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

STI pathogens in the oropharynx: update on screening and treatment

PURPOSE OF REVIEW

The rise in antimicrobial resistance in several STI pathogens such as Neisseria gonorrhoeae has become a public health threat as only one first-line treatment remains. Reducing screening interval for gonorrhoea and chlamydia in high-prevalence populations has been proposed to address antimicrobial stewardship, but this remains controversial. This review aimed to revisit the epidemiology of infections at the oropharynx and review the current screening recommendations and treatment guidelines in different populations.

RECENT FINDINGS

Emerging evidence suggests that the oropharynx is the primary anatomical site for gonorrhoea transmission but maybe not for chlamydia transmission. Most international guidelines recommend 3-monthly oropharyngeal gonorrhoea and chlamydia screening for high-prevalence populations (e.g. men who have sex with men) but not low-prevalence populations (e.g. heterosexuals) given the clinical and public health benefits of screening in low-prevalence populations are still unclear. Doxycycline remains the first-line treatment for oropharyngeal chlamydia in most guidelines. However, some countries have moved from dual therapy (ceftriaxone and azithromycin) to monotherapy (ceftriaxone) for oropharyngeal gonorrhoea treatment to address antimicrobial stewardship.

SUMMARY

The transmission of gonorrhoea and chlamydia is still not fully understood. Further work will be required to evaluate the benefits and harms of reducing screening in high-prevalence populations.

Determinants and prediction of Chlamydia trachomatis re-testing and re-infection within 1 year among heterosexuals with chlamydia attending a sexual health clinic

Background

Chlamydia trachomatis (chlamydia) is one of the most common sexually transmitted infections (STI) globally, and re-infections are common. Current Australian guidelines recommend re-testing for chlamydia 3 months after treatment to identify possible re-infection. Patient-delivered partner therapy (PDPT) has been proposed to control chlamydia re-infection among heterosexuals. We aimed to identify determinants and the prediction of chlamydia re-testing and re-infection within 1 year among heterosexuals with chlamydia to identify potential PDPT candidates.

Methods

Our baseline data included 5,806 heterosexuals with chlamydia aged ≥18 years and 2,070 re-tested for chlamydia within 1 year of their chlamydia diagnosis at the Melbourne Sexual Health Center from January 2, 2015, to May 15, 2020. We used routinely collected electronic health record (EHR) variables and machine-learning models to predict chlamydia re-testing and re-infection events. We also used logistic regression to investigate factors associated with chlamydia re-testing and re-infection.

Results

About 2,070 (36%) of 5,806 heterosexuals with chlamydia were re-tested for chlamydia within 1 year. Among those retested, 307 (15%) were re-infected. Multivariable logistic regression analysis showed that older age (≥35 years old), female, living with HIV, being a current sex worker, patient-delivered partner therapy users, and higher numbers of sex partners were associated with an increased chlamydia re-testing within 1 year. Multivariable logistic regression analysis also showed that younger age (18-24 years), male gender, and living with HIV were associated with an increased chlamydia re-infection within 1 year. The XGBoost model was the best model for predicting chlamydia re-testing and re-infection within 1 year among heterosexuals with chlamydia; however, machine learning approaches and these self-reported answers from clients did not provide a good predictive value (AUC < 60.0%).

Conclusion

The low rate of chlamydia re-testing and high rate of chlamydia re-infection among heterosexuals with chlamydia highlights the need for further interventions. Better targeting of individuals more likely to be re-infected is needed to optimize the provision of PDPT and encourage the test of re-infection at 3 months.

Gonorrhoea: a systematic review of prevalence reporting globally

BACKGROUND

The World Health Organization (WHO) recommends periodic gonorrhoea prevalence assessments in the general population or proxies thereof (including pregnant women, women attending family planning clinics, military recruits, and men undergoing employment physicals for example) and in population groups at increased risk, including men-who-have-sex-with-men (MSM) and sex workers.

METHOD

We evaluated reported prevalence data, including estimates from proxy general population samples to reflect the WHO recommendations. We describe the outcomes from the general population country-by-country and extend previous reviews to include MSM, sex workers, and extragenital infections.

RESULT AND CONCLUSION

In our systematic search, 2015 titles were reviewed (January 2010-April 2019) and 174 full-text publications were included. National, population-based prevalence data were identified in only four countries (the United States of America, the United Kingdom, Peru, New Caledonia) and local population-based estimates were reported in areas within five countries (China, South Africa, Brazil, Benin, and Malawi). The remaining studies identified only reported test positivity from non-probability, proxy general population samples. Due to the diversity of the reviewed studies, detailed comparison across studies was not possible. In MSM, data were identified from 64 studies in 25 countries. Rectal infection rates were generally higher than urogenital or pharyngeal infection rates, where extragenital testing was conducted. Data on sex workers were identified from 41 studies in 23 countries; rates in female sex workers were high. Current prevalence monitoring was shown to be highly suboptimal worldwide. Serial prevalence monitoring of critical epidemiological variables, and guidelines to optimize prevalence study conduct and reporting beyond antenatal settings are recommended.

Epidemiology of gonorrhoea: a global perspective

Although understanding the local epidemiology of gonorrhoea is critical for local efforts, understanding the multinational epidemiology may support development of national and international prevention and control policies and strategies. In this paper, current epidemiology of gonorrhoea is reviewed through an international lens and with a focus on selected populations. The World Health Organization (WHO) estimates that ~87 million new gonococcal infections occurred among people aged 15-49 years in 2016. Gonorrhoea rates are rising in many countries. Gay, bisexual and other men who have sex with men, racial or ethnic minorities, Indigenous populations and sex workers appear to bear disproportionate burdens of gonorrhoea. International travel can facilitate spread of gonorrhoea, including resistant strains, across international borders. Critical gaps in epidemiological knowledge are highlighted, including data on gonorrhoea among transgender persons and the burden of extragenital gonorrhoea. Even as further data are gathered, action - informed by currently available data - is needed now to confront this growing international threat.

Providing competent, comprehensive and inclusive sexual health services for men who have sex with men in low- and middle-income countries: a scoping review

Although men who have sex with men (MSM) are disproportionately affected by HIV and other sexually transmissible infections, sexual health services for MSM in low- and middle-income countries (LMIC) remain under-resourced and are poorly understood. A scoping review of literature on MSM sexual health in LMIC was conducted in order to identify key clinical services and gaps in knowledge. Three databases were searched, in addition to hand-reviewing key journals and bulletins, to identify literature with a focus on MSM sexual health. Key services related to providing care to MSM in LMIC that emerged from our review are described. These services include creation of safe and confidential clinic environments, HIV testing services, behavioural interventions, HIV pre-exposure prophylaxis (PrEP), rapid antiretroviral therapy (ART) initiation and STI services. Compared with high-income settings, major differences in LMIC include lack of diagnostic technology, unfavourable legal environments and lack of funding for MSM health. Innovative approaches to healthcare delivery, such as harnessing mobile technology, self-testing and crowdsourcing interventions, can improve health services among MSM in LMIC. There are gaps in the evidence about how best to provide sexual health services for MSM in LMIC settings. Implementation research and scale-up of existing biomedical and behavioural interventions, such as HIV/STI testing services, PrEP and early antiretroviral initiation are urgently needed in LMIC.

Assessing Sexually Transmitted Infections and HIV Risk Among Transgender Women in Lima, Peru: Beyond Behavior

Purpose: The purpose of this study was to explore risk factors for HIV and sexually transmitted infections (STIs) among transgender women (TW) in Lima, Peru. Methods: HIV-negative or serostatus unknown TW reporting recent condomless receptive anal intercourse underwent testing for STIs and HIV and completed a sociobehavioral survey. Results: Among 120 TW, 29.6% had rectal Neisseria gonorrhoeae (GC) or Chlamydia trachomatis (CT) and 12.6% had HIV. Age and migrant status were associated with rectal GC/CT, and rectal GC/CT predicted HIV infection. Conclusions: Further study is needed to understand individual and social factors that contribute to HIV/STI vulnerability among TW.

STI in times of PrEP: high prevalence of chlamydia, gonorrhea, and mycoplasma at different anatomic sites in men who have sex with men in Germany

BACKGROUND

Men who have sex with men (MSM) are disproportionally affected by sexually transmitted infections (STI). STI are often extragenital and asymptomatic. Both can delay diagnosis and treatment. Approval of HIV pre-exposure prophylaxis (PrEP) might have influenced sexual behaviour and STI-prevalence of HIV- MSM. We estimated STI-prevalence and risk factors amongst HIV- and HIV+ MSM in Germany to plan effective interventions.

METHODS

We conducted a nationwide, cross-sectional study between February and July 2018. Thirteen MSM-friendly STI-practices screened MSM for Chlamydia trachomatis (CT), Mycoplasma genitalium (MG), Neisseria gonorrhea (NG), and Trichomonas vaginalis (TV) using self-collected rectal and pharyngeal swabs, and urine samples. APTIMA™ STI-assays (Hologic™ Inc., San Diego, USA) were used for diagnostics, and samples were not pooled. We collected information on socio-demographics, HIV-status, clinical symptoms, sexual behaviour within the last 6 months, and PrEP use. We combined HIV status and PrEP use for defining risk groups, and used directed acyclic graphs and multivariable logistic regression to identify risk factors for STI.

RESULTS

Two thousand three hundred three MSM were included: 50.5% HIV+, median age 39 [18-79] years. Median number of male sex partners within the last 6 months was five. Sex without condom was reported by 73.6%, use of party drugs by 44.6%. 80.3% had a STI history, 32.2% of STI+ MSM reported STI-related symptoms. 27.6% of HIV- MSM used PrEP. Overall STI-prevalence was 30.1, 25.0% in HIV-/PrEP- MSM (CT:7.2%; MG:14.2%; NG:7.4%; TV:0%), 40.3% in HIV-/PrEP+ MSM (CT:13.8%; MG:19.4%; NG:14.8%; TV:0.4%), and 30.8% in HIV+ MSM (CT:10.1%; MG:18.4%; NG:8.6%; TV:0.1%). Being HIV+ (OR 1.7, 95%-CI 1.3-2.2), using PrEP (OR 2.0, 95%-CI 1.5-2.7), having > 5 sex partners (OR:1.65; 95%-CI:1.32-2.01.9), having condomless sex (OR:2.11.9; 95%-CI:1.65-2.86), and using party drugs (OR:1.65; 95%-CI:1.32-2.0) were independent risk factors for being tested positive for at least one STI.

CONCLUSIONS

We found a high STI-prevalence in MSM in Germany, especially in PrEP users, frequently being asymptomatic. As a relevant proportion of PrEP users will not use a condom, counselling and comprehensive STI screening is essential and should be low threshold and preferably free of cost. Counselling of PrEP users should also address use of party drugs.

Chlamydia trachomatis Infection of the Neovagina in Transgender Women

We report 2 cases of neovaginal Chlamydia trachomatis infection in transgender women who underwent penile-inversion vaginoplasty procedures with integrated peritoneum and urethral grafts. These tissue types may have facilitated C. trachomatis infection. Medical providers should implement neovaginal screening for bacterial sexually transmitted infections in transgender patients at risk for infection.

Contextualizing condoms: a cross-sectional study mapping intersections of locations of sexual contact, partner type, and substance use as contexts for sexual risk behavior among MSM in Peru

Background

Condomless anal intercourse (CAI) appears to be increasing among men who have sex with men (MSM) globally, and is reported to be as high as 70% in recent studies in Peru. To improve understanding of the evolving context of CAI among MSM in Peru, we studied associations between partner type, substance use, and condomless anal intercourse (CAI) in locations where MSM commonly report having sexual encounters.

Methods

In a 2017 cross-sectional study of rectal STI screening and HIV prevention, a convenience sample of MSM recruited from community venues in Lima completed a survey of demographic characteristics and sexual risk behavior with their three most recent partners. Generalized estimating equations estimated correlations of CAI with location of last sexual contact, participant substance use prior to sex, and negotiation of condom use before or during sex. The network data integration application, Cytoscape, mapped intersections of partner type, sexual orientation, substance use, and CAI by four types of locations where sex occurred: 1) Home, 2) Hotel, 3) Sauna or Internet Cabin, and 4) Public Spaces.

Results

Of 447 MSM (median age 27 years), 76.9% reported CAI with ≥1 of their last three partners. Participants reported sex with casual partners most commonly in homes (64.6%) and hotels (60.4%), and with anonymous partners most often in saunas/Internet cabins (57.5%) and public spaces (52.6%). CAI was less commonly reported in hotels (aPR, 95% CI: 0.85, 0.75–0.97) compared to homes. Participants who used marijuana before sex at home were more likely to report CAI than MSM who did not use marijuana (1.36, 1.01–1.92). Partner alcohol use before sex was associated with CAI in saunas/Internet cabins (3.17, 1.45–6.91) and public spaces (2.65, 1.41–4.98). In the sexual network maps, almost all MSM who used drugs prior to their sexual encounters used drugs with more than one of their last three partners.

Conclusions

CAI was common and associated with different risk factors, like partner type and substance use, based on location where sex occurred. Novel combination HIV, STI, and substance use prevention interventions must consider how the social environments of MSM influence condom use and other sexual risk behaviors.

Trial registration

ClinicalTrials.gov Identifier NCT03010020, January 4, 2017.

Body Parts Matter: Social, Behavioral, and Biological Considerations for Urethral, Pharyngeal, and Rectal Gonorrhea and Chlamydia Screening Among MSM in Lima, Peru

BACKGROUND

Gonorrhea (Neisseria gonorrhoeae [GC]) and chlamydia (Chlamydia trachomatis [CT]) disproportionately affect men who have sex with men (MSM), and public health implications vary by anatomic site and bacterial agent. Urethral and rectal GC and CT can increase risk of HIV transmission, whereas pharyngeal GC may be a reservoir for antimicrobial resistance. To define screening priorities in Latin America, we compare differences in the prevalence and correlates of urethral, pharyngeal, and rectal GC and CT among MSM in Peru.

METHODS

A cross-sectional sample of 787 MSM from Lima was screened between 2012 and 2014. We described prevalence of urethral, pharyngeal, and rectal GC and CT infection and conducted bivariate analyses of associations with social, behavioral, and biological characteristics. Poisson regression analyses assessed the correlates of each infection at each anatomic site.

RESULTS

The most commonly symptomatic infection (urethral GC; 42.1%) was the least prevalent (2.4%). The most prevalent infections were rectal CT (15.8%) and pharyngeal GC (9.9%). Rectal CT was the least commonly symptomatic (2.4%) infection, and was associated with younger age (adjusted prevalence ratio [95% confidence interval], 0.96 [0.94-0.98]), HIV infection (1.46 [1.06-2.02]), and pasivo (receptive; 3.59 [1.62-7.95]) and moderno (versatile; 2.63 [1.23-5.60]) sexual roles.

CONCLUSIONS

Results highlight limitations of current syndromic screening strategies for sexually transmitted diseases in Peru, wherein urethral CT and rectal GC and CT may be missed due to their frequently asymptomatic presentations. Successful management of GC and CT infections among MSM in low-resource settings requires differentiating between bacterial agent, symptomatic presentation, associated risk factors, and public health implications of untreated infection at different anatomic sites.

Venue-Based HIV-Testing: An Effective Screening Strategy for High-Risk Populations in Lima, Peru

Venue-based testing may improve screening efforts for HIV and syphilis, thereby reducing transmission. We offered onsite rapid dual HIV and syphilis testing at venues popular among MSM and/or transgender women in Lima, Peru. We used Poisson regression to calculate adjusted prevalence ratios (aPRs) for factors associated with each infection. Most (90.4%) of the 303 participants would test more frequently if testing was available at alternative venues. New cases of HIV (69) and syphilis infection (84) were identified. HIV was associated with recent sex work (aPR 1.11; 95% CI 1.02-1.22), sex with a partner of unknown serostatus (aPR 1.18; 95% CI 1.09-1.27), exclusively receptive anal sex role (aPR 1.16; 95% CI 1.03-1.30) or versatile sex role (aPR 1.17; 95% CI 1.06-1.30) compared to insertive. Syphilis was associated with reporting role versatility (aPR = 2.69; 95% CI 1.52-5.74). Sex work venues had higher syphilis prevalence 47% versus 28% in other venues, p value = 0.012. Venue-based testing may improve case finding.

Sexually transmitted rectal infections in a cohort of 'men having sex with men'

PURPOSE

We assessed the prevalence and predictors of Chlamydia trachomatis, Neisseriagonorrhoeae and Mycoplasmagenitalium rectal infections in a population of 'men having sex with men' (MSM).

METHODOLOGY

From January to November 2017, 165 MSM attending a STI outpatients clinic in Bologna (Italy) and reporting unsafe anal intercourses were enrolled. An ano-rectal swab was collected from each patient: chlamydial and gonococcal infections were diagnosed by a commercial NAAT, whereas an in-house quantitative PCR was used for M. genitalium detection. In addition, 131 urine samples and 84 pharyngeal swabs underwent testing for C. trachomatis and N. gonorrhoeae. A molecular C. trachomatis typing, a serological screening for anti-Chlamydia IgG and IgA, as well as the assessment of HIV, HCV and syphilis infections, were performed.Results/Key findings. The prevalence of C. trachomatis, N. gonorrhoeae and M. genitalium rectal infections was 27.2, 25.4 and 4.8 %, respectively. Globally, 63.1 % of cases were asymptomatic and up to 80 % of chlamydial and gonococcal infections would have been missed if the rectal site had not been tested. All the patients with rectal M. genitalium carriage were asymptomatic and characterized by low bacterial loads (<2500 DNA copies/reaction). Lymphogranuloma venereum (LGV) prevalence was 12.1 % with a considerable proportion of asymptomatic infections (35 %). The presence of symptoms, age >30, HIV-positivity and elevated levels of anti-Chlamydia antibodies were the most significant predictors of LGV.

CONCLUSIONS

Sexually transmitted rectal infections are frequent and often asymptomatic among MSM. LGV prevalence is high in our country and there is increasing evidence of symptomless cases.

Biological feasibility and importance of a gonorrhea vaccine for global public health

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78 million new infections annually; greatest impact on women and neonates in LMIC.

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Current control measures are inadequate and challenged by antibiotic resistance.

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Conserved candidate vaccine antigens and adjuvant strategies are being developed.

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There is a need for human studies to investigate correlates of immunity.

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A meningococcal outer membrane vesicle vaccine may protect against gonorrhea.

There is a growing public health interest in controlling sexually transmitted infections (STIs) through vaccination due to increasing recognition of the global disease burden of STIs and the role of STIs in women’s reproductive health, adverse pregnancy outcomes, and the health and well-being of neonates. Neisseria gonorrhoeae has historically challenged vaccine development through the expression of phase and antigenically variable surface molecules and its capacity to cause repeated infections without inducing protective immunity. An estimated 78 million new N. gonorrhoeae infections occur annually and the greatest disease burden is carried by low- and middle-income countries (LMIC). Current control measures are clearly inadequate and threatened by the rapid emergence of antibiotic resistance. The gonococcus now holds the status of “super-bug” as there is currently no single reliable monotherapy for empirical treatment of gonorrhea. The problem of antibiotic resistance has elevated treatment costs and necessitated the establishment of large surveillance programs to track the spread of resistant strains. Here we review the need for a gonorrhea vaccine with respect to global disease burden and related socioeconomic and treatment costs, with an emphasis on the impact of gonorrhea on women and newborns. We also highlight the challenge of estimating the impact of a gonorrhea vaccine due to the need for more data on the burden of gonococcal pelvic inflammatory disease and related sequelae and of gonorrhea-associated adverse pregnancy outcomes and the problem of empirical diagnosis and treatment of STIs in LMIC. There is also a lack of clinical and basic science research in the area of gonococcal/chlamydia coinfection, which occurs in a high percentage of individuals with gonorrhea and should be considered when testing the efficacy of gonorrhea vaccines. Finally, we review recent research that suggests a gonorrhea vaccine is feasible and discuss challenges and research gaps in gonorrhea vaccine development.

Perceived Barriers and Facilitators to Integrating HIV Prevention and Treatment with Cross-Sex Hormone Therapy for Transgender Women in Lima, Peru

Transgender women (TW) represent a vulnerable population at increased risk for HIV infection in Peru. A mixed-methods study with 48 TW and 19 healthcare professionals was conducted between January and February 2015 to explore barriers and facilitators to implementing a model of care that integrates HIV services with gender-affirmative medical care (i.e., hormone therapy) in Lima, Peru. Perceived acceptability of the integrated care model was high among TW and healthcare professionals alike. Barriers included stigma, lack of provider training or Peruvian guidelines regarding optimal TW care, and service delivery obstacles (e.g., legal documents, spatial placement of clinics, hours of operation). The hiring of TW staff was identified as a key facilitator for engagement in health care. Working in partnership with local TW and healthcare provider organizations is critical to overcoming existing barriers to successful implementation of an integrated HIV services and gender-affirmative medical care model for this key population in Peru.

The medical care of the neovagina of transgender women: a review

For transgender women, genital adjustment surgery involves removal of the natal reproductive organs and creation of a neovagina, vulva and clitoris. We conducted a review of the medical literature in order to summarise the issues that can affect the health of the neovagina in the long term, and to make recommendations on how to manage these issues.

Transgender populations and HIV: unique risks, challenges and opportunities

Due to unique social, behavioural, structural and biological issues, transgender (TG) populations, especially TG women, are at high risk for HIV acquisition. This increased risk is multifactorial, due to differing psychosocial risk factors, poorer access to TG-specific healthcare, a higher likelihood of using exogenous hormones or fillers without direct medical supervision, interactions between hormonal therapy and antiretroviral therapy, and direct effects of hormonal therapy on HIV acquisition and immune control. Further research is needed to elucidate these mechanisms of risk and to help design interventions to reduce HIV risk among transgender populations.