Incidence of sexually transmitted infections in men who have sex with men and who are at substantial risk of HIV infection - A meta-analysis of data from trials and observational studies of HIV pre-exposure prophylaxis

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.

Recurrence of sexually transmitted infections is commonly found in a subpopulation of Austrian users of HIV pre-exposure prophylaxis

BACKGROUND

In recent years there has been an increase in the diagnoses of sexually transmitted infections (STI) among men who have sex with men (MSM) using human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP); however, data on PrEP users in Austria are limited.

PATIENTS, MATERIAL AND METHODS

In June 2020, we initiated a prospective observational cohort study at Vienna General Hospital including PrEP users from Vienna. Participants underwent STI testing quarterly and provided behavioral information using a questionnaire.

RESULTS

Between June 2020 and December 2023 a total of 360 individuals (99% MSM) were enrolled comprising 379 person-years of follow-up. We identified 276 STIs in 154 individuals, of which 23% (36/154) were symptomatic. The incidence rates per 100 person-years were 29.9 (95% confidence interval, CI 24.3-35.3 per 100 person-years) for gonorrhea, 22.7 (95% CI 17.9-27.5 per 100 person-years) for chlamydia and 9.8 (95% CI 6.6-12.9 per 100 person-years) for syphilis. Extragenital infections accounted for 95% (97/102) of gonorrhea and 81% (65/80) of chlamydia cases. A case of HIV infection was recorded in a 20-year-old male with inconsistent PrEP use. Participants with one or more reinfection (18%; 65/360) accounted for 68% (187/276) of all STIs. Sexualized drug use (Chemsex) was reported by 44% (157/360) of participants and was significantly associated with higher rates of gonorrhea (38% vs. 21%, p < 0.001) and syphilis (17% vs. 5%, p < 0.001) but not chlamydia (26% vs. 19%, p = 0.118).

CONCLUSION

Throughout the study, 43% of participants experienced a bacterial STI, which was mostly asymptomatic and at extragenital sites. Chemsex was commonly reported and identified as a predictor for STI reinfection, underlining the importance of harm reduction strategies in Austrian STI prevention.

Updates on HIV Pre-exposure Prophylaxis in Latin America: Available Drugs and Implementation Status

Latin America has reported a 9% increase in new HIV infections from 2010 to 2023. Pre-exposure prophylaxis (PrEP) is a crucial biomedical intervention for preventing HIV transmission. Currently, several antiretroviral drugs, in various forms of administration, have demonstrated high efficacy and effectiveness to protect against HIV. Among the oral drugs, we have emtricitabine/tenofovir and emtricitabine/tenofovir alafenamide, while alternative options include the dapivirine vaginal ring, injectable drugs such as Cabotegravir, and the most recently studied Lenacapavir. Despite their high efficacy and effectiveness, implementing PrEP in Latin America has been challenging throughout the region. Although some countries such as Brazil, Mexico, and Colombia have shown progress in increasing the number of users, there is a significant gap between these countries and others where PrEP access remains limited or non-existent. Barriers such as lack of awareness, inadequate funding, political instability, and outdated policies contribute to disparities in access, leaving many populations at high risk of HIV infection without this preventative measure. Innovative strategies need to be implemented to address and monitor policies that ensure access for all at-risk populations.

Non-Consensual Sex and Help-Seeking Behavior Among PrEP Users in Belgium: Findings from an Online Survey

Non-consensual sex poses a threat not only to sexual health but also to mental and physical health in general. HIV pre-exposure prophylaxis (PrEP) users might be particularly vulnerable to non-consensual sex because of interplaying factors such as mental health disorders, a high number of sex partners, engagement in chemsex, and the widespread use of dating apps. The objectives of this study were to assess the occurrence of non-consensual sex, its associated factors, and related help-seeking behavior among PrEP users. We analyzed data from an online survey among PrEP users in Belgium (09/2020-02/2022). Almost one in five participants (34/187, 18.2%) reported having ever experienced non-consensual sex. The most reported form was having sex against one's will, followed by having been given drugs against one's will, and having had sex without a condom against one's will. The vast majority of those who had experienced non-consensual sex (29/34, 85.3%) did not seek help afterward, mostly due to a lack of perceived need (21/29, 72.4%). Reported barriers to seeking help were shame (6/29, 20.7%) and lack of awareness of help services (3/29, 10.3%). Having experienced non-consensual sex in the past five years was associated with younger age and suicidal ideation in a multivariable logistic regression model. We conclude that addressing barriers to non-consensual sex help services is crucial to maximize their use and minimize the consequences of non-consensual sex experiences. PrEP consultations also represent an opportunity to offer such help given PrEP users are already familiar with these PrEP services and engaged in care.

Risk and demographic factors associated with STI testing adherence among non-single men who have sex with men (MSM) in the United States

Though men who have sex with men (MSM) are disproportionately affected by sexually transmitted infections (STIs), factors that impact STI testing adherence among non-single MSM remain under-explored. While being in a relationship per se does not necessarily increase one's risk for STIs, certain behavioral risks and demographic factors may impact STI testing adherence. Through a sample of 296 non-single MSM located in the United States, we examined key behavioral and demographic factors and their associations with adherence to CDC's STI testing guidelines. Overall, the results showed inconsistent STI testing adherence rates among divergent subgroups of higher-risk non-single MSM. First, non-single MSM who take PrEP were more likely to adhere to STI testing and showed significantly higher adherence rates than those who do not take PrEP, but adherence rates were not related to nor significantly different than those who reported extra-relational sex or condomless anal sex. Further, STI testing adherence was positively associated with having a shorter relationship length, identifying as non-White, and living in an LGBTQ+-friendly neighborhood. Practical implications and recommendations for clinical practices, persuasive messages, and promotion strategies are discussed.

Routine Data Analysis of HIV Pre-Exposure Prophylaxis Use and Rates of Sexually Transmitted Infections Since Coverage of HIV Pre-Exposure Prophylaxis by the Statutory Health Insurance in Germany

Human immunodeficiency virus pre-exposure prophylaxis (PrEP) is considered as an effective protection against a human immunodeficiency virus (HIV) infection. However, it is still unclear, how PrEP use is associated with the incidence of sexually transmitted infections (STI) other than HIV. PrEP became reimbursable in Germany from September 1, 2019 for persons with statutory health insurance (SHI). With the EvE-PrEP study, the Federal Ministry of Health commissioned the evaluation of the effects of the new reimbursement situation in Germany. In the presented module of the EvE-PrEP study, routine data from three large German SHI funds were analyzed in anonymized form for the period January 1, 2019 to March 31, 2020. Data were analyzed regarding: Characteristics and adherence of PrEP users, treatment success of PrEP, and changes in STI incidence rates before and since PrEP use. The cooperating SHI funds collectively covered about 52% of the overall population in Germany in 2019. A total of 7102 persons with PrEP use were included into the analysis. These were predominantly male (99%), on average 37.4 years old and a high proportion of persons lived in large cities. The average quotient of PrEP daily defined doses and assumed days on PrEP was 87%. The average STI rates normalized per 100 person-years at individual level pre PrEP did not statistically significant differ compared to since PrEP (chlamydia: 17.5 vs. 17.6, gonococcal infection: 29.1 vs. 30.7, and syphilis: 14.6 vs.13.6). A large data set was used to evaluate the introduction of PrEP as a SHI benefit in Germany. A potentially suspected increase in bacterial STI incidence rates was not found. A rather high average adherence rate was observed. The very high proportion of men and people from the largest German cities among PrEP users is striking. These results could indicate barriers to PrEP access for people at risk of HIV, especially if they are women or people living in less urban areas.

Missed opportunities for guidance on sexually transmitted infection services: a global review of national HIV PrEP guidance

OBJECTIVES

People who use or would benefit from pre-exposure prophylaxis (PrEP) for HIV infection are disproportionately affected by sexually transmitted infections (STIs). Integrating STI services when offering PrEP fosters synergies and efficiencies in response to HIV/STI and promotes people-centred care. Including guidance on STI interventions for people on PrEP may facilitate implementation and uptake. We conducted a global review of national PrEP guidance documents and analysed the inclusion of recommendations for the provision of STI services by country level of income.

METHODS

We searched national PrEP guidance documents published by WHO Member States through the WHO, the Joint United Nations Programme on HIV/AIDS (UNAIDS) databases, the PrEPWatch repository and Google. Information on a range of STI-related interventions was extracted from documents available by October 2023.

RESULTS

Of the 113 national PrEP guidance documents retrieved, STIs were mentioned in 77% (90/117). Viral hepatitis B testing and vaccination were recommended by most high-income countries (HICs) and low-income and middle-income countries (LMICs). Recommendation for syphilis testing was prominent in HICs (91%) and moderately noted in LMICs (68%). Gonorrhoea and chlamydia testing was recommended frequently in HICs (88%) and 42% in LMICs. However, the review noted that, to a much lesser extent, specific type of testing for these pathogens was mentioned. Recommendation for quarterly STI testing for syphilis, gonorrhoea and chlamydia was ubiquitous, while the need to offer STI partner services was rarely mentioned.

CONCLUSIONS

PrEP services offer an opportunity for improved and expanded STI services, increasing person-centred care and addressing STI epidemics alongside HIV. Our review highlights the strengths and gaps in incorporating critical STI interventions into national PrEP normative guidance. Addressing these gaps through a stepwise approach and increasing targeted testing and partner services can help improve quality of care and support an effective response to HIV and other STIs.

Slovenia's national HIV PrEP programme: Evaluation of real-world implementation

BACKGROUND

The aim of our study was to evaluate real-world implementation of Slovenia's national HIV PrEP programme, which is fully covered by our national health insurance.

METHODS

In retrospective cohort study we analysed the data from all men who have sex with men (MSM) who were enrolled in PrEP programme of our clinic between 1 January 2022 and 31 December 2022.

RESULTS

A total of 190 MSM with an average age of 36.7 years were included in our analysis. 151 (79.5%) decided for event-driven PrEP and 39 (20.5%) opted for daily PrEP. Self-reported adherence was 95%. Among eligibility criteria, unprotected sex was the most common one, followed by one or more STIs in the past, use of chemsex and use of HIV post-exposure prophylaxis in the past. No new cases of HIV infection and no significant deterioration of kidney or liver function were observed during the follow-up. Sixty-seven episodes of STIs were diagnosed and treated. Gonorrhea (32), chlamydia (14), and Mpox (10) were the most common ones.

CONCLUSIONS

PrEP was successfully implemented into everyday clinical practice, proving to be both safe and effective. High number of diagnosed STIs suggests that the PrEP programme, combined with STI screening and vaccination, provides a strong public health impact among MSM in Slovenia.

Reach of GetCheckedOnline among gay, bisexual, transgender and queer men and Two-Spirit people and correlates of use 5 years after program launch in British Columbia, Canada

OBJECTIVES

Understanding who uses internet-based sexually transmitted and blood-borne infection (STBBI) services can inform programme implementation, particularly among those most impacted by STBBIs, including gender and sexual minority (GSM) men. GetCheckedOnline, an internet-based STBBI testing service in British Columbia, Canada, launched in 2014. Our objectives were to assess reach, identify factors associated with use of GetCheckedOnline 5 years into implementation and describe reasons for using and not using GetCheckedOnline among GSM men.

METHODS

The Sex Now 2019 Survey was an online, cross-sectional survey of GSM men in Canada administered from November 2019 to February 2020. Participants were asked a subset of questions related to use of GetCheckedOnline. Multivariable binary logistic regression modelling was used to estimate associations between correlates and use of GetCheckedOnline.

RESULTS

Of 431 British Columbia (BC) participants aware of GetCheckedOnline, 27.6% had tested using the service. Lower odds of having used GetCheckedOnline were found among participants with non-white race/ethnicity (adjusted OR (aOR)=0.41 (95% CI 0.21 to 0.74)) and those living with HIV (aOR=0.23 (95% CI 0.05 to 0.76)). Those who usually tested at a walk-in clinic, relative to a sexual health clinic, had greater odds of using GetCheckedOnline (aOR=3.91 (95% CI 1.36 to 11.61)). The most commonly reported reason for using and not using GetCheckedOnline was convenience (78%) and only accessing the website to see how the service worked (48%), respectively.

CONCLUSION

Over a quarter of GSM men in BC aware of GetCheckedOnline had used it. Findings demonstrate the importance of social/structural factors related to use of GetCheckedOnline. Service promotion strategies could highlight its convenience and privacy benefits to enhance uptake.

Patterns and Characteristics of Amphetamine-type Stimulant Use in a North-eastern State of India: A Cross-sectional Study

Background

South Asia generally reports low levels of amphetamine-type stimulant (ATS) use, with few studies on the pattern of ATS use. We assessed the pattern of ATS use and associated high-risk behavior in Manipur, a north-eastern state of India.

Methods

209 adult male ATS users (mean age 28.8 years) from three districts of Manipur were interviewed. Data were collected on the patterns of high-risk behavior with ATS use, health consequences, and help-seeking. The severity of use with various substances was assessed using the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST). Depression and anxiety were assessed by the Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder (GAD-7) scale, respectively.

Results

The mean duration of ATS use was 3.7 years (SD 2.3). The majority used ATS almost daily (88%) and depended on ATS (77%). Methamphetamine (99.5%) was the most used ATS orally. Around 87% also suffered from opioid dependence. About 76% injected drugs, most commonly heroin. Almost three-fourths (78%) used ATS before their sexual intercourse, 31% of whom did not use condoms. Most reported physical problems with ATS and had above-cut-off scores on PHQ-9 and GAD-7. The majority (95%) reported that they could procure ATS easily. Also, the majority (93%) had thought of quitting ATS use.

Discussion

Most ATS users start using ATS at a young age and have comorbid other drug use, including heroin. ATS use is associated with various physical and psychological problems. Focusing on ATS use in India and developing strategies to address this problem is essential.

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

BACKGROUND

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

OBJECTIVES AND DESIGN

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

KEY RESULTS

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

CONCLUSIONS

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

Gaps in HIV and Hepatitis C Testing Among 3486 HIV-Negative Men Who have Sex with Men in Spain in the Era of Highly Effective Antiviral Therapies

High uptake of HIV and hepatitis C (HCV) testing in Gay, bisexual, and other men who have sex with men (GBMSM) is needed to interrupt transmission. The objective was to identify subgroups with increased probability of lack of testing among HIV-negative GBMSM in Spain. Cross-sectional study including 3486 HIV-negative GBMSM attending prevention facilities in Madrid and Barcelona, 2018-2020. Data came from self-administered online sociodemographic, health, and risk behaviors questionnaires. Outcomes were lack of HCV (lifetime) and HIV (lifetime, last year) testing. Crude and adjusted prevalences and prevalence ratios were assessed for each outcome using negative binomial regression models. Lifetime lack of HIV and HCV testing prevalence was 6.3% and 35.8%, respectively, while lack of HIV testing in the last year was 22.4%. Prevalences were also substantial in GBMSM with high-risk behaviors. After sociodemographic adjustment, the highest probability of lack of HCV testing (lifetime) and HIV (last year) was among GBMSM with insufficient viral hepatitis knowledge, no history of STI, or HCV (or HIV) testing, aged < 25, non-outness about sex life with men, and less high-risk behaviors. Lack of HCV (lifetime) and HIV testing (last year) among HIV-negative GBMSM in Spain is still high, despite high-risk behaviors.

Incidence of sexually transmitted infections and association with behavioural factors: Time-to-event analysis of a large pre-exposure prophylaxis (PrEP) cohort

OBJECTIVES

Our objective was to obtain long-term data on the incidence of sexually transmitted infections (STIs) and their association with behavioural factors after widespread pre-exposure prophylaxis (PrEP) implementation.

METHODS

This was a time-to-event analysis of a national PrEP cohort in Switzerland (SwissPrEPared study). Participants were people without HIV interested in taking PrEP with at least two STI screening visits. Primary outcomes were incidence rate of gonorrhoea, chlamydia, and syphilis. The association between behavioural factors and STI diagnosis was expressed using hazard ratios. We adjusted for testing frequency and calendar year.

RESULTS

This analysis included 3907 participants enrolled between April 2019 and April 2022, yielding 3815.7 person-years of follow-up for gonorrhoea (15 134 screenings), 3802.5 for chlamydia (15 141 screenings), and 3858.6 for syphilis (15 001 screenings). The median age was 39 years (interquartile range [IQR] 32-47), 93.8% (n = 3664) identified as men who have sex with men (MSM). The incidence was 22.8 (95% confidence interval [CI] 21.3-24.4) per 100 person-years for gonorrhoea, 26.3 (95% CI 24.7-28.0) for chlamydia, and 4.4 (95% CI 3.8-5.1) for syphilis. Yearly incidence rates decreased between 2019 (all bacterial STIs: 81.6; 95% CI 59.1-109.9) and 2022 (all bacterial STIs: 49.8; 95% CI 44.6-55.3). Participants reporting chemsex substance use were at higher risk of incident STIs, as were those reporting multiple sexual partners. Younger age was associated with a higher risk of gonorrhoea and chlamydia.

CONCLUSIONS

Incidence rates of bacterial STIs decreased over time. Young MSM, those with multiple partners, and those using chemsex substances were at increased risk of STIs.

Bacterial sexually transmitted infections are concentrated in subpopulations of men who have sex with men using HIV pre-exposure prophylaxis

OBJECTIVE

Studies have shown varying trends in incidence of sexually transmitted infections (STIs) among individuals using HIV pre-exposure prophylaxis (PrEP). Characterization of individuals at increased risk for STIs may offer an opportunity for targeted STI screening.

DESIGN

Group-based trajectory modeling.

METHODS

We screened participants from the AMPrEP demonstration project (2015-2020) for urogenital, anal, and pharyngeal chlamydia and gonorrhea, and syphilis every 3 months and when needed. We identified trajectories of STI incidence within individuals over time and determinants of belonging to a trajectory group. We calculated cumulative proportions of STIs within STI trajectory groups.

RESULTS

Three hundred and sixty-six participants with baseline and at least one screening visit during follow-up were included (median follow-up time = 3.7 years [interquartile range, IQR = 3.5-3.7]). We identified three trajectories of STI incidence: participants with a mean of approximately 0.1 STIs per 3 months ('low overall', 52% of the population), participants with a mean 0.4 STI per 3 months ('medium overall', 43%), and participants with high and fluctuating (between 0.3 and 1 STIs per 3 months) STI incidence ('high and fluctuating', 5%). Participants in the 'low overall' trajectory were significantly older, and reported less chemsex and condomless anal sex with casual partners than participants in the other trajectories. Participants in the 'high and fluctuating' and 'medium overall' groups accounted for respectively 23 and 64% of all STIs observed during follow-up.

CONCLUSIONS

STI incidence was concentrated in subpopulations of PrEP users who were younger, had more chemsex and condomless anal sex. Screening frequency for STIs could be reduced for subpopulations with low risk for incident STIs.

HCV Microelimination for High-risk Special Populations

The World Health Organization has set tremendous goals to eliminate viral hepatitis by 2030. However, most countries are currently off the track for achieving these goals. Microelimination is a more effective and practical approach that breaks down national elimination targets into goals for smaller and more manageable key populations. These key populations share the characteristics of being highly prevalent for and vulnerable to hepatitis C virus (HCV) infection. Microelimination allows for identifying HCV-infected people and linking them to care more cost-effectively and efficiently. In this review, we discuss the current obstacles to and progress in HCV microelimination in special populations, including uremic patients undergoing hemodialysis, people who inject drugs, incarcerated people, people living in hyperendemic areas, men who have sex with men with or without human immunodeficiency virus (HIV) infection, transgender and gender-diverse populations, and sex workers. Scaling up testing and treatment uptake to achieve HCV microelimination may facilitate global HCV elimination by 2030.

Demystifying Ocular Syphilis - A Major Review

Syphilis, caused by the spirochaete, Treponema pallidum, continues to be a public health challenge globally with its rates steadily increasing in the past few years. The disease is transmitted through small breaks in the skin during sexual contact, or via congenital transmission in utero, either across the placenta or by contact with an active genital lesion during delivery. Estimated 5.7-6 million new cases are detected every year worldwide in the 15-49 years age group. An increased incidence has been reported in most populations with particular clusters in special groups like men who have sex with men, female sex workers, and their male clients. Ocular syphilis has a varied presentation and is considered a great mimicker in all cases of uveitis. The laboratory diagnosis of syphilis is predominantly based on serological tests including TPHA and VDRL. Parenteral penicillin is the cornerstone of treatment for all stages of ocular syphilis.

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.

Safety, immunogenicity and effect on viral rebound of HTI vaccines in early treated HIV-1 infection: a randomized, placebo-controlled phase 1 trial

HIVACAT T-cell immunogen (HTI) is a novel human immunodeficiency virus (HIV) vaccine immunogen designed to elicit cellular immune responses to HIV targets associated with viral control in humans. The AELIX-002 trial was a randomized, placebo-controlled trial to evaluate as a primary objective the safety of a combination of DNA.HTI (D), MVA.HTI (M) and ChAdOx1.HTI (C) vaccines in 45 early-antiretroviral (ART)-treated individuals (44 men, 1 woman; NCT03204617). Secondary objectives included T-cell immunogenicity, the effect on viral rebound and the safety of an antiretroviral treatment interruption (ATI). Adverse events were mostly mild and transient. No related serious adverse events were observed. We show here that HTI vaccines were able to induce strong, polyfunctional and broad CD4 and CD8 T-cell responses. All participants experienced detectable viral rebound during ATI, and resumed ART when plasma HIV-1 viral load reached either >100,000 copies ml^-1, >10,000 copies ml^-1 for eight consecutive weeks, or after 24 weeks of ATI. In post-hoc analyses, HTI vaccines were associated with a prolonged time off ART in vaccinees without beneficial HLA (human leukocyte antigen) class I alleles. Plasma viral load at the end of ATI and time off ART positively correlated with vaccine-induced HTI-specific T-cell responses at ART cessation. Despite limited efficacy of the vaccines in preventing viral rebound, their ability to elicit robust T-cell responses towards HTI may be beneficial in combination cure strategies, which are currently being tested in clinical trials.

Back2PrEP: Rates of Bacterial Sexually Transmitted Infection Diagnosis Among Individuals Returning to HIV Pre-Exposure Prophylaxis Care: A Retrospective Review of a New York City Comprehensive HIV Prevention Program

HIV pre-exposure prophylaxis (PrEP) effectively reduces new HIV diagnoses. High rates of incident bacterial sexually transmitted infections (STIs) have been observed in patients eligible for and adherent to PrEP. Observational studies generally report low long-term retention in PrEP care. Limited data exist on the rates of bacterial STI diagnosis upon re-engagement with PrEP services. We conducted a retrospective chart review within the HIV prevention program of an urban academic medical center in New York City. Eligible patients started PrEP from 2015 to 2019, then resumed PrEP services after a gap in care of at least 180 days. Demographic, clinical, and laboratory data were used to characterize the patient population and rates of bacterial STI diagnosis at re-engagement. In total, 286 patients were identified, with 316 qualifying re-engagement visits. Twenty-nine percent of patients had continued PrEP during the care gap, and 30% reported discontinuing medication due to a perceived change in risk. A new STI was diagnosed at 19% of re-engagement visits. There was no statistically significant difference in rates of new STI between individuals returning on or off PrEP, nor between those with perceived lower risk and those without. Individuals who fall out of PrEP services and subsequently re-engage remain at high risk of bacterial STI during the gap in care, regardless of whether PrEP medication is continued or the patient perceives themselves to be at lower HIV acquisition risk. Providers should strongly encourage patients discontinuing PrEP to remain engaged in sexual health services. Alternatives to clinic-based PrEP care must still include regular bacterial STI screening.

Retrospective audit of a convenience cohort of individuals on HIV pre-exposure prophylaxis in Alberta, Canada

BACKGROUND

We undertook an audit of a province-wide HIV pre-exposure prophylaxis (PrEP) program in Alberta (Canada).

METHODS

A retrospective record review of individuals accessing PrEP in Alberta included demographics, PrEP indication(s), and reported non-prescription drug and alcohol use from March 2016 to June 2019. Hepatitis A, B, C, HIV and syphilis serology, serum creatinine, and nucleic acid amplification tests testing for chlamydia and gonorrhea were collected. Descriptive statistics, incidence, and prevalence were calculated.

RESULTS

A total of 511 participants were seen at STI, sexual, and reproductive health clinics and private family practitioner (FP) offices; 98.4% (503) were men, median age was 34 years (IQR 28-43 years), and 89.8% (459) were gay or bisexual men who have sex with men. Non-prescription drug use was reported by 39.3% (201) and alcohol use by 55.4% (283). 94.3% (482) reported condomless anal sex in the past 6 months. Testing rates were high (>95%) for all tests except for chlamydia and gonorrhea at the first follow-up visit 89.6%; (3-4 months). There was one HIV seroconversion. The incidence of new bacterial STIs was high: chlamydia 17 cases per 100 person-years (95% CI 13.5% to 21.4%), gonorrhea 11.14 cases per 100 person-years (95% CI 8.3% to 15.0%), and syphilis 1.94 cases per 100 person-years (95% CI 0.73% to 5.12%).

CONCLUSIONS

Following implementation of a provincial program for PrEP in Alberta, PrEP initiation and continuation was feasible in a range of settings and by both specialists and FPs.

Low incidence of HIV infection and decreasing incidence of sexually transmitted infections among PrEP users in 2020 in Germany

Introduction

Objectives of this study, as part of a nation-wide HIV pre-exposure prophylaxis (PrEP) evaluation project, were to determine the incidence of infections with HIV, chlamydia, gonorrhea, syphilis, hepatitis A/B/C in persons using PrEP, and to describe the health care funded PrEP use in Germany. Additionally, factors associated with chlamydia/gonorrhea and syphilis infections were assessed.

Methods

Anonymous data of PrEP users were collected at 47 HIV-specialty centers from 09/2019–12/2020. Incidence rates were calculated per 100 person years (py). Using longitudinal mixed models, we analyzed risk factors associated with sexually transmitted infections (STIs).

Results

4620 PrEP users were included: 99.2% male, median age 38 years (IQR 32–45), 98.6% men who have sex with men (MSM). The median duration of PrEP exposure was 451 days (IQR 357–488), totaling 5132 py. Four HIV infections were diagnosed, incidence rate 0,078/100py (95% CI 0.029–0.208). For two, suboptimal adherence was reported and in the third case, suboptimal adherence and resistance to emtricitabine were observed. One infection was likely acquired before PrEP start. Incidence rates were 21.6/100py for chlamydia, 23.7/100py for gonorrhea, 10.1/100py for syphilis and 55.4/100py for any STI and decreased significantly during the observation period. 65.5% of syphilis, 55.6% of chlamydia and 50.1% of gonorrhea cases were detected by screening of asymptomatic individuals. In a multivariable analysis among MSM younger age, PrEP start before health insurance coverage and daily PrEP were associated with greater risk for chlamydia/gonorrhea. Symptom triggered testing and a history of STI were associated with a higher risk for chlamydia/gonorrhea and syphilis. A significantly lower risk for chlamydia/gonorrhea and syphilis was found for observations during the COVID-19 pandemic period.

Conclusions

We found that HIV-PrEP is almost exclusively used by MSM in Germany. A very low incidence of HIV infection and decreasing incidence rates of STIs were found in this cohort of PrEP users. The results were influenced by the SARS-CoV-2 pandemic. Rollout of PrEP covered by health insurance should be continued to prevent HIV infections. Increased PrEP availability to people at risk of HIV infection through the elimination of barriers requires further attention. Investigation and monitoring with a longer follow-up would be of value.

Supplementary Information

The online version contains supplementary material available at 10.1007/s15010-022-01919-3.

Sexually Transmitted Infections Among Men and Transgender Women Using HIV Pre-exposure Prophylaxis in a Large Integrated Health System-A Cohort Study

BACKGROUND

Sexually transmitted infections (STIs) are common in people using pre-exposure prophylaxis (PrEP). We examined risk and factors associated with STIs in a cohort of PrEP users in an integrated health system in the United States.

SETTING

The Kaiser Permanente Southern California is a large integrated health system that provides comprehensive medical services to approximately 4.7 million demographically diverse members.

METHODS

We identified men and transgender women initiating PrEP between January 1, 2014, and June 1, 2018, and followed through December 31, 2018. Demographic and clinical factors potentially associated with the risk of bacterial STIs during PrEP use were evaluated using Poisson regression models.

RESULTS

Among 5042 individuals tested for STIs with 7198 person-years of follow-up, 1709 (33.9%) had at least one new STI. The estimated incidence of STIs was 48.3 per 100 person-years, and the most common STI was rectal chlamydia. Most repeat STIs (61.4%) occurred <180 days apart. In a multivariable analysis, an history of STIs in the prior 6 months through 7 days after the PrEP initiation was the most prominent risk factor of STIs during PrEP use (adjusted risk ratio: 1.78, 95% confidence intervals: 1.65 to 1.93). Other risk factors included younger age (<35 years), being Hispanic, and having a history of alcohol use disorder or drug use disorder.

CONCLUSIONS

Quarterly STI testing and targeted intervention to mitigate STI risk are warranted for young and racial minority PrEP users, particularly for those with prior history of STIs and substance use disorders.

Impact of daily, oral pre-exposure prophylaxis on the risk of bacterial sexually transmitted infections among cisgender women: a systematic review and narrative synthesis

Background: There are concerns that the use of pre-exposure prophylaxis (PrEP) may result in an increased incidence of sexually transmitted infections (STIs). Evidence for this is mixed and has mostly been based on reviews focussed on gay and bisexual men and transgender women, while none have summarised evidence in cisgender women. Methods: We conducted a systematic review to explore whether daily, oral PrEP use is associated with changes in bacterial STI occurrence (diagnoses or self-reported) and/or risk among HIV seronegative cisgender women (ciswomen). The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) tool. Results: We included 11 full text articles in a narrative synthesis, with the studies published between 2012 and 2021. The studies were mostly based in Africa (n=7, 63.6%) and reported on 3168 ciswomen using PrEP aged 16-56 years. Studies had marked differences in variables, including measurements and definitions (e.g., STI type) and limited data available looking specifically at ciswomen, principally in studies with both male and female participants. The limited evidence suggests that PrEP use is not associated with increased STI rates in ciswomen generally; however, adolescent girls and young women in Sub Saharan Africa have a higher prevalence of bacterial STIs prior to PrEP initiation, compared to adult ciswomen and female sex workers. Conclusions: We suggest future PrEP research make efforts to include ciswomen as study participants and report stratified results by gender identity to provide adequate data to inform guidelines for PrEP implementation. PROSPERO registration: CRD42019130438.

Factors associated with testing for HIV and other sexually transmitted infections in men who have sex with men and transgender women in Bangkok, Thailand

Background

Routine screening for HIV and other sexually transmitted infections (STIs) facilitates early diagnosis and treatment, thereby preventing morbidity and onward transmission. We estimated the prevalence of prior HIV/STI testing among men who have sex with men (MSM) and transgender women (TGW) in Bangkok, Thailand, and identified factors associated with prior testing.

Methods

Cross-sectional analyses were performed using data collected at enrollment into an HIV incidence cohort. From April to October 2017, MSM and TGW were enrolled if they were aged 18–35 years, reported anal intercourse with a male or TGW partner, and reported behavioral vulnerability to HIV. Participants answered questions about demographics, sexual behaviors, and lifetime HIV/STI testing history. Multivariable robust Poisson regression was used to estimate risk ratios (RRs) and 95% confidence intervals (CIs) for factors potentially associated with prior testing.

Results

Among 1,014 participants, 348 (34.3%) were TGW and the median age was 21.6 (interquartile range 20.0-24.8) years. Prior testing for HIV was reported by 421 (41.5%) and for other STIs by 268 (26.4%). HIV testing was more common among participants aged ≥ 22 years (RR 1.37 [95% CI 1.13–1.67]), with college education as compared to secondary or less (RR 1.37 [95% CI 1.08–1.72]), and who met male sexual partners online (RR 1.52 [95% CI 1.24–1.85]), but lower among participants attracted to both men and women as compared to men only (RR 0.64 [95% CI 0.51–0.81]) and who met male sexual partners in bars (RR 0.83 [95% CI 0.72–0.97]). Similar associations were observed with prior testing for other STIs, including increased testing among participants with college education (RR 1.52 [95% CI 1.11–2.09]) and who met male sexual partners online (RR 1.73 [95% CI 1.30–2.31]), but lower among participants attracted to both men and women (RR 0.70 [95% CI 0.51–0.96]) and who met male sexual partners in bars (RR 0.67 [95% CI 0.54–0.83]).

Conclusions

Despite behavioral vulnerability, prior testing for HIV and other STIs was uncommon. Online engagement strategies may be effectively reaching Thai MSM and TGW who meet sexual partners online, but new interventions are needed to encourage testing among younger, less educated, and bisexual MSM and TGW.

LGBQ-affirmative cognitive-behavioral therapy for young gay and bisexual men's mental and sexual health: A three-arm randomized controlled trial

OBJECTIVE

Effective Skills to Empower Effective Men (ESTEEM) represents the first intervention to address the psychological pathways through which minority stress undermines young sexual minority men's (SMM's) mental and sexual health using transdiagnostic cognitive-behavioral therapy. This study compared the efficacy of ESTEEM against two existing interventions.

METHOD

Participants were young HIV-negative SMM (N = 254; ages = 18-35; 67.2% racial/ethnic minority) experiencing a depression, anxiety, and/or stress-/trauma-related disorder and past-90-day HIV transmission risk behavior. After completing HIV testing and counseling, participants were randomized to receive 10-session ESTEEM (n = 100); 10-session community-based LGBQ-affirmative counseling (n = 102); or only HIV testing and counseling (n = 52).

RESULTS

For the primary outcome of any HIV transmission risk behavior at 8 months, ESTEEM was not significantly associated with greater reduction compared to HIV testing and counseling (risk ratio [RR] = 0.89, p = .52). Supportive analyses of the frequency of HIV transmission risk behavior at 8 months showed a nonsignificant difference between ESTEEM compared to HIV testing and counseling (RR = 0.69) and LGBQ-affirmative counseling (RR = 0.62). For secondary outcomes (e.g., depression, anxiety, substance use, suicidality, number of mental health diagnoses) at 8 months, ESTEEM had a larger effect size than the two comparison conditions, but these comparisons did not reach statistical significance when adjusting for the false discovery rate. Observed effect sizes for condition comparisons were smaller than the effect sizes used to power the study. In exploratory analyses, ESTEEM showed promise for reducing comorbidity.

CONCLUSIONS

Because the control conditions were associated with stronger effects than anticipated, and given the heterogeneous nature of transdiagnostic outcomes, the study possessed insufficient power to statistically detect the consistently small-to-moderate benefit of ESTEEM compared to the two control conditions. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Awareness of, Willingness to Take PrEP and Its Actual Use Among Belgian MSM at High Risk of HIV Infection: Secondary Analysis of the Belgian European MSM Internet Survey

We examined PrEP awareness, willingness to take it and early PrEP use among men who have sex with men (MSM) at increased risk of HIV acquisition in Belgium. This analysis of the Belgian EMIS online data of 2017-2018 adopts a cascade approach, with the following steps quantified as conditional probabilities: being eligible for, aware of, willing to take PrEP, and PrEP use. One out of three MSM was eligible to use PrEP according to the operationalized Belgian reimbursement criteria. PrEP awareness was lower among socioeconomically vulnerable MSM, MSM living outside large cities, MSM who were less open about their sexuality and those who did not identify as gay or homosexual. A lack of PrEP knowledge, a higher self-efficacy regarding safe sex, having a steady partner and reporting more symptoms of depression were related to unwillingness to use PrEP. Among those willing to take PrEP, less than one third were actually using PrEP. Not using PrEP was associated with living in small cities and experiencing financial problems.

Using machine learning approaches to predict timely clinic attendance and the uptake of HIV/STI testing post clinic reminder messages

Timely and regular testing for HIV and sexually transmitted infections (STI) is important for controlling HIV and STI (HIV/STI) among men who have sex with men (MSM). We established multiple machine learning models (e.g., logistic regression, lasso regression, ridge regression, elastic net regression, support vector machine, k-nearest neighbour, naïve bayes, random forest, gradient boosting machine, XGBoost, and multi-layer perceptron) to predict timely (i.e., within 30 days) clinic attendance and HIV/STI testing uptake after receiving a reminder message via short message service (SMS) or email). Our study used 3044 clinic consultations among MSM within 12 months after receiving an email or SMS reminder at the Melbourne Sexual Health Centre between April 11, 2019, and April 30, 2020. About 29.5% [899/3044] were timely clinic attendance post reminder messages, and 84.6% [761/899] had HIV/STI testing. The XGBoost model performed best in predicting timely clinic attendance [mean [SD] AUC 62.8% (3.2%); F1 score 70.8% (1.2%)]. The elastic net regression model performed best in predicting HIV/STI testing within 30 days [AUC 82.7% (6.3%); F1 score 85.3% (1.8%)]. The machine learning approach is helpful in predicting timely clinic attendance and HIV/STI re-testing. Our predictive models could be incorporated into clinic websites to inform sexual health care or follow-up service.

Can we screen less frequently for STI among PrEP users? Assessing the effect of biannual STI screening on timing of diagnosis and transmission risk in the AMPrEP Study

BACKGROUND

In many countries, HIV pre-exposure prophylaxis (PrEP) users are screened quarterly for STIs. We assessed the consequences of less frequent STI testing. We also assessed determinants of asymptomatic STI and potential for onward transmission.

METHODS

Using data from the AMPrEP study, we assessed the proportion of syphilis, and genital, anal, and pharyngeal chlamydia and gonorrhoea diagnoses which would have been delayed with biannual versus quarterly screening. We assessed the potential for onward transmission by examining reported condomless anal sex (CAS) in periods after to-be-omitted visits when screening biannually. We assessed determinants of incident asymptomatic STIs using Poisson regression and calculated individual risk scores on the basis of the coefficients from this model.

RESULTS

We included 366 participants. Median follow-up was 47 months (IQR 43-50). 1,183STIs were diagnosed, of which 932(79%) asymptomatic. With biannual screening, 483 asymptomatic STIs (52%) diagnoses would have been delayed at 364 study visits. Of these visits, 129 (35%), 240 (66%) and 265 (73%) were followed by periods of CAS with steady, known casual or unknown casual partners, respectively. Older participants had a lower risk of asymptomatic STI (incidence rate ratio (IRR) 0.86/10-year increase, 95% CI 0.80 to 0.92), while CAS with known (IRR 1.36, 95% CI 1.10 to 1.68) and unknown (IRR 1.86, 95% CI 1.48 to 2.34) casual partners and chemsex (IRR 1.51, 95% CI 1.28 to 1.78) increased the risk. The individual risk scores had limited predictive value (sensitivity=0.70 (95% CI 0.66 to 0.74), specificity=0.50 (95% CI 0.48 to 0.51)).

CONCLUSION

Reducing the STI screening frequency to biannually among PrEP users will likely result in delayed diagnoses, potentially driving onward transmission. Although determinants for asymptomatic STIs were identified, predictive power was low.

HIV pre-exposure prophylaxis was associated with no impact on sexually transmitted infection prevalence in a high-prevalence population of predominantly men who have sex with men, Germany, 2018 to 2019

Introduction

Despite increased use of pre-exposure prophylaxis (PrEP) in Germany, HIV infection rates are not declining and little is known about how this prevention method affects the prevalence of sexually transmitted infections (STI) among men who have sex with men (MSM).

Aim

We studied, in a large multicentre cohort, STI point prevalence, co-infection rates, anatomical location and influence of PrEP.

Methods

The BRAHMS study was a prospective cohort study conducted at 10 sites in seven major German cities that enrolled MSM reporting increased sexual risk behaviour. At screening visits, MSM were tested for Mycoplasma genitalium (MG), Neisseria gonorrhoeae (NG), Chlamydia trachomatis (CT) and Treponema pallidum (TP), and given a behavioural questionnaire. With binomial regression, we estimated prevalence ratios (PR) and 95% confidence intervals (CI) for the association of PrEP and STI.

Results

We screened 1,043 MSM in 2018 and 2019, with 53.0% currently using PrEP. At screening, 370 participants (35.5%) had an STI. The most common pathogen was MG in 198 (19.0%) participants, followed by CT (n = 133; 12.8%), NG (n = 105; 10.1%) and TP (n = 37; 3.5%). Among the 370 participants with at least one STI, 14.6% (n = 54) reported STI-related symptoms. Infection prevalence was highest at anorectal site (13.4% MG, 6.5% NG, 10.2% CT). PrEP use was not statistically significant in adjusted models for STI (PR: 1.10; 95% CI: 0.91–1.32), NG/CT, only NG or only CT.

Conclusions

Prevalence of asymptomatic STI was high, and PrEP use did not influence STI prevalence in MSM eligible for PrEP according to national guidelines.

Sexually transmitted infections incidence in young Thai men who have sex with men and transgender women using HIV pre-exposure prophylaxis

BACKGROUND

Sexually transmitted infections are a major public health issue worldwide. HIV pre-exposure prophylaxis (PrEP) use among youth may be associated with increased incidence of sexually transmitted infections (STIs).

OBJECTIVES

To measure the prevalence and incidence of STIs among young men who have sex with men (YMSM) and young transgender women (YTGW) using PrEP.

METHODS

A prospective cohort of 15- to 19-year-old YMSM and YTGW with HIV risk defined as inconsistent condom use and/or multiple sex partners were enrolled. Participants were provided daily oral tenofovir disoproxil fumarate/emtricitabine. STI screening was done at baseline and month 6 for syphilis, urine, and anal swab nucleic acid amplification testing for C. trachomatis (CT) and N. gonorrheaoe (NG).

RESULTS

From March 2018 to June 2019, 200 adolescents (147 MSM and 53 TGW) with a median (IQR) age of 18 years (17-19) were enrolled. STI prevalence was 22.5% (95% CI 16.7-28.3). STI incidence was 25.2 per 100 person-years (95% CI 14.7, 40.3). Factors associated with STI incidence were self-reported >2 sex partners in the past month (unadjusted rate ratio [uRR] 4.6, 95% CI 1.0, 20.6), and moderate PrEP adherence (uRR 7.3, 95% CI 1.6, 32.6).

CONCLUSIONS

STI incidence in YMSM and YTGW PrEP users was high at approximately one in five. Regular screening and treatment of STIs should be implemented in youth HIV prevention packages.

Impact of daily, oral pre-exposure prophylaxis on the risk of bacterial sexually transmitted infections among cisgender women: a systematic review and narrative synthesis

Background: There are concerns that the use of pre-exposure prophylaxis (PrEP) may result in an increased incidence of sexually transmitted infections (STIs). Evidence for this is mixed and has mostly been based on reviews focussed on gay and bisexual men and transgender women, while none have summarised evidence in cisgender women. Methods: We conducted a systematic review to explore whether daily, oral PrEP use is associated with changes in bacterial STI occurrence (diagnoses or self-reported) and/or risk among HIV seronegative cisgender women (ciswomen). The quality of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) tool. Results: We included 11 full text articles in a narrative synthesis, with the studies published between 2012 and 2021. The studies were mostly based in Africa (n=7, 63.6%) and reported on 3168 ciswomen using PrEP aged 16-56 years. Studies had marked differences in variables, including measurements and definitions (e.g., STI type) and limited data available looking specifically at ciswomen, principally in studies with both male and female participants. The limited evidence suggests that PrEP use is not associated with increased STI rates in ciswomen generally; however, adolescent girls and young women in Sub Saharan Africa have a higher prevalence of bacterial STIs prior to PrEP initiation, compared to adult ciswomen and female sex workers. Conclusions: We suggest future PrEP research make efforts to include ciswomen as study participants and report stratified results by gender identity to provide adequate data to inform guidelines for PrEP implementation. PROSPERO registration: CRD42019130438.

Human Immunodeficiency Virus/Sexually Transmitted Infection Testing Preferences for Young Black Men Who Have Sex With Men in the Southeastern United States: Implications for a Post-COVID-19 Era

BACKGROUND

Little is known regarding human immunodeficiency virus (HIV)/sexually transmitted infection (STI) testing preferences for location, staffing, and hours of operation among Young Black men who have sex with men (YBMSM) in the Southeastern United States, a population at high risk for HIV/STIs. We used a discrete choice experiment to explore these preferences.

METHODS

Young Black men who have sex with men ages 16 to 35 years in Birmingham, AL and Jackson, MS completed online surveys evaluating their preferences (best/worst) for HIV/STI testing locations, staffing, hours, method of results notification, and cost. They also selected preferred combinations of these variables through choice tasks. Results were analyzed using joint best/worst and discrete choice experiment models.

RESULTS

Between June 2018 and December 2019, participants in Alabama (n = 54) and Mississippi (n = 159) completed online surveys. Both groups preferred stationary testing locations over mobile testing vans, with the most significant difference favoring STI testing-only clinics in Mississippi and local health departments in Alabama (P < 0.001). Technician-performed tests or self-testing were significantly less preferred compared with clinician-performed testing for both groups (P < 0.0001 and P < 0.0001, respectively). Free testing and phone results notification (versus text) were preferred by both groups. The most desirable combination among all participants was weekday clinician-performed testing at the health department for $5.

CONCLUSIONS

Young Black men who have sex with men in the Southeastern United States prefer traditional testing locations staffed by experienced personnel. Combination choices are influenced by services that are low or no cost. More research is needed to inform the best way(s) to provide affordable, high-quality HIV/STI testing services for YBMSM, particularly in the post-COVID-19 era when sexual health care delivery models are evolving toward home-based and remote health-focused strategies.

Incidence of Hepatitis C Virus Infections Among Users of Human Immunodeficiency Virus Pre-exposure Prophylaxis

BACKGROUND & AIMS

Sexual transmission of hepatitis C virus (HCV) is well documented among human immunodeficiency virus (HIV)-uninfected individuals. The use of HIV pre-exposure prophylaxis (PrEP) may be associated with engagement in activities that facilitate the transmission of sexually transmitted infections (STIs) and possibly HCV among PrEP users.

METHODS

Between 2012 and 2019, the incidence of HCV and bacterial STIs were calculated among HIV-negative indviduals receiving PrEP at the University Health Network HIV Prevention Clinic. Mucosal, anal, and blood samples were taken to test for HIV, syphilis, and anti-HCV antibodies.

RESULTS

Among 344 HIV-uninfected patients receiving PrEP, 86% were men having sex with men (MSM). Five individuals were HCV-antibody positive at the time of PrEP initiation. Serologic and virologic follow-up data were available for 109 HCV-negative individuals over 282 patient-years (PY). Two new infections were recorded, yielding an incidence of primary HCV infection of 0.7 per 100 PY. In contrast with HCV, the incidence rates of chlamydia, gonorrhea, and syphilis were 49.2 per 100 PY, 36.3 per 100 PY, and 5.2 per 100 PY, respectively. Both individuals with new HCV diagnoses reported being MSM with a history of unprotected intercourse and 1 individual also reported recreational drug use. Both individuals were asymptomatic at the time of diagnosis and the infections were detected by routine laboratory monitoring.

CONCLUSIONS

The low incidence of HCV infections despite significantly higher rates of other STIs suggests that sexual transmission of HCV is uncommon in HIV-negative MSM PrEP users in this community. Performing routine risk-based HCV surveillance among PrEP users should be evaluated. The high incidence of STIs in this population indicates a vital role for periodic STI monitoring in those receiving PrEP.

Adherence, Sexual Behavior and Sexually Transmitted Infections in a New Zealand Prospective PrEP Cohort: 12 Months Follow-up and Ethnic Disparities

Inequities in pre-exposure prophylaxis (PrEP) experiences will impede HIV epidemic elimination among gay and bisexual men (GBM). Ethnicity is a strong marker of inequity in the United States, but evidence from other countries is lacking. We investigated experiences on-PrEP to 12 months follow-up in a prospective cohort of 150 GBM in Auckland, New Zealand with an equity quota of 50% non-Europeans. Retention at 12 months was 85.9%, lower among Māori/Pacific (75.6%) than non-Māori/Pacific participants (90.1%). Missed pills increased over time and were higher among Māori/Pacific. PrEP breaks increased, by 12 months 35.7% of Māori/Pacific and 15.7% of non-Māori/Pacific participants had done so. Condomless receptive anal intercourse partners were stable over time. STIs were common but chlamydia declined; 12-month incidence was 8.7% for syphilis, 36.0% gonorrhoea, 46.0% chlamydia, 44.7% rectal STI, 64.0% any STI. Structural interventions and delivery innovations are needed to ensure ethnic minority GBM gain equal benefit from PrEP.

Clinical trial number ACTRN12616001387415.

Game Plan-a Brief Web-Based Intervention to Improve Uptake and Use of HIV Pre-exposure Prophylaxis (PrEP) and Reduce Alcohol Use Among Gay and Bisexual Men: Content Analysis

Background

HIV pre-exposure prophylaxis (PrEP) has considerable potential for reducing incidence among high-risk groups, such as gay, bisexual, and other men who have sex with men (GBM). However, PrEP’s effectiveness is closely linked with consistent use, and a variety of individual-level barriers, including alcohol use, could impede optimal uptake and use. Web-based interventions can encourage medication adherence, HIV prevention behaviors, and responsible drinking and may help support PrEP care, particularly in resource-limited settings.

Objective

We previously developed a web application called Game Plan that was designed to encourage heavy drinking GBM to use HIV prevention methods and reduce their alcohol use and was inspired by brief motivational interventions. This paper aims to describe the web-based content we designed for integration into Game Plan to help encourage PrEP uptake and consistent use among GBM. In this paper, we also aim to describe this content and its rationale.

Methods

Similar to the original site, these components were developed iteratively, guided by a thorough user-centered design process involving consultation with subject-matter experts, usability interviews and surveys, and user experience surveys.

Results

In addition to Game Plan’s pre-existing content, the additional PrEP components provide specific, personal, and digestible feedback to users about their level of risk for HIV without PrEP and illustrate how much consistent PrEP use could reduce it; personal feedback about their risk for common sexually transmitted infections to address low-risk perceptions; content challenging common beliefs and misconceptions about PrEP to reduce stigma; content confronting familiar PrEP and alcohol beliefs; and a change planning module that allows users to select specific goals for starting and strategies for consistent PrEP use. Users can opt into a weekly 2-way SMS text messaging program that provides similar feedback over a 12-week period after using Game Plan and follows up on the goals they set.

Conclusions

Research preliminarily testing the efficacy of these components in improving PrEP outcomes, including uptake, adherence, sexually transmitted infection rates, and alcohol use, is currently ongoing. If supported, these components could provide a scalable tool that can be used in resource-limited settings in which face-to-face intervention is difficult.

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

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

Diagnostic accuracy of pooling urine, anorectal, and oropharyngeal specimens for the detection of Chlamydia trachomatis and Neisseria gonorrhoeae: a systematic review and meta-analysis

BACKGROUND

Screening for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) at genital and extragenital sites is needed for most key populations, but molecular diagnostic tests for CT/NG are costly. We aimed to determine the accuracy of pooled samples from multiple anatomic sites from one individual to detect CT/NG using the testing of a single sample from one anatomic site as the reference.

METHODS

In this systematic review and meta-analysis, we searched five databases for articles published from January 1, 2000, to February 4, 2021. Studies were included if they contained original data describing the diagnostic accuracy of pooled testing compared with single samples, resource use, benefits and harms of pooling, acceptability, and impact on health equity. We present the pooled sensitivities and specificities for CT and NG using a bivariate mixed-effects logistic regression model. The study protocol is registered in PROSPERO, an international database of prospectively registered systematic reviews (CRD42021240793). We used GRADE to evaluate the quality of evidence.

RESULTS

Our search yielded 7814 studies, with 17 eligible studies included in our review. Most studies were conducted in high-income countries (82.6%, 14/17) and focused on men who have sex with men (70.6%, 12/17). Fourteen studies provided 15 estimates for the meta-analysis for CT with data from 5891 individuals. The pooled sensitivity for multisite pooling for CT was 93.1% [95% confidence intervals (CI) 90.5-95.0], I²=43.3, and pooled specificity was 99.4% [99.0-99.6], I²=52.9. Thirteen studies provided 14 estimates for the meta-analysis for NG with data from 6565 individuals. The pooled sensitivity for multisite pooling for NG was 94.1% [95% CI 90.9-96.3], I²=68.4, and pooled specificity was 99.6% [99.1-99.8], I²=83.6. Studies report significant cost savings (by two thirds to a third).

CONCLUSION

Multisite pooled testing is a promising approach to improve testing coverage for CT/NG in resource-constrained settings with a small compromise in sensitivity but with a potential for significant cost savings.

Game Plan, a Web-Based Intervention to Improve Adherence and Persistence to HIV Pre-exposure Prophylaxis and Reduce Heavy Drinking in Gay, Bisexual, and Other Men Who Have Sex With Men: Usability and User Experience Testing

Background

Encouraging consistent use of pre-exposure prophylaxis (PrEP) is essential for reducing HIV incidence, particularly among gay, bisexual, and other men who have sex with men (GBM), and especially those who engage in heavy drinking. Although practice guidelines recommend providing adherence counseling to PrEP patients, clinics and providers may not have the resources or expertise to provide it. Internet-facilitated interventions have been shown to improve HIV prevention outcomes, including medication and care adherence. Game Plan is a website we created to help users make a tangible plan for reducing their HIV risk. We designed additional components of Game Plan to address key individual level barriers to PrEP use.

Objective

The aim of this mixed methods research is to test the usability and user experience of these components with intended users: GBM who drink heavily and are on PrEP.

Methods

In study 1 (usability), we completed a detailed individual interview in which participants (n=10) walked through a prototype of the website, thinking aloud as they did, and completed a follow-up interview and web-based survey afterward. Study 2 (user experience) involved providing participants (n=40) with a link to the prototype website to explore on their own and asking them to complete the same follow-up survey afterward. Qualitative data were analyzed using thematic analysis, and descriptive statistics were used to analyze quantitative data.

Results

Users in both studies gave the website excellent ratings for usability, overall satisfaction, and quality, and most often described the site as informative, helpful, and supportive. Users also rated the site’s content and feel as respectful of them and their autonomy, empathetic, and they stated that it conveyed confidence in their ability to change. The study 1 interviews highlighted the importance of the website’s esthetics to the participants’ engagement with it and its credibility in prompting genuine reflection.

Conclusions

GBM who reported heavy drinking and used PrEP generally found a website focused on helping them to create a plan to use PrEP consistently to be helpful. Adopting user-centered design methods and attending to the esthetics of mobile health interventions are important steps toward encouraging engagement and reducing at-risk behaviors.

Participation, retention and uptake in a multicentre pre-exposure prophylaxis cohort using online, smartphone-compatible data collection

Objectives

The aim of the study was to assess the feasibility of a national pre‐exposure prophylaxis (PrEP) programme using smartphone‐compatible data collection.

Methods

This was a multicentre cohort study (NCT03893188) enrolling individuals interested in PrEP in Switzerland. All centres participate in the SwissPrEPared programme, which uses smartphone‐compatible data collection. Feasibility was assessed after centres had enrolled at least one participant. Participants were HIV‐negative individuals presenting for PrEP counselling. Outcomes were participation (number enrolled/number eligible), enrolment rates (number enrolled per month), retention at first follow‐up (number with first follow‐up/number enrolled), and uptake (proportion attending first visit as scheduled). Participant characteristics were compared between those retained after baseline assessment and those who dropped out.

Results

Between April 2019 and January 2020, 987 individuals were assessed for eligibility, of whom 969 were enrolled (participation: 98.2%). The median enrolment rate was 86 per month [interquartile range (IQR) 52–137]. Retention at first follow‐up and uptake were both 80.7% (782/969 and 532/659, respectively). At enrolment, the median age was 40 (IQR 33–47) years, 95% were men who have sex with men, 47% had a university degree, and 75.5% were already taking PrEP. Most reported multiple casual partners (89.2%), previous sexually transmitted infections (74%) and sexualized drug use (73.1%). At baseline, 25.5% tested positive for either syphilis, gonorrhoea or chlamydia. Participants who dropped out were at lower risk of HIV infection than those retained after baseline assessment.

Conclusions

In a national PrEP programme using smartphone‐compatible data collection, participation, retention and uptake were high. Participants retained after baseline assessment were at considerable risk of HIV infection. Younger, less educated individuals were underrepresented in the SwissPrEPared cohort.

Underlying factors related to HIV/AIDS prevention: investigating the willingness to take pre-exposure prophylaxis among men-who-have-sex-with-men in Germany

BACKGROUND

This study investigates the willingness of men-who-have-sex-with-men (MSM) to use HIV pre-exposure prophylaxis (PrEP). Research in the HIV/AIDS field typically relies on clinical and epidemiological studies, thereby often excluding social dimensions of the illness as well as factors explaining its prevention. The current study analyzes HIV-prevention through an interdisciplinary theoretical approach. It aims to comprehensively understand the mechanisms associated with the willingness to take PrEP among MSM in terms of psychological, social, behavioral, cultural, and demographic factors.

METHODS

We analyze data from the survey "Gay Men and AIDS" conducted in Germany in 2013 prior to market approval for PrEP. Analyses were performed using the statistical software SPSS 25.0, while results were visualized using the R programming language.

RESULTS

We find that perceived risk of infection, social norms (anticipated HIV-stigma), practices (e.g. regular condomless sex), and socio-demographic factors (young age, being single) all have a positive effect on the willingness to take PrEP, while education reveals a negative, and income no effect.

CONCLUSIONS

Results indicate that beyond well-established socio-psychological mechanisms of health behavior, social factors play a crucial role in understanding the willingness of PrEP uptake. This study enriches existing health behavior theories with sociological concepts such as social norms and social practices.

Clinical Presentation of Incident Syphilis Among Men Who Have Sex with Men Taking HIV Pre-Exposure Prophylaxis in Melbourne, Australia

BACKGROUND

Current international guidelines on human immunodeficieny virus (HIV) Pre-Exposure Prophylaxis (PrEP) recommend serological screening for syphilis at routine 3-monthly PrEP appointments. The aim of our study was to describe the pattern of clinical presentation of syphilis among men who have sex with men (MSM) taking PrEP. We were interested in whether syphilis is detected through screening at scheduled3-monthly PrEP clinic appointments or whether primary or secondary syphilis presented at unscheduled interval visits.

METHODS

This was a retrospective study of MSM attending the PrEP clinic at the Melbourne Sexual Health Centre between February 2016 and March 2019. Serological screening for syphilis was routinely undertaken at 3-monthly PrEP clinic appointments. Diagnoses of early syphilis were identified from PrEP clinic visits and from interim walk-in STI clinic attendances.

RESULTS

There were 69 cases of early syphilis among 61 MSM taking PrEP during the study period. There were 24 (35%) primary, 16 (23%) secondary, and 29 (42%) early latent infections. The incidence of early syphilis was 8.6 per 100 person-years. A substantial proportion of primary (58%) and secondary (44%) syphilis diagnoses were made at interim STI clinic attendances, between PrEP appointments.

CONCLUSIONS

Syphilis screening at routine 3-monthly PrEP visits alone fails to detect a proportion of primary and secondary syphilis infections and may be insufficient in preventing onward transmission. Education of MSM taking PrEP regarding the risk of syphilis and symptom recognition is necessary together with access to syphilis testing between PrEP visits.

The Intersection of HIV and Syphilis: Update on the Key Considerations in Testing and Management

PURPOSE OF REVIEW

To highlight recent trends in the epidemiology of HIV and syphilis, the impact of the COVID epidemic, our approach to care of co-infected patients, and our views on important next steps in advancing the field.

RECENT FINDINGS

HIV and syphilis co-infection has been on the rise in recent years although since the COVID pandemic there is a decrease in new diagnoses-it remains unclear if this represents a true decline or inadequate testing or under-reporting. Standard HIV care should include regular syphilis serology .Treatment and serological follow-up of syphilis in HIV positive and negative patients can be conducted similarly. Challenges remain in the diagnosis and management of neurosyphilis. New models for testing and prevention will be crucial next steps in controlling co-infection. The intersection of HIV and syphilis infections continues to pose new and unique challenges in diagnosis, treatment, and prevention.

Incident Cases of Sexually Transmitted Infections among Users of Pre-Exposure Prophylaxis for HIV Prevention in Honolulu, Hawai'i

Emtricitabine/tenofovir disoproxil fumarate [FTC-TDF] is a daily oral medication taken by HIV-negative individuals for pre-exposure prophylaxis (PrEP) to prevent human immunodeficiency virus (HIV) infection. A higher incidence of sexually transmitted infections (STIs) among PrEP users has been reported compared to STI incidence before PrEP use. Asymptomatic incident STI rates were investigated among 78 patients presenting for PrEP in Honolulu, Hawai'i, from April 2018 to May 2019. Testing for oropharyngeal gonorrhea, urethral gonorrhea and chlamydia, rectal gonorrhea and chlamydia, and syphilis was performed. Incident STI percentages were calculated at each follow-up visit. Ninety-seven percent of patients were men who have sex with men (MSM). Forty-seven percent of patients had follow-up data 6 months after initiation and 28% after 1 year. Thirty-two percent of patients self-reported an STI before initiating PrEP. More than half reported anonymous partners. There were 35 positive STI tests during the study period, and 25% of patients had one or more positive tests during this time. At initiation, 17% of patients were found to have an STI, followed by 16% at 3 months, 14% at 6 months, 8% at 9 months, and 5% at 12 months. At all visits, chlamydia was the most common STI detected; at 6 months, 18% of all rectal tests were positive for chlamydia. There were inconsistent condom use and high STI rates from screening during PrEP initiation and follow-up, offering an opportunity to identify asymptomatic STIs in this population. This study is the first report in Hawai'i of STI rates among PrEP users.

HIV Pre-exposure Prophylaxis in the LGBTQ Community: A Review of Practice and Places

One in six bisexual and gay men will be diagnosed with HIV in their lifetime (Human Rights Campaign, 2017). Without a vaccine or cure, prevention may be the best tool to control the HIV pandemic. Since 2012, the World Health Organization (WHO) recommends HIV pre-exposure prophylaxis (PrEP) for a high-risk population. To this day, in the United States (U.S.), the group with the highest risk is MSM (men who have sex with other men) that have condom-less sexual intercourse (Center for Disease Control and Prevention, 2019). In fact, in 2018, over 50% of all HIV infections occurred in MSM and members of the LGBT community. A systematic review was conducted using PubMed, Google Scholar, and Cochrane Library. The inclusive criteria were articles published from 2015-2020, focusing specifically on HIV PrEP among the members of the LGBTQ+ community. The keywords for our search were "Pre-exposure prophylaxis," "HIV," "men who have sex with other men" (MSM), "Bisexual," "transgender." A total of 25 articles met the inclusion criteria. About 50% of the articles focused on MSM while others highlighted bisexual and transgender women. Globally, PrEP is a priority. Programs to educate and promote its use are being developed, but challenges are present regarding access to PrEP and its maintenance for longer than 12 months. In the U.S., PrEP programs started in 2012, intending to promote and educate. Research shows that more than 60% of the high-risk patients are willing to try PrEP if they are correctly educated, showing that physicians were not doing a thorough job educating their patients. PrEP is essential for preventing the transmission of HIV among the LGBTQ+ subpopulation. Existing gaps need to be bridged to create or improve to educate high-risk populations and physicians on HIV PrEP.

Ocular syphilis in patients with human immunodeficiency virus/acquired immunodeficiency syndrome in the era of highly active antiretroviral therapy

Purpose:

Re-emergent ocular syphilis in patients with Human immunodeficiency virus (HIV) co-infection has both diagnostic and management difficulties because of the overlapping risk factors. The clinical manifestations described in non-HIV may not be the same in patients with HIV coinfection. Immune recovery uveitis (IRU) may also alter the course of the disease causing recurrences. We studied the clinical features in correlation with CD4 counts, systemic immune status, sexual preferences and management outcomes in HIV/AIDS patients with ocular syphilis in the highly active antiretroviral treatment (HAART) era from a high endemic HIV population like India.

Methods:

Retrospective analysis of all patients with ocular syphilis and HIV/AIDS seen between 2016 and 2019 was done.

Results:

A total of 33 patients (56 eyes) with a CD4 count range of 42–612 cells/cu.mm were included. Ocular syphilis was found to be higher in individuals with high risk behavior such as men who have sex with men (MSMs) (45%). Panuveitis was the commonest manifestation (53.57%) and was even the presenting feature of HIV and syphilis in many patients. Significant vitritis, usually uncommon in HIV/AIDS immunocompromised patients was noted even with low CD4 counts in patients with ocular syphilis. Significant correlation was noted between ocular presentation and CD4 counts (P < 0.05).

Conclusion:

Ocular syphilis presents differently in patients with HIV/AIDS. Diffuse retinitis is seen commonly in low counts (<100 cells/cu.mm). Classical placoid chorioretinitis lesions usually described in non-HIV individuals is uncommon in HIV patients and is seen in higher CD4 counts ( >400 cells/cu.mm). Ocular manifestations can be an indicator of the immune status of the patient. Not all patients with ocular manifestations have associated features of systemic syphilis. Ocular manifestations can be the first presentation of HIV/AIDS. Although, there is good response to systemic penicillin and HAART, recurrences and immune recovery uveitis (IRU) can also occur.

Bugs That Can Resist Antibiotics but Not Men: Gender-Specific Differences in Notified Infections and Colonisations in Germany, 2010-2019

Data from surveillance networks show that men have a higher incidence rate of infections with anti-microbial-resistant (AMR) pathogens than women. We systematically analysed data of infections and colonisations with AMR pathogens under mandatory surveillance in Germany to quantify gender-specific differences. We calculated incidence-rates (IR) per 100,000 person-years for invasive infections with Methicillin-resistant Staphylococcus aureus (MRSA), and for infections or colonisations with carbapenem-non-susceptible Acinetobacter spp. (CRA), and Enterobacterales (CRE), using the entire German population as a denominator. We limited the study periods to years with complete notification data (MRSA: 2010-2019, CRA/CRE: 2017-2019). We used Poisson regression to adjust for gender, age group, federal state, and year of notification. In the study periods, IR for all notifications were 4.2 for MRSA, 0.90 for CRA, and 4.8 for CRE per 100,000 person--years. The adjusted IR ratio for infections of men compared to women was 2.3 (95% confidence interval [CI]: 2.2-2.3) for MRSA, 2.2 (95%CI: 1.9-2.7) for CRA, and 1.7 (95%CI: 1.6-1.8) for CRE. Men in Germany show about double the risk for infection with AMR pathogens than women. This was also true for colonisations, where data were available. Screening procedures and associated hygiene measures may profit from a gender-stratified approach.

Control of sexually transmitted infections and global elimination targets, South-East Asia Region

The World Health Organization (WHO) set targets for a 90% reduction in the incidence of syphilis and gonorrhoea between 2018 and 2030. We review trends in sexually transmitted infections in the WHO South-East Asia Region to assess the feasibility of reaching these targets. Myanmar, Sri Lanka and Thailand reported 90% or greater reductions in the incidence or prevalence of syphilis and/or gonorrhoea between 1975 and 2005. Evidence suggests that smaller, more recent reductions in trends in sexually transmitted infections in India have driven regional declines. In other countries, sexually transmitted infections remain high or are increasing or data are not reliable enough to measure change. Sri Lanka and Thailand have strong control programmes for sexually transmitted infections that ensure universal access to services for these infections and targeted interventions in key populations. India and Myanmar have implemented targeted control efforts on a large scale. Other countries of the region have prioritized control of human immunodeficiency virus, and limited resources are available for other sexually transmitted infections. At national and subnational levels, data show rapid declines in sexually transmitted infections when targeted promotion of condom use and sexually transmitted infection services are scaled up to reach large numbers of sex workers. In contrast, recent outbreaks of sexually transmitted infections in underserved populations of men who have sex with men have been linked to rising trends in sexually transmitted infections in the region. A renewed and focused response to sexually transmitted infections in the region is needed to meet global elimination targets.