sex n = 289, transactional sex n = 290) from November 2021 or at the end of the study 12 months later (control; n = 568; commercial sex n = 290, transactional sex n = 278). We collected data on socioeconomic characteristics of participants. Primary outcomes included incidence of HIV and STIs and were measured at baseline, 6 months after randomisation, and 12 months after randomisation. We found that study participants who engaged in transactional sex and were assigned to the intervention group were less likely to become infected with HIV post-intervention (combined result of 6 months post-intervention or 12 months post-intervention, depending on the follow-up data available; odds ratio (OR) = 0.109 (95% confidence interval (CI) [0.014, 0.870]); p = 0.036). There was no evidence of a reduction in HIV incidence among women and girls involved in commercial sex. There was also no effect on STI acquisition among both strata of high-risk sexual activity. The main limitations of this study were the challenges of collecting reliable STI incidence data and the low incidence of HIV in women and girls involved in commercial sex, which might have prevented detection of study effects.

CONCLUSION

The study provides to our knowledge the first evidence of the effectiveness of a formal shock coping strategy for HIV prevention among women who engage in transactional sex in Africa, reinforcing the importance of structural interventions to prevent HIV.

TRIAL REGISTRATION

The trial was registered with the ISRCTN Registry: ISRCTN 22516548. Registered on 31 July 2021.

Predictors of PrEP Retention and Attrition in an Urban Publicly Funded Safety-net Specialty Clinic

Pre-exposure prophylaxis (PrEP) is an effective tool for human immunodeficiency virus (HIV) prevention. The purpose of this study is to identify correlates of PrEP retention using patient data from an urban, publicly funded safety-net clinic in Washington, DC. Cox proportional hazards regression, logistical regression, and survival curves were used to assess the association of age, gender, race/ethnicity, insurance, number of partners, and sexually transmitted infection (STI) diagnosis at PrEP initiation with time on PrEP. From August 2016-December 2020, 1,126 people were prescribed PrEP - patients were mostly Black (44.8%) or Latinx (30.4%) and identified as cisgender men (84.6%). Half had no insurance (49.1%), with the remaining patients reporting private (28.9%) or public (21.5%) insurance. Age at PrEP prescription ranged from 15 to 66 with 80% being 20 to 39 years. For the 87.7% (n = 987) of patients who discontinued PrEP, mean PrEP time was 158 days and median was 28 days. The highest rates of discontinuation were observed within the first month with 44.3% discontinuing by day 30, 52.3% by 3 months, and 73.2% by 1 year. Cisgender women, transgender persons, and those younger than 30 years were more likely to discontinue PrEP. Latinx and patients with less than 3 male partners in the last 90 days were less likely to discontinue PrEP. We demonstrated a high level of PrEP uptake among populations disproportionally affected by HIV. Future analyses are needed to examine ways of reducing barriers to PrEP initiation and improving PrEP adherence.

Demonstrating service delivery models for effective initiation and retention on pre-exposure prophylaxis (PrEP) among female bar workers in Dar es Salaam, Tanzania: A double randomized intervention study protocol

BACKGROUND

Pre-Exposure Prophylaxis (PrEP) has demonstrated efficacy in preventing HIV infection. Female Bar Workers (FBWs) often act as informal sex workers, placing them at risk of HIV infection. Despite expressing interest in PrEP, FBWs face barriers to accessing public-sector clinics where PrEP is delivered. We developed a study to compare the effectiveness of workplace-based PrEP provision to standard-of-care facility-based provision for PrEP initiation, retention and adherence among FBWs.

METHODS

In this double-randomized intervention study, FBWs aged 15 years and above will be screened, consented and initiated on PrEP (emtricitabine/tenofovir disoproxil), and followed for six months. Participants will be randomized at the bar level and offered PrEP at their workplace or at a health facility. Those who are initiated will be independently individually randomized to either receive or not receive an omni-channel PrEP champion intervention (support from an experienced PrEP user) to improve PrEP adherence. We expect to screen 1,205 FBWs to enroll at least 160 HIV negative women in the study. Follow-up visits will be scheduled monthly. HIV testing will be performed at baseline, month 1, 4 and 6; and TDF testing at months 2 and 6. Primary outcomes for this trial are: (1) initiation on PrEP (proportion of those offered PrEP directly observed to initiate PrEP); and (2) adherence to PrEP (detectable urine TDF drug level at 6-months post-enrollment). The primary outcomes will be analyzed using Intention-to-Treat (ITT) analyses.

DISCUSSION

Using a randomized trial design, we will evaluate two interventions aiming to reduce barriers to uptake and retention on PrEP among FBWs, a vulnerable population at risk of HIV acquisition and onward transmission. If these interventions prove effective in promoting PrEP among FBWs, they could assist in abating the HIV epidemic in Africa.

TRIAL REGISTRATION

Registered with German Clinical Trials Register (www.drks.de) on 29 April 2020; Registration number DRKS00018101.

The Prevalence of Sexually Transmitted Infections among Male Patients at a Dermato-Venereology Outpatient Clinic in Gdańsk, Poland: Findings from a Single-Center Study

Background: Sexually transmitted infections (STIs) are a significant public health concern worldwide, yet data on their prevalence and epidemiology, particularly in Central and Eastern Europe, remain scarce. This study aimed to assess the prevalence, anatomical localization, symptomatic/asymptomatic course, and co-infection patterns of STIs among men. Methods: This retrospective study analyzed data collected between May 2021 and July 2023, including sociodemographic, sexual behavior, and clinical data from 139 male participants. Molecular polymerase chain reaction (PCR) tests were conducted for Neisseria gonorrhoeae (NG), Chlamydia trachomatis (CT), Mycoplasma genitalium, and Trichomonas vaginalis. Results: Of the participants, 36% tested positive for at least one STI, with the urethra being the most common site of infection. NG and CT were the most prevalent infections. The majority of infections were asymptomatic, highlighting the importance of comprehensive screening, especially in high-risk populations like men who have sex with men (MSM). Conclusions: This study emphasizes the need for targeted screening strategies, particularly for extragenital STIs, and underscores the role of MSM in STI epidemiology. The findings highlight the importance of routine screening, even for asymptomatic individuals, to effectively control STI spread. Future research should validate and expand upon these findings to enhance STI prevention and management efforts.

Relative Cost and Infectious Days Averted Associated With Rapid Gonorrhea and Chlamydia Testing Among Men Who Have Sex With Men

BACKGROUND

Standard-of-care nucleic acid amplification tests (routine NAATs) for Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) can take several days to result and therefore delay treatment. Rapid point-of-care GC/CT NAAT (rapid NAAT) could reduce the time to treatment and therefore onward transmission. This study evaluated the incremental cost per infectious day averted and overall cost of implementation associated with rapid compared with routine NAAT.

METHODS

Prospective sexually transmitted infection (STI) treatment data from men who have sex with men and transgender women in San Diego who received rapid NAAT between November 2018 and February 2021 were evaluated. Historical time from testing to treatment for routine NAAT was abstracted from the literature. Costs per test for rapid and routine NAAT were calculated using a micro-costing approach. The incremental cost per infectious day averted comparing rapid to routine NAAT and the costs of rapid GC/CT NAAT implementation in San Diego Public Health STI clinics were calculated.

RESULTS

Overall, 2333 individuals underwent rapid NAAT with a median time from sample collection to treatment of 2 days compared with 7 to 14 days for routine NAAT equating to a reduction of 5 to 12 days. The cost of rapid and routine GC/CT NAAT was $57.86 and $18.38 per test, respectively, with a cost-effectiveness of between $2.43 and $5.82 per infectious day averted. The incremental cost of rapid NAAT improved when at least 2000 tests were performed annually.

CONCLUSIONS

Although rapid GC/CT NAAT is more expensive than routine testing, the reduction of infectious days between testing and treatment may reduce transmission and provide improved STI treatment services to patients.

Trends in chlamydia prevalence in the United States, 2005-2016

In the United States (US), chlamydia is the most frequently reported sexually transmitted infection that is nationally notifiable. We examined trends in chlamydia prevalence in the US in 2011-2016 compared with 2005-2010. Cross-sectional, nationally representative surveys, National Health and Nutrition Examination Surveys (NHANES), were used to compare national chlamydia prevalence estimates from 2011 to 2016 with those from 2005 to 2010, and changes in prevalence since 1999-2004 were also reviewed. Persons aged 18-39 years were included in these analyses. Prevalence of chlamydia was based on results from urine specimens. Results were weighted to represent the U.S. civilian, noninstitutionalized population. The baseline characteristics of the study population were similar in gender, age and race/ethnicity between the two groups (P > 0.05). The overall chlamydia prevalence was 1.88% (95% confidence interval [CI] 1.55-2.22%) in 2011-2016 and 1.57% (95% CI 1.27-1.87%) in 2005-2010, a relative increase of 19.7% (95% CI 0.2-39.2%; P < 0.05) between the two surveys. Increases in chlamydia prevalence was especially concentrated in persons who were male, aged 18 to 29 years, had > high school educational level, never married, age at first sex < 18 years, had 2-5 sexual partners in lifetime and had no past sexually transmitted diagnosis between 2005 and 2016 (P < 0.05). Multivariable logistic regression analysis demonstrated that chlamydia was more prevalent in those aged 18-29 years, being non-Hispanic Blacks, had high school educational level, being widowed/divorced/separated and had > 5 sexual partners. The chlamydia prevalence had an increasing trend from 2005-2010 to 2011-2016. Those with high chlamydia prevalence such as sexually active young adults and Non-Hispanic Black should be screened annually so that infected persons can be diagnosed and they and their sex partners can be treated promptly.

Communicable Disease Screening and Human Immunodeficiency Virus Prevention in the Emergency Department

Emergency departments (ED) provide care to populations with high rates of communicable diseases, like HIV, hepatitis C virus, and syphilis. For many patients, the ED is their sole entry point into the healthcare system and they do not routinely access screening and prevention services elsewhere. As such, the ED can serve an important public health role through communicable disease identification, treatment, and prevention. In this article, we examine national recommendations, peer-reviewed literature, and expert consensus to provide cutting edge strategies for implementing communicable infectious disease screening and prevention programs into routine ED care.

Clinical Decision Support System for Guidelines-Based Treatment of Gonococcal Infections, Screening for HIV, and Prescription of Pre-Exposure Prophylaxis: Design and Implementation Study

BACKGROUND

The syndemic nature of gonococcal infections and HIV provides an opportunity to develop a synergistic intervention tool that could address the need for adequate treatment for gonorrhea, screen for HIV infections, and offer pre-exposure prophylaxis (PrEP) for persons who meet the criteria. By leveraging information available on electronic health records, a clinical decision support (CDS) system tool could fulfill this need and improve adherence to Centers for Disease Control and Prevention (CDC) treatment and screening guidelines for gonorrhea, HIV, and PrEP.

OBJECTIVE

The goal of this study was to translate portions of CDC treatment guidelines for gonorrhea and relevant portions of HIV screening and prescribing PrEP that stem from a diagnosis of gonorrhea as an electronic health record-based CDS intervention. We also assessed whether this CDS solution worked in real-world clinic.

METHODS

We developed 4 tools for this CDS intervention: a form for capturing sexual history information (SmartForm), rule-based alerts (best practice advisory), an enhanced sexually transmitted infection (STI) order set (SmartSet), and a documentation template (SmartText). A mixed methods pre-post design was used to measure the feasibility, use, and usability of the CDS solution. The study period was 12 weeks with a baseline patient sample of 12 weeks immediately prior to the intervention period for comparison. While the entire clinic had access to the CDS solution, we focused on a subset of clinicians who frequently engage in the screening and treatment of STIs within the clinical site under the name "X-Clinic." We measured the use of the CDS solution within the population of patients who had either a confirmed gonococcal infection or an STI-related chief complaint. We conducted 4 midpoint surveys and 3 key informant interviews to quantify perception and impact of the CDS solution and solicit suggestions for potential future enhancements. The findings from qualitative data were determined using a combination of explorative and comparative analysis. Statistical analysis was conducted to compare the differences between patient populations in the baseline and intervention periods.

RESULTS

Within the X-Clinic, the CDS alerted clinicians (as a best practice advisory) in one-tenth (348/3451, 10.08%) of clinical encounters. These 348 encounters represented 300 patients; SmartForms were opened for half of these patients (157/300, 52.33%) and was completed for most for them (147/300, 89.81%). STI test orders (SmartSet) were initiated by clinical providers in half of those patients (162/300, 54%). HIV screening was performed during about half of those patient encounters (191/348, 54.89%).

CONCLUSIONS

We successfully built and implemented multiple CDC treatment and screening guidelines into a single cohesive CDS solution. The CDS solution was integrated into the clinical workflow and had a high rate of use.

Changes in Inflammatory Cytokine Levels in Rectal Mucosa Associated With Neisseria gonorrheae and/or Chlamydia trachomatis Infection and Treatment Among Men Who Have Sex With Men in Lima, Peru

BACKGROUND

Neisseria gonorrheae and Chlamydia trachomatis are associated with mucosal inflammation and human immunodeficiency virus 1 (HIV-1) transmission. We assessed levels of inflammatory cytokines in men who have sex with men (MSM) with and without rectal gonorrhea and/or chlamydia in Lima, Peru.

METHODS

We screened 605 MSM reporting condomless receptive anal intercourse for rectal N. gonorrheae/C. trachomatis using nucleic acid testing. We identified 101 cases of gonorrhea and/or chlamydia and randomly selected 50 N. gonorrheae/C. trachomatis positive cases and matched 52 negative controls. We measured levels of IL-1β, IL-6, IL-8, and TNF-α in rectal secretions. Tests for HIV-1, rectal N. gonorrheae/C. trachomatis, and mucosal cytokines were repeated after 3 and 6 months. Cytokine levels in cases and uninfected controls were compared using Wilcoxon rank-sum tests and linear regression.

RESULTS

MSM with gonorrhea/chlamydia had elevated levels of all cytokines in rectal mucosa compared with matched controls (all P values <.001). Following antibiotic treatment there were no significant differences in cytokine levels at 3- or 6-month follow-up evaluations (all P values >.05).

DISCUSSION

Rectal gonorrhea/chlamydia infection is associated with transient mucosal inflammation and cytokine recruitment. Our data provide proof of concept for rectal sexually transmitted infection screening as an HIV prevention strategy for MSM. Clinical Trials Registration. NCT03010020.

The global burden of sexually transmitted infections

Understanding the global burden of sexually transmitted infections (STIs) is fundamental to being able to address and control these infections and the health harms they cause. The World Health Organization has renewed its global health sector strategy for the prevention and control of STIs. Reducing STIs remains an integral part of HIV prevention and of sexual and reproductive health programs. Data to measure and describe the global burden continue to improve, with systematic reviews and modeling providing global and regional data for the major STIs. Although substantial gaps remain, as many countries have limited data, the measures available demonstrate the scale of the problem for the main curable STIs, gonorrhea, chlamydia, syphilis, and trichomoniasis; the most common viral STIs, human papillomavirus and genital herpes; the interrelation between STIs and HIV; and the substantially unequal burden of these infections globally and among key populations. Regional and global trends in these infections are affected by population changes; the impact and availability of interventions, such as vaccination; changing behaviors that alter the dynamics of STI transmission; and the role of international travel in promulgating STIs in an increasingly interconnected world.

Clinic-based evaluation of the dual Xpert CT/NG assay on the GeneXpert System for screening for extragenital chlamydial and gonococcal infections amongst men who have sex with men

BACKGROUND

Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections have increased globally. Asymptomatic infections represent a significant risk of long-term complications. Men who have sex with men (MSM) are disproportionally affected, underscoring the need to offer screening programmes to this population. CT/NG Point of Care Testing (POCT) constitutes a strategic tool to improve the continuum of STI care, however extensive real-life evaluations amongst at risk populations are lacking. The aim of this study is to estimate the GeneXpert CT/NG assay performance and usability for CT and NG at genital and extragenital sites for screening amongst MSM.

METHODS

This study was a multi-site sexual health clinic-based evaluation (Italy, Malta and Peru) with consecutive enrolment. A first void urine sample (divided in two aliquots), two oropharyngeal and two anorectal swabs were collected for each study participant. One specimen set (one for each anatomical site) was tested with the dual index test (Cepheid) at the clinics by the healthcare staff, the other set with FDA/CE approved Nucleic Acid Amplification Tests (NAATs) at the laboratory. Clinical sites and reference laboratories participated in an internal and external quality control programme. Sensitivity, specificity, positive and negative likelihood ratios, positive and negative predictive values for each anatomical site were estimated using a meta-analytic approach.

RESULTS

One thousand seven hundred two MSM were recruited across all clinical sites for a total of 5049 biological specimens. NG and CT were respectively detected in 274 and 287 of samples. Overall, the NG POCT sensitivity and specificity was 91.43% and 99.75% in urine (LR + 372.80, LR- 0.09), 89.68% and 99.55% in rectal specimens (LR + 197.30, LR- 0.10) and 75.87% and 98.77% at the pharynx respectively (LR + 61.94, LR- 0.24). The CT component of the POCT sensitivity was 84.82% and specificity 99.63% in urine (LR + 228.68, LR- 0.15), 78.07% and 99.19% respectively on rectal site (LR + 96.23, LR-0.22), 67.79% and 99.88% respectively at pharyngeal site (LR + 554.89, LR- 0.32). 95.95% of MSM reported to be willing to wait for POCT results and no provider reported difficulties in terms of performance or interpretation of the results of the Xpert CT/NG.

CONCLUSION

Rapid turnaround time, ease of use and high acceptability make the Xpert CT/NG testing system a strategic tool for increasing testing frequency, reaching those not yet tested and offering the possibility of immediate treatment if needed. The assay showed good negative likelihood ratios and confirms its use to rule out CT/NG infections. Sensitivity varied across sites and pathogens. Periodic staff training at the testing sites should be mandatory.

Clinical and immunological characteristics of HIV/syphilis co-infected patients following long-term antiretroviral treatment

Objective

This study aims to analyze the efficacy of anti-syphilis treatment and the impact of syphilis events on HIV virology and immunology in HIV/syphilis co-infected patients on long-term antiretroviral therapy (ART) and to investigate the incidence and factors of syphilis recurrence/re-infection/serofast state. The insights derived from this investigation can potentially guide strategies for preventing and managing syphilis and AIDS.

Methods

A retrospective case-control study was conducted at the AIDS clinic of Peking Union Medical College Hospital from January 2003 to December 2022. The study involved 86 HIV/syphilis co-infected patients and 86 HIV mono-infected patients matched based on age, baseline CD4 + T cell counts, and viral load. We examined the clinical characteristics of HIV/syphilis co-infected patients, evaluated the efficacy of anti-syphilis treatment, and analyzed the dynamic changes in HIV virology and immunology. The Generalized Estimating Equations (GEE) model investigated the factors associated with HIV/syphilis co-infection and syphilis recurrence/reinfection/serofast state.

Results

Syphilis serofast state was observed in 11.6% (10/86) of HIV/syphilis co-infected patients after treatment, and 33.7% (29/86) had syphilis recurrence or re-infection. The overall effectiveness of syphilis treatment stood at 76.8% (63/82). Notably, the effectiveness of syphilis treatment displayed a significant correlation with baseline syphilis titers exceeding 1:128 (p = 0.003). Over the 10-year follow-up period on ART, the HLA-DR + CD8+/CD8 + % levels in the HIV/syphilis co-infected group were markedly higher than those in the HIV mono-infected group (p < 0.05). However, no significant differences were observed between the two groups regarding HIV viral load, CD4+ T cell counts, CD8+ T cell counts, CD4/CD8 ratio, and CD38 + CD8+/CD8 + % (p > 0.05). GEE analysis model revealed that elevated HLA-DR + CD8+/CD8 + % levels were associated with HIV/syphilis co-infection (OR = 1.026, 95% CI = 1.007-1.046; p = 0.007) and syphilis recurrence/reinfection/serofast state (OR = 1.036, 95% CI = 1.008-1.065; p = 0.012).

Conclusion

While HIV/syphilis co-infected patients typically receive adequate treatment, the incidence of syphilis recurrence and reinfection remain notably elevated. A heightened HLA-DR + CD8+/CD8+ % is a notable risk factor for HIV/syphilis co-infection and syphilis recurrence/reinfection/serofast state. Therefore, it is advisable to reinforce health education efforts and ensure regular follow-ups for people living with HIV undergoing ART to monitor syphilis infection or increased risk of syphilis infection.

Neurological manifestations of syphilis-HIV coinfection in South Africa

OBJECTIVE

Syphilis and HIV coinfection is highly prevalent in South Africa, and both can cause neurological complications. We describe the clinical presentation and outcome of neurosyphilis in patients with and without HIV coinfection diagnosed at a tertiary facility, Groote Schuur Hospital (GSH), in South Africa.

METHODS

We retrospectively analyzed folders of adults with positive cerebrospinal fluid (CSF) fluorescent treponemal antibody absorption test in 2018 and 2019, with follow-up data collected until 2022.

RESULTS

HIV-coinfection was identified in 35% of the 69 included patients. Patients with HIV-coinfection were more likely to be female (58% vs 25% female, p < 0.01), and present earlier (median age = 31 years vs. 40 years, p < 0.001). Neuropsychiatric manifestations (confusion, dementia, psychosis), and strokes were the commonest clinical presentations in both groups. Those with HIV-coinfection were significantly less likely to be diagnosed with neurosyphilis by the treating clinician (71% vs. 91%, p < 0.05), as were those with a negative CSF Venereal Disease Research Laboratory (74% vs. 94%, p < 0.05). Accurate diagnosis of neurosyphilis was associated with an increased 12-month survival (alive: N = 36 [63%]) relative to those who did not receive an accurate diagnosis (alive: N = 2 [17%], p < 0.05). Those who were optimally treated with antibiotics had significantly higher 12-month survival (alive: N = 33, 63%) compared to those with suboptimal treatment (alive: N = 5, 29%), p < 0.01.

CONCLUSION

Neurosyphilis presented similarly in those with and without HIV-coinfection. Accurate identification and optimal antibiotic treatment of neurosyphilis, particularly in CSF VDRL negative patients and those with HIV-coinfection, is necessary to improve patient survival.

Development of a Tag/Catcher-mediated capsid virus-like particle vaccine presenting the conserved Neisseria gonorrhoeae SliC antigen that blocks human lysozyme

Virus-like particles (VLPs) are promising nanotools for the development of subunit vaccines due to high immunogenicity and safety. Herein, we explored the versatile and effective Tag/Catcher-AP205 capsid VLP (cVLP) vaccine platform to address the urgent need for the development of an effective and safe vaccine against gonorrhea. The benefits of this clinically validated cVLP platform include its ability to facilitate unidirectional, high-density display of complex/full-length antigens through an effective split-protein Tag/Catcher conjugation system. To assess this modular approach for making cVLP vaccines, we used a conserved surface lipoprotein, SliC, that contributes to the Neisseria gonorrhoeae defense against human lysozyme, as a model antigen. This protein was genetically fused at the N- or C-terminus to the small peptide Tag enabling their conjugation to AP205 cVLP, displaying the complementary Catcher. We determined that SliC with the N-terminal SpyTag, N-SliC, retained lysozyme-blocking activity and could be displayed at high density on cVLPs without causing aggregation. In mice, the N-SliC-VLP vaccines, adjuvanted with AddaVax or CpG, induced significantly higher antibody titers compared to controls. In contrast, similar vaccine formulations containing monomeric SliC were non-immunogenic. Accordingly, sera from N-SliC-VLP-immunized mice also had significantly higher human complement-dependent serum bactericidal activity. Furthermore, the N-SliC-VLP vaccines administered subcutaneously with an intranasal boost elicited systemic and vaginal IgG and IgA, whereas subcutaneous delivery alone failed to induce vaginal IgA. The N-SliC-VLP with CpG (10 µg/dose) induced the most significant increase in total serum IgG and IgG3 titers, vaginal IgG and IgA, and bactericidal antibodies.

Mapping Implementation Science with Expert Recommendations for Implementing Change (MIS-ERIC): Strategies to Improve PrEP Use among Black Cisgender Women Living in Mississippi

BACKGROUND

Black women are disproportionately affected by the HIV epidemic. Strategies to increase Black women's use of pre-exposure prophylaxis (PrEP) are needed.

METHODS

Interviews were conducted in Mississippi (MS) with Black, cisgender women at risk for HIV, and community healthcare clinic (CHC) staff who work directly with this population. Reflexive thematic analysis was used to identify barriers and select appropriate implementation strategies to increase PrEP care.

RESULTS

Twenty Black women and twelve CHC staff were interviewed. PrEP use barriers resulted from low HIV risk awareness, lack of PrEP knowledge, and structural and stigma-related barriers. Methods for PrEP education and motivation included normalizing PrEP in public communications, providing education at places where women congregate, and tailoring PrEP content with Black women as educators. The Expert Recommendations for Implementing Change (ERIC) project provides a way for implementation scientists to select strategies that are consistent within research and practice across studies. Strategies from the ERIC project were selected to address implementation barriers.

CONCLUSIONS

Tailoring PrEP implementation protocols to increase Black women's access, engagement, and adherence to PrEP is needed. This is one of the first implementation studies to incorporate these four implementation concepts into a single study: (1) implementation outcomes, (2) i-PARIHS, (3) ERIC's strategy list, and (4) operationalizing the strategies using the Proctor et al., guidelines. Results provide an in-depth comprehensive list of implementation strategies to increase PrEP uptake for Black women in MS.

High level of HIV viral suppression in a cross-sectional study of Ugandan men with urethritis and bacterial STI

BACKGROUND

Urethritis associated with non-viral sexually transmitted infections (STI) increases the risk of HIV acquisition and transmission in those living with HIV (LWH) without viral load suppression (VLS). Compared to women, men typically have lower rates of HIV VLS. We assessed the prevalence of VLS and drug resistance mutations in men LWH and urethral discharge syndrome (UDS) in Kampala, Uganda.

METHODS

Men with UDS were recruited in Kampala October 2019-November 2020. Medical, demographic, and behavioural data were collected with biological samples. All reactive HIV results (rapid, sequential algorithm) underwent confirmatory HIV antibody- and HIV incidence-testing, and viral load (VL) measurement. The pol and gp41 regions were sequenced on samples with VLs >1000 cpm, phylogenetic trees were generated, and resistance mutations were investigated.

RESULTS

50 of 250 participants (20%) had reactive HIV rapid tests and 48/50 (96%) were aware of their HIV status and using antiretroviral therapy (ART). The median age was 38 years (IQR 32-45), 27/50 (54%) had engaged in transactional sex, and 30/50 (60%) reported alcohol before sex. VLS was present in 46/50 (92%). There were no major resistance mutations present in any samples analyzed.

CONCLUSIONS

The prevalence of HIV and VLS was greater in these men than in the general Ugandan adult population. Most men LWH were on ART and thus less likely to transmit HIV despite demonstrating sexual behaviours associated with high-risk of STIs. These data emphasize that high levels of ART coverage and VLS are achievable among men with UDS in urban Kampala.

Utilizing Digital Health Technology to Increase Sexual Health Care Access: Youth Preferences on Self-Collect, Mail-In Sexually Transmitted Infection Testing in a High Sexually Transmitted Infection Prevalence Area

PURPOSE

The COVID-19 pandemic highlighted the need for innovative approaches to delivering care. Self-collect, mail-in sexually transmitted infection (STI) testing could address barriers to in-person STI testing, particularly for youth, who bear a disproportionate burden of STIs. This study sought to obtain youth input on the development of a free self-collect, mail-in STI testing program.

METHODS

Focus group discussions (n = 5, 45-60 minutes each) were conducted with 28 youth ages 14-19 years old living in Baltimore, Maryland. Focus group discussions were based on a conceptual framework of patient-centered health-care access, and a prototype online program was discussed. Transcribed data were coded thematically. Memos were written to synthesize findings and identify representative quotes.

RESULTS

Participants noted existing barriers to in-person STI testing barriers including individual-level (e.g., lack of knowledge), interpersonal-level (e.g., stigma), and structural-level (e.g., financial). Although participants expressed concerns about self-collect, mail-in STI testing (e.g., accuracy of self-swabbing), there was overall acceptance of the program, and many felt it would address current barriers to testing. Opportunities to improve the testing program included all four steps of testing process: kit ordering, receipt of the kit and swabbing, post-testing experience, and communication of results and treatment. Specifically, participants desired expanded shipping options to schools, and mail drop-off points such as lockers and local convenience stores; more transparency about testing and treatment; and hearing directly from health-care providers to assuage any concerns.

DISCUSSION

Self-collect, mail-in STI testing was favorable among youth, and could be a viable option for increasing youth access to STI testing.

Prevalence and risk factors associated with Haemophilus ducreyi cutaneous ulcers in Cameroon

Epidemics of yaws-like cutaneous ulcers are regularly documented in children in the tropics. They occur mainly in poor and remote communities without access to health facilities. The integration of molecular tools into yaws control efforts has made it possible to describe Haemophilus ducreyi (HD) as a major cause of cutaneous ulcers. The objective of this study was to determine the prevalence of HD as cause of cutaneous ulcers, investigate its presence in asymptomatic individuals and identify associated risk factors. A cross-sectional study was conducted in yaws endemic districts of Cameroon. Participants included people presenting yaws-like ulcers and asymptomatic individuals. Swab samples were collected from each participant and tested for HD and Treponema pallidum (TP) using an established qPCR method. Additionally, demographic, habitat, proximity, and hygiene characteristics were collected using a structured questionnaire. A total of 443 individuals participated in the study, including 271 ulcer cases and 172 asymptomatic contacts. The prevalence of HD in ulcers was 30.3% (Confidence Interval (CI) 95% [24.8-35.7]) and the prevalence of asymptomatic HD carriage was 8.6% (CI95% [4.5-12.9]). TP was also detected in our sample among ulcer cases but in lower proportion (5.2% CI95% [2.5-7.8]) compared to HD. The adjusted logistic regression model showed that women were as much at risk of having HD cutaneous ulcer as men regardless of age. Physical proximity to a confirmed ulcer case was the major factor identified favouring HD transmission. HD ulcers were more likely to be present on Bantu individuals compared to Baka as well as HD colonization. These findings highlight HD as the most common cause of cutaneous ulcers in yaws-endemic communities in Cameroon. The exact implications of detecting HD on intact skin are not yet clear. Further studies are needed to understand the significance of this carriage in the spread dynamics of the disease.

Characterization of differential susceptibility and differential infectivity epidemic models

Heterogeneity in susceptibility and infectivity is a central issue in epidemiology. Although the latter has received some attention recently, the former is often neglected in modeling of epidemic systems. Moreover, very few studies consider both of these heterogeneities. This paper is concerned with the characterization of epidemic models with differential susceptibility and differential infectivity under a general setup. Specifically, we investigate the global asymptotic behavior of equilibria of these systems when the network configuration of the Susceptible-Infectious interactions is strongly connected. These results prove two conjectures by Bonzi et al. (J Math Biol 62:39-64, 2011) and Hyman and Li (Math Biosci Eng 3:89-100, 2006). Moreover, we consider the scenario in which the strong connectivity hypothesis is dropped. In this case, the model exhibits a wider range of dynamical behavior, including the rise of boundary and interior equilibria, all based on the topology of network connectivity. Finally, a model with multidirectional transitions between infectious classes is presented and completely analyzed.

Dramatic Shift in the Etiology of Genital Ulcer Disease Among Patients Visiting a Sexually Transmitted Infections Clinic in Lilongwe, Malawi

BACKGROUND

Genital ulcer diseases (GUDs) are a common syndrome associated with sexually transmitted infections. Genital ulcer diseases increase the risk of HIV transmission, necessitating appropriate diagnosis and treatment. We provide an updated GUD etiology assessment in Malawi to guide diagnostic development and treatment algorithms.

METHODS

We enrolled patients 18 years or older presenting with GUD at a sexually transmitted infection clinic in Lilongwe, Malawi, between May and October 2021. We purposively sampled by HIV status. Swabs of ulcers were tested for Treponema pallidum, herpes simplex virus (HSV)-1 and HSV-2, Haemophilus ducreyi, and Chlamydia trachomatis using polymerase chain reaction. Blood was collected for syphilis and HSV-2 serologies and acute HIV testing. Participants were treated per Malawi guidelines. Ulcer resolution (size reduced by >50%) was evaluated 14 days later.

RESULTS

Fifty participants enrolled (30 without HIV, 2 with acute HIV infection, 18 with HIV seropositivity; 32 men, 18 women). Forty-six (92%) had an etiology identified. Syphilis was more common among those without HIV (22 of 30 [73%]) than participants with HIV (PWH; 8 of 20 [40%]; P = 0.04). Herpes simplex virus was more common among PWH (11 of 20 [55%]) than participants without (2 of 30 [7%]; P = 0.0002). One-fifth (9 of 50 [18%]) had H. ducreyi. Among those who returned for follow-up (n = 45), 9 (20%) had unresolved ulcers; persistent GUD was slightly more common in PWH (6 of 19 [32%]) than participants without (3 of 26 [12%]; P = 0.14).

CONCLUSIONS

We observed a dramatic increase in syphilis ulcer proportion in a population whose GUDs were previously HSV predominant. Observed differences in etiology and resolution by HIV status could play an important role in the ongoing transmission and treatment evaluation of GUD.

Antimicrobial Resistance Profiling and Genome Analysis of the penA-60.001 Neisseria gonorrhoeae Clinical Isolates in China in 2021

BACKGROUND

Neisseria gonorrhoeae antimicrobial resistance (AMR) is an urgent public health threat. With dissemination of FC428-related clones, the efficacy of ceftriaxone has become controversial.

METHODS

Agar dilution and whole genome sequencing were used to analyze AMR.

RESULTS

High resistance to penicillin (75.2%), tetracycline (87.9%), ciprofloxacin (98.3%), ceftriaxone (8.9%), cefixime (14.3%), and azithromycin (8.6%) was observed among 463 isolates first collected in China in 2021. All penA-60.001 clones exhibited resistance to ceftriaxone or cefixime, and 1 of the 12 cases was resistant to azithromycin. ngMAST and ngSTAR of penA-60.001 isolates showed that single-nucleotide polymorphisms in the porB, tbpB, ponA, gyrA, and parC genes were the major causes of different sequence types. MLST-7365 (n = 5) and MLST-1903 (n = 3) were main genotypes, and the other 4 strains featured MLST-10314, MLST-13871, MLST-7827 and MLST-1600. Furthermore, resistance markers (eg, penA, blaTEM-1, blaTEM-135) and virus factors were detected. Most penA-60.001 strains were fully mixed with global FC428-related clones; 2021-A2 and F89 had the same origin; and 2021-A1 exhibited a unique evolutionary trajectory.

CONCLUSIONS

Results provide the first demonstration of extremely severe AMR rates of N gonorrhoeae in China in 2021, particularly strains with ceftriaxone decreased susceptibility. The sustained transmission of penA-60.001 subclones might further threaten treatment effectiveness.

Ensuring equity with pre-clinical planning for chlamydia vaccines

Chlamydia trachomatis (Ct) remains the most common bacterial sexually transmitted pathogen worldwide, causing significant morbidity particularly among women, including pelvic inflammatory disease, ectopic pregnancy, and infertility. Several vaccines are advancing through pre-clinical and clinical development, and it is likely that one or more vaccines will progress into human efficacy trials soon. In this Perspective, we present a case for considering the challenges of Ct vaccine development through a lens of equity and justice. These challenges include the need to protect against multiple serovars, in both females and males, at multiple anatomic sites, and in resource poor areas of the world. We propose that early consideration of vaccine implementation by conducting community-engaged research will ensure that a scientifically sound chlamydia vaccine promotes equity, justice, and shared-gendered responsibility for STI prevention.

Immune responses to Neisseria gonorrhoeae and implications for vaccine development

Neisseria gonorrheoae is the causative agent of gonorrhea, a sexually transmitted infection responsible for a major burden of disease with a high global prevalence. Protective immunity to infection is often not observed in humans, possible due to high variability of key antigens, induction of blocking antibodies, or a large number of infections being relatively superficial and not inducing a strong immune response. N. gonorrhoeae is a strictly human pathogen, however, studies using mouse models provide useful insights into the immune response to gonorrhea. In mice, N. gonorrhoea appears to avoid a protective Th1 response by inducing a less protective Th17 response. In mouse models, candidate vaccines which provoke a Th1 response can accelerate the clearance of gonococcus from the mouse female genital tract. Human studies indicate that natural infection often induces a limited immune response, with modest antibody responses, which may correlate with the clinical severity of gonococcal disease. Studies of cytokine responses to gonococcal infection in humans provide conflicting evidence as to whether infection induces an IL-17 response. However, there is evidence for limited induction of protective immunity from a study of female sex workers in Kenya. A controlled human infection model (CHIM) has been used to examine the immune response to gonococcal infection in male volunteers, but has not to date demonstrated protection against re-infection. Correlates of protection for gonorrhea are lacking, which has hampered the progress towards developing a successful vaccine. However, the finding that the Neisseria meningitidis serogroup B vaccines, elicit cross-protection against gonorrhea has invigorated the gonococcal vaccine field. More studies of infection in humans, either natural infection or CHIM studies, are needed to understand better gonococcal protective immunity.

Prevalence of gonococcal and chlamydial infections among men who have sex with men in sub-Saharan Africa: protocol for a systematic review and meta-analysis

BACKGROUND

Bacterial sexually transmitted infections (STIs) including Neisseria gonorrhoeae and Chlamydia trachomatis are common in men who have sex with men (MSM). These infections increase the risk of acquiring and transmitting human immunodeficiency virus (HIV) in this key population. Access to MSM in many countries in sub-Saharan Africa remains generally difficult due to discrimination or criminalization of their sexual orientation which could lead to depression and risky sexual practices associated with prevalence. This protocol therefore proposes to undertake a systematic review and meta-analysis of literature on the prevalence of gonococcal and chlamydial infections among MSM in Sub-Saharan Africa.

METHODS

This review which aims to ascertain the pooled prevalence and risk factors of these infections in sub-Saharan Africa's MSM population will follow the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines. The search strategy will review relevant articles from the following databases: PubMed, Scopus, ISI Web of Science and the Directory of Open Access Journals (DOAJ). Articles screening for eligibility and data extraction will be conducted by two independent reviewers. All discrepancies will be resolved by the third and fourth reviewers. Heterogeneity in studies will be evaluated using the I2 statistic and where heterogeneity is high and significant, a random effect model will be used to estimate the pooled prevalence. Publication bias will be assessed using the Doi plot. Extracted data will be analysed using MetaXL add-on for Microsoft excel. Data will be presented in tables and graphically presented in forest plots.

DISCUSSION

In this study, we anticipate being able to systematically determine the prevalence of Neisseria gonorrhoeae and Chlamydia trachomatis among MSM as well as explore possible risk factors associated with prevalence. The outcomes of the systematic review and meta-analyses will serve to support researchers and public health stakeholders in identifying healthcare priorities and in addressing issues pertaining to the overall wellbeing of the MSM community.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022327095.

The effect of screening on the health burden of chlamydia: An evaluation of compartmental models based on person-days of infection

Sexually transmitted diseases (STDs) are detrimental to the health and economic well-being of society. Consequently, predicting outbreaks and identifying effective disease interventions through epidemiological tools, such as compartmental models, is of the utmost importance. Unfortunately, the ordinary differential equation compartmental models attributed to the work of Kermack and McKendrick require a duration of infection that follows the exponential or Erlang distribution, despite the biological invalidity of such assumptions. As these assumptions negatively impact the quality of predictions, alternative approaches are required that capture how the variability in the duration of infection affects the trajectory of disease and the evaluation of disease interventions. So, we apply a new family of ordinary differential equation compartmental models based on the quantity person-days of infection to predict the trajectory of disease. Importantly, this new family of models features non-exponential and non-Erlang duration of infection distributions without requiring more complex integral and integrodifferential equation compartmental model formulations. As proof of concept, we calibrate our model to recent trends of chlamydia incidence in the U.S. and utilize a novel duration of infection distribution that features periodic hazard rates. We then evaluate how increasing STD screening rates alter predictions of incidence and disability adjusted life-years over a five-year horizon. Our findings illustrate that our family of compartmental models provides a better fit to chlamydia incidence trends than traditional compartmental models, based on Akaike information criterion. They also show new asymptomatic and symptomatic infections of chlamydia peak over drastically different time frames and that increasing the annual STD screening rates from 35% to 40%-70% would annually avert 6.1-40.3 incidence while saving 1.68-11.14 disability adjusted life-years per 1000 people. This suggests increasing the STD screening rate in the U.S. would greatly aid in ongoing public health efforts to curtail the rising trends in preventable STDs.

A Sore Subject? An Examination of National Case-Based Chancroid Surveillance

BACKGROUND

Chancroid has been a nationally notifiable condition in the United States since 1944, with cases reported to Centers Disease Control and Prevention through the National Notifiable Diseases Surveillance System. Although frequently reported during the 1940s, <20 cases have been reported annually since 2011. We assessed the performance and utility of national case-based chancroid surveillance.

METHODS

We reviewed the literature to contextualize chancroid surveillance through National Notifiable Diseases Surveillance System. We then assessed 4 system attributes, including data quality, sensitivity, usefulness, and representativeness: we reviewed chancroid cases reported during 2011-2020, conducted interviews with (a) sexually transmitted disease programs reporting ≥1 case in 2019 or 2020 (n = 9) and (b) Centers Disease Control and Prevention subject matter experts (n = 10), and reviewed published communicable disease reporting laws.

RESULTS

Chancroid diagnostic testing is limited, which affects the surveillance case definition. National case-based surveillance has poor data quality; of the 2019 and preliminary 2020 cases (n = 14), only 3 were verified by jurisdictions as chancroid cases. Sexually transmitted disease programs report the system has low sensitivity given limited clinician knowledge and resources; experts report the system is not useful in guiding national control efforts. Review of reporting laws revealed it is not representative, as chancroid is not a reportable condition nationwide.

CONCLUSIONS

Critical review of system attributes suggest that national case-based chancroid surveillance data have limited ability to help describe and monitor national trends, and chancroid's inclusion on the national notifiable list might need to be reconsidered. Alternative strategies might be needed to monitor national chancroid burden.

Pharmacokinetic serum concentrations of VRC01 correlate with prevention of HIV-1 acquisition

BACKGROUND

The phase 2b proof-of-concept Antibody Mediated Prevention (AMP) trials showed that VRC01, an anti-HIV-1 broadly neutralising antibody (bnAb), prevented acquisition of HIV-1 sensitive to VRC01. To inform future study design and dosing regimen selection of candidate bnAbs, we investigated the association of VRC01 serum concentration with HIV-1 acquisition using AMP trial data.

METHODS

The case-control sample included 107 VRC01 recipients who acquired HIV-1 and 82 VRC01 recipients who remained without HIV-1 during the study. We measured VRC01 serum concentrations with a qualified pharmacokinetic (PK) Binding Antibody Multiplex Assay. We employed nonlinear mixed effects PK modelling to estimate daily-grid VRC01 concentrations. Cox regression models were used to assess the association of VRC01 concentration at exposure and baseline body weight, with the hazard of HIV-1 acquisition and prevention efficacy as a function of VRC01 concentration. We also compared fixed dosing vs. body weight-based dosing via simulations.

FINDINGS

Estimated VRC01 concentrations in VRC01 recipients without HIV-1 were higher than those in VRC01 recipients who acquired HIV-1. Body weight was inversely associated with HIV-1 acquisition among both placebo and VRC01 recipients but did not modify the prevention efficacy of VRC01. VRC01 concentration was inversely correlated with HIV-1 acquisition, and positively correlated with prevention efficacy of VRC01. Simulation studies suggest that fixed dosing may be comparable to weight-based dosing in overall predicted prevention efficacy.

INTERPRETATION

These findings suggest that bnAb serum concentration may be a useful marker for dosing regimen selection, and operationally efficient fixed dosing regimens could be considered for future trials of HIV-1 bnAbs.

FUNDING

Was provided by the National Institutes of Health, National Institute of Allergy and Infectious Diseases (NIAID) (UM1 AI068614, to the HIV Vaccine Trials Network [HVTN]; UM1 AI068635, to the HVTN Statistical Data and Management Center [SDMC], Fred Hutchinson Cancer Center [FHCC]; 2R37 054165 to the FHCC; UM1 AI068618, to HVTN Laboratory Center, FHCC; UM1 AI068619, to the HPTN Leadership and Operations Center; UM1 AI068613, to the HIV Prevention Trials Network [HPTN] Laboratory Center; UM1 AI068617, to the HPTN SDMC; and P30 AI027757, to the Center for AIDS Research, Duke University (AI P30 AI064518) and University of Washington (P30 AI027757) Centers for AIDS Research; R37AI054165 from NIAID to the FHCC; and OPP1032144 CA-VIMC Bill & Melinda Gates Foundation.

Prevalence, Antibiotic Resistance and Associated Factors of Neisseria gonorrhoeae Among Patients Attending Non-Profitable Private Clinics in Mekelle, Tigrai, Ethiopia

Background

Globally, Neisseria gonorrhoeae is the second most common cause of bacterial sexually transmitted diseases. The prominent predicament of this bacterium is its complications, non-susceptibility for many drugs, and aggravated transmission of other sexually transmitted infections. There is limited information about the prevalence, antibiotic resistance, and risk factors of N. gonorrhoeae in Tigrai, Ethiopia. Therefore, we aimed to determine the prevalence, antibiotic resistance, and risk factors of N. gonorrhoeae among patients attending non-profitable private clinics in Mekelle, Tigrai, Ethiopia.

Methods

A cross-sectional study among 229 patients was conducted from February to June 2018. The socio-demographic data and associated factors were gathered using structured questionnaire, and swabs were taken from urethra and cervix of males and females, respectively. Specimens were inoculated on standard bacteriological culture media and antibiotic susceptibility testing was performed using Kirby-Bauer disc diffusion technique following the Clinical and Laboratory Standard Institute. Data were analyzed using Statistical Package for Social Sciences Version 21. The level of significance at p-value <0.05 was considered statistically significant.

Results

The overall prevalence of N. gonorrhoeae was 23 (10.04%). High prevalence rates of N. gonorrhoeae were observed in females, urban residents and married ones. N. gonorrhoeae had shown statistically significant association with HIV positive, previous history of STIs, shisha users, Khat (Catha edulis) users, condom non-users and having more than two sexual partners. All isolates showed resistance to penicillin followed by tetracycline 16 (69.6%) and ciprofloxacin 8 (34.8%). Four isolates (7.4%) exhibited resistance to azithromycin with no resistance to ceftriaxone. Twelve (52.2%) isolates showed multidrug resistance (MDR).

Conclusions

The prevalence of N. gonorrhoeae and drug resistance, including multidrug resistance, was high in the study. Multiple factors were associated with the acquisition of N. gonorrhoeae. Therefore, behavioral change and communication should be strengthened.

Comparison of the burden of self-reported bacterial sexually transmitted infections among men having sex with men across 68 countries on four continents

BACKGROUND

Men who have sex with men (MSM) are in general more vulnerable to sexually transmitted infections (STIs) than the heterosexual men population. However, surveillance data on STI diagnoses lack comparability across countries due to differential identification of MSM, diagnostic standards and methods, and screening guidelines for asymptomatic infections.

METHODS

We compared self-reported overall diagnostic rates for syphilis, gonorrhea, and chlamydia infections, and diagnostic rates for infections that were classified to be symptomatic in the previous 12 months from two online surveys. They had a shared methodology, were conducted in 68 countries across four continents between October 2017 and May 2018 and had 202,013 participants.

RESULTS

Using multivariable multilevel regression analysis, we identified age, settlement size, number of sexual partners, condom use for anal intercourse, testing frequency, sampling rectal mucosa for extragenital testing, HIV diagnosis, and pre-exposure prophylaxis use as individual-level explanatory variables. The national proportions of respondents screened and diagnosed who notified some or all of their sexual partners were used as country-level explanatory variables. Combined, these factors helped to explain differences in self-reported diagnosis rates between countries. The following differences were not explained by the above factors: self-reported syphilis diagnoses were higher in Latin America compared with Europe, Canada, Israel, Lebanon, and the Philippines (aORs 2.30 - 3.71 for symptomatic syphilis compared to Central-West Europe); self-reported gonorrhea diagnoses were lower in Eastern Europe and in Latin America compared with all other regions (aORs 0.17-0.55 and 0.34 - 0.62 for symptomatic gonorrhea compared to Central-West Europe); and self-reported chlamydia diagnoses were lower in Central East and Southeast Europe, South and Central America, and the Philippines (aORs 0.25 - 0.39 for symptomatic chlamydia for Latin American subregions compared to Central West Europe).

CONCLUSIONS

Possible reasons for differences in self-reported STI diagnosis prevalence likely include different background prevalence for syphilis and syndromic management without proper diagnosis, and different diagnostic approaches for gonorrhea and chlamydia.

Investigating point-of-care diagnostics for sexually transmitted infections and antimicrobial resistance in antenatal care in Zimbabwe (IPSAZ): protocol for a mixed-methods study

INTRODUCTION

Sexually transmitted infections (STIs) can cause serious morbidity, including pelvic inflammatory disease, and adverse pregnancy outcomes. In low/middle-income countries, limited laboratory infrastructure has resulted in a syndrome-based approach being used for management of STIs, which has poor sensitivity and specificity, leading to considerable underdiagnosis and overtreatment. The WHO has called for development and evaluation of strategies to inform replacement of syndromic management by diagnostic testing.The aim of this project is to evaluate a strategy of point-of-care testing for six STIs in antenatal care (ANC) in Zimbabwe.

METHODS AND ANALYSIS

A prospective interventional study will be conducted in ANC clinics in Harare province, Zimbabwe. One thousand pregnant women will be recruited when registering for routine ANC. Alongside routine HIV and syphilis testing, participants will be offered an integrated screening package including testing for Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), Trichomonas vaginalis (TV) and hepatitis B. All individuals with STIs will receive treatment, partner notification services, risk reduction counselling and referral if needed according to national guidelines. Gonorrhoea samples will be cultured and tested for antimicrobial resistance as per WHO enhanced gonococcal antimicrobial surveillance programme guidelines.The primary outcome measure is the composite prevalence of CT, NG, TV, syphilis and hepatitis B. A mixed-methods process evaluation and economic evaluation will be conducted to understand the acceptability, feasibility and cost-effectiveness of integrated STI testing, compared with standard of care (syndromic management).

ETHICS AND DISSEMINATION

The study protocol was approved by the Medical Research Council of Zimbabwe, the Biomedical Research and Training Institute Institutional Review Board, and the London School of Hygiene & Tropical Medicine Research Ethics Committee. Results will be submitted to open-access peer-reviewed journals, presented at academic meetings and shared with participating communities and with national and international policymaking bodies.

TRIAL REGISTRATION NUMBER

NCT05541081.

Cyr SB, Pham CD, Kreisel KM. Assessing the National Representativeness of Estimates of Antimicrobial-Resistant Urogenital Neisseria gonorrhoeae in US Men, Gonococcal Isolate Surveillance Project, 2008-2018

BACKGROUND

The percentage of Neisseria gonorrhoeae (GC) isolates with resistance or elevated minimum inhibitory concentrations to antimicrobials has steadily increased. Current estimates are based on the Gonococcal Isolate Surveillance Project (GISP), a sentinel surveillance study of male GC in the United States. This analysis seeks to assess for adjustment before treating aggregated GISP estimates as nationally representative of all reported male urogenital infections.

METHODS

We used multilevel regression with poststratification (MRP) to compute national estimates of the proportion of antimicrobial resistance (AMR) (defined as exceeding minimum inhibitory concentration thresholds) in male GC using data from 2008 to 2018 GISP and case reports. Sensitivity analyses investigated the impact of analysis assumptions and unmeasured variables. We additionally produced estimates of 2018 AMR GC cases among US men.

RESULTS

National estimates were consistent with unweighted estimates. The estimated proportion of incident AMR GC infections in men with urogenital GC in 2018 was 51.5% (95% confidence interval [CI], 50.1%-52.9%), equating to an estimated 366,300 incident AMR GC infections in US men aged 15 to 39 years. Estimates of AMR for tested antimicrobials in male GC infections in 2018 ranged from 0.16% (95% CI, 0.08%-0.24%) for ceftriaxone to 29.9% (95% CI, 28.6%-31.1%) for ciprofloxacin. Sensitivity analyses revealed that unmeasured data on sex of sex partners could substantially impact weighted estimates.

CONCLUSIONS

Antimicrobial resistance among reported incident male urogenital GC infections remains rare for ceftriaxone, the current standard of care. Aggregated GISP data are generally representative of men in the US who are reported with urogenital gonorrhea.

Trends, patterns, and factors associated with HIV infection among males diagnosed with syphilis, 2014-2019, Hawaii

OBJECTIVE

This study describes HIV infection and associated risk factors among males diagnosed with syphilis in Hawaii.

METHODS

Hawaii sexually transmitted infection (STI) registry records of males diagnosed with syphilis, 2014-2019, were crossmatched with Hawaii HIV surveillance registry records through 2020 using CDC's Registry Plus Link Plus software. HIV status from the STI registry was validated by matching results. Logistic regression was used to examine demographic and behavioral factors associated with HIV infection.

RESULTS

Among the 947 male syphilis cases, 257 (27.1%) had both syphilis and HIV infections. Dual infection rates were higher in earlier years (39.5% in 2015), among older patients (41.6% among persons ≥45 years old), males who have sex with males (MSM, 36.6%), and cases with repeated syphilis events (59.5%). The overall agreement on HIV status between the STI registry and matching results was 95.7%.

CONCLUSIONS

Over a quarter (27.1%) of male syphilis cases were living with HIV. HIV infection rates were higher among older patients, MSM, and males with repeated syphilis events. Periodic matching between STI and HIV registries provides opportunities for quality control to both registries and opportunities to identify patients not linked to HIV care or who have fallen out of HIV care.

A new mixed agent-based network and compartmental simulation framework for joint modeling of related infectious diseases- application to sexually transmitted infections

Background

A model that jointly simulates infectious diseases with common modes of transmission can serve as a decision-analytic tool to identify optimal intervention combinations for overall disease prevention. In the United States, sexually transmitted infections (STIs) are a huge economic burden, with a large fraction of the burden attributed to HIV. Data also show interactions between HIV and other sexually transmitted infections (STIs), such as higher risk of acquisition and progression of co-infections among persons with HIV compared to persons without. However, given the wide range in prevalence and incidence burdens of STIs, current compartmental or agent-based network simulation methods alone are insufficient or computationally burdensome for joint disease modeling. Further, causal factors for higher risk of coinfection could be both behavioral (i.e., compounding effects of individual behaviors, network structures, and care behaviors) and biological (i.e., presence of one disease can biologically increase the risk of another). However, the data on the fraction attributed to each are limited.

Methods

We present a new mixed agent-based compartmental (MAC) framework for jointly modeling STIs. It uses a combination of a new agent-based evolving network modeling (ABENM) technique for lower-prevalence diseases and compartmental modeling for higher-prevalence diseases. As a demonstration, we applied MAC to simulate lower-prevalence HIV in the United States and a higher-prevalence hypothetical Disease 2, using a range of transmission and progression rates to generate burdens replicative of the wide range of STIs. We simulated sexual transmissions among heterosexual males, heterosexual females, and men who have sex with men (men only and men and women). Setting the biological risk of co-infection to zero, we conducted numerical analyses to evaluate the influence of behavioral factors alone on disease dynamics.

Results

The contribution of behavioral factors to risk of coinfection was sensitive to disease burden, care access, and population heterogeneity and mixing. The contribution of behavioral factors was generally lower than observed risk of coinfections for the range of hypothetical prevalence studied here, suggesting potential role of biological factors, that should be investigated further specific to an STI.

Conclusions

The purpose of this study is to present a new simulation technique for jointly modeling infectious diseases that have common modes of transmission but varying epidemiological features. The numerical analysis serves as proof-of-concept for the application to STIs. Interactions between diseases are influenced by behavioral factors, are sensitive to care access and population features, and are likely exacerbated by biological factors. Social and economic conditions are among key drivers of behaviors that increase STI transmission, and thus, structural interventions are a key part of behavioral interventions. Joint modeling of diseases helps comprehensively simulate behavioral and biological factors of disease interactions to evaluate the true impact of common structural interventions on overall disease prevention. The new simulation framework is especially suited to simulate behavior as a function of social determinants, and further, to identify optimal combinations of common structural and disease-specific interventions.

Fertility trends by HIV status in a health and demographic surveillance study in Magu District, Tanzania, 1994-2018

BACKGROUND

Sub-Saharan Africa (SSA) has the highest fertility rates and highest HIV disease burden globally. However, it is not clear how the rapid expansion of anti-retroviral therapy (ART) for HIV has impacted the fertility gap between HIV-infected and uninfected women. We used data from a Health and Demographic Surveillance System (HDSS) in north-western Tanzania to explore trends in fertility rates and the relationship between HIV and fertility over the 25-year period.

METHODS

From 1994 to 2018, births and population denominators from the HDSS population were used to obtain age-specific fertility rates (ASFRs) and total fertility rates (TFRs). HIV status was extracted from eight rounds of epidemiologic serological surveillances (1994-2017). Fertility rates by HIV status and in different levels of ART availability were compared over time. Independent risk factors for fertility changes were examined using Cox proportional hazard models.

RESULTS

There were 24,662 births from 36,814 women (15-49) who contributed a total of 145,452.5 Person-Years of follow-ups. The TFR declined from 6.5 births per woman in 1994-1998 to 4.3 births per woman in 2014-2018. The number of births per woman was 40% lower in women living with HIV than in HIV-uninfected women (4.4 vs. 6.7), although this difference narrowed over time. The fertility rate in HIV-uninfected women was 36% lower in 2013-2018 than in 1994-1998(age-adjusted HR = 0.641; 95% CI 0.613-0.673). In contrast, the fertility rate in women living with HIV was relatively unchanged over the same follow up period (age-adjusted HR = 1.099; 95% CI 0.870-1.387).

CONCLUSIONS

There was a notable fertility decline among women in the study area from 1994 to 2018. Fertility remained lower in women living with HIV than in HIV-uninfected women, but the difference continued to narrow over time. These results highlight the need for more research into fertility changes, fertility desire and family planning use in Tanzanian rural communities.

Screening and diagnostic testing protocols for HIV and Syphilis infections in health care setting in Qatar: Evaluation and recommendations

BACKGROUND

HIV and Syphilis are common STIs, which have become a concern and burden on healthcare systems, as many infections go untreated and lead to potentially serious complications. HIV is usually diagnosed with Western blot, PCR, and p24 antigen testing. Whereas, Syphilis is mainly diagnosed through clinical findings and serologic testing. The Medical Commission Department (MC) under MOPH is responsible for screening all newcomers to Qatar, aiming to keep the country free from serious infectious diseases.

OBJECTIVE

We aimed to evaluate the diagnostic efficiency of the protocols used in the MC for screening HIV and Syphilis infections.

METHODS

We conducted a retrospective study of samples analyzed by 4th Generation ARCHITECT® HIV Ag/Ab Combo and Rapid Plasma Reagin (RPR) between January to December 2019. ARCHITECT® HIV Ag/Ab Combo positive samples were confirmed by INNO-LIA™ HIVI/II and RT-PCR. RPR-reactive samples were confirmed by ARCHITECT® Syphilis Treponema pallidium Antibody (Syphilis TPA) assay.

RESULTS

For HIV, data were collected from 585,587 individuals, of which 595 (0.1%) were positive by the ARCHITECT® HIV Ag/Ab Combo (Analyzer A). When all initially positive sera were re-tested on newly collected blood samples using different ARCHITECT® HIV Ag/Ab Combo analyzer (analyzer B), 99.8% (594/595) of samples were also positive, suggesting high reproducibility. The positive predictive value (PPV) between ARCHITECT® HIV Ag/Ab Combo and the INNO-LIA™ HIVI/II confirmatory assay was 31.8%. The PPV between ARCHITECT® HIV Ag/Ab Combo and HIV-PCR assay was 26.8%. Retrospective data for Syphilis were collected from a total of 97,298 individuals who visited the MC, of which 198 (0.20%) were initially positive by RPR. The PPV between RPR and Syphilis TPA confirmatory assay was 36.6%.

CONCLUSION

Despite the high rate of false positivity using ARCHITECT® HIV Ag/Ab Combo and RPR screening assays, both assays have proven to be highly effective as screening testing methods.

Estimated Number of Incident HIV Infections in Men Who Have Sex With Men Attributable to Gonorrhea and Chlamydia, Per Gonococcal or Chlamydial Infection, in the United States

Using a network model, we simulated transmission of HIV, gonorrhea, and chlamydia among men who have sex with men to estimate the number of HIV infections that can be attributed to gonorrhea and chlamydia, per gonococcal and chlamydial infection. This metric can inform future modeling and health economic studies.

Treatment of Chlamydial Infections

Sexually transmitted infections (STIs) are a major health problem with an estimated burden of disease transmission as high as one million new cases per day globally. Chlamydia trachomatis, a member of the genus Chlamydia, is one of the most common and curable causative agents of STIs. C. trochomatis infections usually affect sexually active young adults and adolescents; and are composed of a broad spectrum of diseases varying from asymptomatic infection to severe genito-urinary infection leading to infertility and acute or chronic ocular infection (trachoma), which may result in blindness and pneumonia. Among the members of the genus Chlamydia, there are also two pathogenic species, Chlamydia pneumoniae and Chlamydia psittaci which are responsible for acute respiratory tract infections and febrile illness in humans. The incidence, pathophysiology, and diagnostic methods are discussed in detail in the previous chapters. The purpose of this chapter is to elucidate the management of infections due to C. trachomatis, C. pneumoniae, and C. psittaci including antibiotic susceptibility and resistance mechanisms, treatment recommendations for ocular infections, genito-urinary and respiratory tract infections, and management of sex partners, pregnant women, neonates, and children according to the latest data.

Otosyphilis

Otosyphilis can be challenging to diagnose, but, if left unrecognized, it may cause irreversible damage. An immunologic interplay between syphilis and human immunodeficiency virus (HIV) makes coinfection likely and may predispose people with HIV to neurosyphilis. In this study, we present a case of a man in his 50s with hearing loss and vertigo diagnosed with otosyphilis as well as a new diagnosis of HIV. This case and corresponding discussion serve to inform the noninfectious disease-trained clinician of the symptoms, diagnostics, and treatment options for otosyphilis as well as to discuss the relationship between HIV and syphilis and demonstrate the importance of disease recognition.