Global Epidemiologic Characteristics of Sexually Transmitted Infections Among Individuals Using Preexposure Prophylaxis for the Prevention of HIV Infection: A Systematic Review and Meta-analysis

Frequent chlamydia and gonorrhoea but very infrequent syphilis among men who have sex with men using HIV pre-exposure prophylaxis in West Africa

OBJECTIVES

Although oral pre-exposure prophylaxis (PrEP) for HIV is being rolled out in West Africa, data on sexually transmitted infections (STIs) in PrEP users are scarce. We assessed the prevalence, incidence and determinants of bacterial STIs in men who have sex with men (MSM) taking PrEP in Burkina Faso, Côte d'Ivoire, Mali and Togo.

METHODS

A prospective cohort study among MSM initiating PrEP as part of a comprehensive HIV prevention package was conducted between 2017 and 2021 in community-based clinics in the four study countries. Molecular screening for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) was performed at months 0, 6 and 12. Serological testing for syphilis was performed every 3 months over the first year of follow-up. Determinants of CT and/or NG incidence were identified using Poisson generalised linear mixed models.

RESULTS

A total of 598 participants with a median age of 24.7 years were included. Prevalence of CT and/or NG was 24.4% (95% CI 21.0 to 28.1), 22.4% (95% CI 18.4 to 26.8) and 29.0% (95% CI 24.2 to 34.1) at months 0, 6 and 12, respectively. The prevalence of syphilis ranged from 0.2% (95% CI 0.0 to 0.9) at month 0 to 0.8% (95% CI 0.2 to 2.4) at month 12. Ninety incident CT and/or NG infections occurred during a total follow-up time of 280.6 person-years (incidence rate 32.1 per 100 person-years, 95% CI 25.8 to 39.4). Three incident syphilis infections were detected during a total follow-up time of 459.7 person-years (incidence rate 0.7 per 100 person-years, 95% CI 0.1 to 1.9). CT and/or NG incidence was associated with condomless insertive anal sex (adjusted incidence rate ratio 1.96, 95% CI 1.04 to 3.71, p=0.038).

CONCLUSIONS

CT and NG were frequent but syphilis was very infrequent in MSM using HIV PrEP in West Africa. HIV programme managers should integrate STI services into PrEP programmes.

High cure rates of Mycoplasma genitalium following empiric treatment with azithromycin alongside frequent detection of macrolide resistance in Austria

BACKGROUND

Mycoplasma genitalium (MG) is an emerging sexually transmitted infection, often harboring resistance-associated mutations to azithromycin (AZM). Global surveillance has been mandated to tackle the burden caused by MG, yet no data are available for Austria. Thus, we aimed to investigate the prevalence of MG, disease characteristics, and treatment outcomes at the largest Austrian HIV-and STI clinic.

METHODS

All MG test results at the Medical University of Vienna from 02/2019 to 03/2022 were evaluated. Azithromycin resistance testing was implemented in 03/2021.

RESULTS

Among 2671 MG tests, 199 distinct and mostly asymptomatic (68%; 135/199) MG infections were identified, affecting 10% (178/1775) of all individuals. This study included 83% (1479/1775) men, 53% (940/1775) men who have sex with men (MSM), 31% (540/1754) HIV+, and 15% (267/1775) who were using HIV pre-exposure prophylaxis (PrEP). In logistic regression analysis, 'MSM' (aOR 2.55 (95% CI 1.65-3.92)), 'use of PrEP' (aOR 2.29 (95% CI 1.58-3.32)), and 'history of syphilis' (aOR 1.57 (95% CI 1.01-2.24) were independent predictors for MG infections. Eighty-nine percent (178/199) received treatment: 11% (21/178) doxycycline (2 weeks), 52% (92/178) AZM (5 days), and 37% ( 65/178) moxifloxacin (7-10 days) and 60% (106/178) had follow-up data available showing negative tests in 63% (5/8), 76% (44/58) and 85% (34/40), respectively. AZM resistance analysis was available for 57% (114/199)) and detected in 68% (78/114). Resistance-guided therapy achieved a cure in 87% (53/61), yet, empiric AZM-treatment (prior to 03/2021) cleared 68% (26/38).

CONCLUSIONS

Mycoplasma genitalium was readily detected in this Austrian observational study, affected predominantly MSM and often presented as asymptomatic disease. We observed a worryingly high prevalence of AZM resistance mutations; however, empiric AZM treatment cleared twice as many MG infections as expected.

Factors associated with hepatitis A susceptibility among men who have sex with men using HIV pre-exposure prophylaxis in Northeastern Brazil: A cross-sectional study

Hepatitis A virus (HAV) infection has disproportionately affected more men who have sex with men (MSM), occurring in outbreaks, despite being vaccine-preventable. We determined the prevalence and factors associated with HAV susceptibility among cisgender MSM on HIV pre-exposure prophylaxis (PrEP) in Northeastern Brazil. From September 30, 2021 to June 19, 2023, 282 cisgender MSM receiving HIV PrEP were enrolled into this cross-sectional study. Sociodemographic and clinical information were collected. Blood samples were collected for screening of sexually transmitted infections (STIs) and serum samples were tested for IgM and total anti-HAV antibodies. Non-reactive results for total anti-HAV antibodies were found in 106 of 282 (37.6%) participants. Factors associated with HAV susceptibility included age <30 years (prevalence ratio [PR]: 2.02; 95% confidence interval [95% CI]: 1.61-2.53), having health insurance (PR: 1.39; 95% CI: 1.19-1.64), sex only with cisgender men (PR: 1.52; 95% CI: 1.23-1.89), non-steady partner (PR: 1.20; 95% CI: 1.01-1.43) and no lifetime history of STIs (PR: 1.25; 95% CI: 1.03-1.53). Identifying clinical correlates of HAV susceptibility in key populations is a fundamental step towards development of public policy focused on prevention, especially following the recent hepatitis A outbreak in Brazil.

Lymphogranuloma venereum verläuft häufig asymptomatisch bei Männern, die Sex mit Männern haben, in Österreich

Hintergrund und Ziele

Lymphogranuloma venereum (LGV) ist eine sexuell übertragene Erkrankung verursacht durch Chlamydia trachomatis (CT), Serovar L1–L3. Eine Zunahme von LGV ist vorwiegend bei Männern, die Sex mit Männern haben (MSM), beobachtet worden. Die Unterscheidung zwischen LGV und Nicht‐LGV‐Serovaren hat therapeutische Konsequenzen, daher wurden Prävalenz und Charakteristika von LGV innerhalb aller CT‐Infektionen untersucht.

Patienten und Methodik

Alle CT‐positiven Befunde, erhoben an den vier größten österreichischen HIV‐ und STI‐Kliniken von 04/2014–12/2021, wurden hinsichtlich Charakteristika der Erkrankung und Demographie der Patienten ausgewertet.

Ergebnisse

Insgesamt wurden n = 2083 CT‐Infektionen bei n = 1479 Personen dokumentiert. Das mediane Alter betrug 31,4 Jahre, 81% waren männlich, 59% MSM, 44% HIV‐positiv, 13% nutzten HIV‐Prä‐Expositionsprophylaxe. Serovaranalysen waren bei 61% (1258/2083) verfügbar, wobei L1–L3 in 15% (192/1258) aller Fälle nachgewiesen wurde. Bei MSM mit rektaler CT‐Infektion waren 23% (101/439) LGV. LGV‐Fälle verglichen mit CT‐Infektionen traten vermehrt bei MSM (92% [177/192] vs. 62% [1179/1891], p < 0,001), HIV‐Positivität (64% [116/180] vs. 46% [631/1376]; p < 0,001) und konkomitanter Syphilisinfektion (18% [32/180] vs. 7% [52/749]; p < 0,001) auf. LGV‐Infektionen verliefen zumeist asymptomatisch (45% [87/192]), gefolgt von Proktitis (38% [72/192]).

Schlussfolgerungen

Lymphogranuloma venereum machte 23% der rektalen CT‐Infektionen bei MSM aus und 45% aller LGV‐Fälle waren asymptomatisch. Bei fehlender CT‐Serovar‐Analyse sollte in Risikopopulationen eine erhöhte LGV‐Prävalenz in Betracht gezogen und bei der empirischen Therapiedauer berücksichtigt werden.

Asymptomatic lymphogranuloma venereum is commonly found among men who have sex with men in Austria

BACKGROUND AND OBJECTIVES

Serovar L1-L3 of Chlamydia trachomatis (CT) causes lymphogranuloma venereum (LGV). A surge in LGV-cases has been observed among HIV-positive men who have sex with men (MSM). Discrimination between LGV and non-LGV is pivotal since it has major treatment implications. Here, we aimed to determine the prevalence and characteristics of LGV among CT-infections.

PATIENTS AND METHODS

All CT-positive results from 04/2014-12/2021 at the four largest Austrian HIV and STI clinics were evaluated. Disease characteristics and patient demographics were analyzed.

RESULTS

Overall, n  =  2,083 infections of CT were documented in n  =  1,479 individual patients: median age was 31.4 years, 81% were male, 59% MSM, 44% HIV-positive, 13% on HIV pre-exposure-prophylaxis. Available serovar analyses (61% [1,258/2,083]) showed L1-L3 in 15% (192/1,258). Considering only MSM with rectal CT-infection, LGV accounted for 23% (101/439). Cases of LGV vs. other CT-infections were primarily MSM (92% [177/192] vs. 62% [1,179/1,891], p < 0.001), more often HIV-positive (64% [116/180] vs. 46% [631/1,376]; p < 0.001) and had frequently concomitant syphilis infection (18% [32/180] vs. 7% [52/749]; p < 0.001). LGV commonly manifested as proctitis (38% [72/192]) whereas 45% (87/192) were asymptomatic.

CONCLUSIONS

Lymphogranuloma venereum accounted for 23% of rectal CT-infections in MSM. Furthermore, 45% of all LGV-cases were asymptomatic. In the absence of CT-serovar analysis, a high LGV prevalence should be considered in risk-populations and guide empiric treatment selection.

Doxycycline Prophylaxis to Prevent Sexually Transmitted Infections in Women

BACKGROUND

Doxycycline postexposure prophylaxis (PEP) has been shown to prevent sexually transmitted infections (STIs) among cisgender men and transgender women, but data from trials involving cisgender women are lacking.

METHODS

We conducted a randomized, open-label trial comparing doxycycline PEP (doxycycline hyclate, 200 mg taken within 72 hours after condomless sex) with standard care among Kenyan women 18 to 30 years of age who were receiving preexposure prophylaxis against human immunodeficiency virus (HIV). The primary end point was any incident infection with Chlamydia trachomatis, Neisseria gonorrhoeae, or Treponema pallidum. Hair samples were collected quarterly for objective assessment of doxycycline use.

RESULTS

A total of 449 participants underwent randomization; 224 were assigned to the doxycycline-PEP group and 225 to the standard-care group. Participants were followed quarterly over 12 months. A total of 109 incident STIs occurred (50 in the doxycycline-PEP group [25.1 per 100 person-years] and 59 in the standard-care group [29.0 per 100 person-years]), with no significant between-group difference in incidence (relative risk, 0.88; 95% confidence interval [CI], 0.60 to 1.29; P = 0.51). Among the 109 incident STIs, chlamydia accounted for 85 (78.0%) (35 in the doxycycline-PEP group and 50 in the standard-care group; relative risk, 0.73; 95% CI, 0.47 to 1.13). No serious adverse events were considered by the trial investigators to be related to doxycycline, and there were no incident HIV infections. Among 50 randomly selected participants in the doxycycline-PEP group, doxycycline was detected in 58 of 200 hair samples (29.0%). All N. gonorrhoeae-positive isolates were resistant to doxycycline.

CONCLUSIONS

Among cisgender women, the incidence of STIs was not significantly lower with doxycycline PEP than with standard care. According to hair-sample analysis, the use of doxycycline PEP among those assigned to receive it was low. (Funded by the National Institutes of Health; dPEP ClinicalTrials.gov number, NCT04050540.).

Trends in Testing and Self-Reported Diagnoses of Sexually Transmitted Infections in Gay and Bisexual Men in Australia, 2017 to 2021: Analysis of National Behavioral Surveillance Surveys

BACKGROUND

Gay, bisexual, and other men who have sex with men (GBM) are overrepresented in diagnoses of sexually transmitted infections (STIs) relative to their population size. This study assessed trends in STI testing and diagnoses among GBM in Australia.

METHODS

The Gay Community Periodic Surveys are repeated cross-sectional behavioral surveillance surveys of GBM. Participants reported the number of anal swabs, throat swabs, urine samples, and blood tests for syphilis they undertook in the last year. "Frequent comprehensive testing" was defined as ≥3 of each test in the previous year. Participants reported STI diagnoses of chlamydia, gonorrhea, syphilis, and other STIs in the last year. Trends in testing and diagnoses from 2017 to 2020 and 2020 to 2021 were assessed with logistic regression models.

RESULTS

We analyzed 24,488 survey responses from participants reporting casual sex in the last 6 months. Between 2017 and 2020, frequent comprehensive STI testing decreased among HIV-negative GBM on preexposure prophylaxis (PrEP) from 71.7% to 68.9% and declined further to 58.6% in 2021. Frequent comprehensive STI testing was stable during 2017-2020 among HIV-negative/untested GBM not on PrEP (17.4%-14.6%) and HIV-positive GBM (30.4%-35.1%) but declined in 2021 to 7.5% among non-PrEP-users and 25.7% among HIV-positive participants. There were minimal changes in STI diagnoses during 2017-2020, but diagnoses declined in 2021.

CONCLUSIONS

Many GBM do not meet Australian STI testing guidelines that recommend quarterly testing. Further evaluation of whether this recommendation is realistic or necessary to reduce STIs among GBM is recommended.

Association between where men who have sex with men (MSM) meet sexual partners and chlamydia/gonorrhoea infection before and during the COVID-19 pandemic in San Diego, California

BACKGROUND

Meeting sex partners online is associated with increased risk of acquiring sexually transmitted infections. We examined whether different venues where men who have sex with men (MSM) meet sex partners was associated with prevalent Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infection, and whether prevalence increased during (vs before) the COVID-19 pandemic.

METHODS

We conducted a cross-sectional analysis of data from San Diego's 'Good To Go' sexual health clinic from two enrolment periods: (1) March-September 2019 (pre-COVID-19) and (2) March-September 2021 (during COVID-19). Participants completed self-administered intake assessments. This analysis included males aged ≥18 years self-reporting sex with males within 3 months before enrolment. Participants were categorised as (1) meeting new sex partners in-person only (eg, bars, clubs), (2) meeting new sex partners online (eg, applications, websites) or (3) having sex only with existing partners. We used multivariable logistic regression, adjusting for year, age, race, ethnicity, number of sex partners, pre-exposure prophylaxis use and drug use to examine whether venue or enrolment period were associated with CT/NG infection (either vs none).

RESULTS

Among 2546 participants, mean age was 35.5 (range: 18-79) years, 27.9% were non-white and 37.0% were Hispanic. Overall, CT/NG prevalence was 14.8% and was higher during COVID-19 vs pre-COVID-19 (17.0% vs 13.3%). Participants met sex partners online (56.9%), in-person (16.9%) or only had existing partners (26.2%) in the past 3 months. Compared with having only existing sex partners, meeting partners online was associated with higher CT/NG prevalence (adjusted OR (aOR) 2.32; 95% CI 1.51 to 3.65), while meeting partners in-person was not associated with CT/NG prevalence (aOR 1.59; 95% CI 0.87 to 2.89). Enrolment during COVID-19 was associated with higher CT/NG prevalence compared with pre-COVID-19 (aOR 1.42; 95% CI 1.13 to 1.79).

CONCLUSIONS

CT/NG prevalence appeared to increase among MSM during COVID-19, and meeting sex partners online was associated with higher prevalence.

Comparing the Integration of Syndromic versus Etiological Management of Sexually Transmitted Infections Into HIV Pre-Exposure Prophylaxis Services for Adolescent Girls and Young Women, in South Africa

South Africa has a high incidence of human immunodeficiency virus and sexually transmitted infections (STIs), particularly among adolescent girls and young women. National and global guidelines recommend varied strategies for integrating STI and pre-exposure prophylaxis (PrEP) services.

PURPOSE

This paper describes the implementation of a syndromic compared to an etiological approach to STI integration within PrEP services in South Africa.

METHODS

We analysed program data from eight fixed and four mobile clinics to describe a cascade of STI care and integration of syndromic management among clients accessing PrEP services. Diagnostic testing was conducted in a subset of clients to determine the prevalence of STIs and estimate the burden of disease missed using a syndromic approach.

RESULTS

Between December 2018 and December 2021, 22,505 clients sought services and a high proportion (92.9%) was screened for STI symptoms. Of these, 9% of females and 3% of males had symptoms and 89.5% had recorded treatment. In a subset of PrEP clients (406 females, 70 males) screened through laboratory testing, chlamydia was identified in 25.7% of female and 20.0% of male samples, gonorrhea in 14.1% of female and 18.6% of male samples, and syphilis in 2.3% of female and 1.4% of male samples. Highest prevalence was found among females aged 18-20 years.

DISCUSSION

Syndromic STI screening and management can be integrated into routine PrEP service delivery and can identify symptomatic STIs, but misses asymptomatic infections. PrEP clients have a high prevalence of treatable STIs. Etiologic approaches can identify more infections than syndromic screening, but cheap point-of-care tests are needed.

Epidemiology and determinants of reemerging bacterial sexually transmitted infections (STIs) and emerging STIs in Europe

In this scoping review, we offer a comprehensive understanding of the current and recent epidemiology, challenges, and emerging issues related to bacterial sexually transmitted infections (STIs) in the WHO European Region. We endeavour in collating data from both EU/EEA and non- EU/EEA countries, thereby giving a complete picture of the region which highlights the higher notification rates in Northern and Western countries than other regions, likely due to differences in testing, access to testing, and surveillance capacity. We provide an up-to-date review on the current knowledge of determinants and persistent inequities in key populations as well as the use of molecular epidemiology for identifying transmission networks in gonorrhoea and syphilis, and detecting chlamydia mutations that evade molecular diagnosis. Finally, we explore the emerging STIs in the region and the evolving transmission routes of food and waterborne diseases into sexual transmission. Our findings call for harmonized STI surveillance systems, proactive strategies, and policies to address social factors, and staying vigilant for emerging STIs.

Sexually Transmitted Dermatophytes Can Cause Severe Infection Among Men who Have Sex With Men as Tinea Genitalis

Very limited data on tinea genitalis, a potentially severe dermatophytosis transmitted during sexual intercourse affecting the genital area, suggest its potential to cause outbreaks. Thus, we investigated genital dermatophyte infections at an HIV/sexually transmitted infection clinic and identified 17 men who have sex with men (all people with HIV or pre-exposure prophylaxis users) diagnosed with tinea genitalis.

Challenges and Solutions to STI Control in the Era of HIV and STI Prophylaxis

PURPOSE OF REVIEW

This article reviews current efforts to control bacterial sexually transmitted infections (STIs) among HIV pre-exposure prophylaxis (PrEP) users and outlines the opportunities and challenges to controlling STIs within HIV PrEP programs.

RECENT FINDINGS

The incidence of STIs continues to rise globally especially among HIV PrEP users, with an estimated 1 in 4 PrEP users having a curable bacterial STI. STIs and HIV comprise a syndemic needing dual interventions. The majority of STIs are asymptomatic, and when testing is available, many STIs occur in extragenital sites that are missed when relying on urine testing or genital swabs. Optimal testing and treatment, including testing for antimicrobial resistance, pose difficulties in high income countries and is essentially non-existent in most low- and middle-income countries. Novel STI primary prevention strategies, like doxycycline post-exposure prophylaxis (PEP) for STI prevention, have proven to be highly efficacious in some populations. A few jurisdictions have issued normative guidelines and position statements for doxycycline PEP; however, clinical standards for implementation and data on public health impact are limited. STI incidence rates are high and rising in sexually active populations. Sexual health programs should leverage the expansion of HIV PrEP delivery services to integrate STI testing, surveillance, and novel STI prevention services.

Sexually transmitted infections and associated risk factors among the transgender population of Pakistan

BACKGROUND

Transgender (TG) people are key drivers for sexually transmitted infections (STIs) all over the world. There is substantial evidence that STIs are associated with an increased likelihood of risky sexual behavior however little is known about the prevalence of STIs (HIV, HBV, HCV, and Syphilis) among HIV infected transgender population in Pakistan.

METHODS

The current study investigated the seroprevalence of four STIs and associated socio-demographic risk factors among TGs of Punjab, Pakistan from July 2019 to June 2021. The samples were tested serologically and final confirmation was done through PCR for HIV, HBV, and HCV.

RESULTS

A total of 1,562 transgenders cross-sectional descriptive records of the Punjab AIDS Control Program (PACP) were reviewed during the period from July 2019 to June 2021. The serological results evidenced that 533 (34.1%) had one pathogen, 309 (19.8%) had two or more (multiple) infections. The most predominant mono-infection among the transgender population was Syphilis 324 (20.7%) followed by HCV 114 (7.3%), HIV 69 (4.4%), and HBV 26 (1.7%). The highest proportions of Infections were found in TG residing in urban areas (68.6%) as compared to rural areas (31.4%). The seropositivity of all STIs was predominantly increased in Sex worker TGs i-e 55%, 46.5%, 38.5%, and 41.8% in HIV, HBV, HCV, and Syphilis respectively. Among 280 HIV-infected Transgender, 177 (63.2%) had Syphilis co-infections. While 87 (31%) and 47 (16.8%) HIV-infected individuals had HC and HBV co-infection respectively.

CONCLUSION

Transgender is neglected population group in society. All STIs were predominantly common among sex worker transgenders, Illiterate educational groups, and TGs residing in urban areas. There is a need to spread awareness about STIs, preventive strategies, and facilitation to health care programs in this high-risk population group.

Association between early sexual initiation and sexually transmitted infections among Peruvian reproductive-age women

Background

Sexually transmitted infections (STIs) are a serious public health problem worldwide, especially among reproductive-age women. The early sexual onset of sexual intercourse (EOSI) has been suggested as a risk factor, although there is no data at the national level.

Objective

To evaluate the association between EOSI and STIs in Peruvian women of childbearing age.

Methods

Analytical cross-sectional study with secondary data analyzes of the Peruvian Demographic and Family Health Survey 2018. The outcome was the presence of STIs in the last 12 months and the exposure variable was EOSI (age < 15 years at the time of their first sexual experience). To evaluate the association of interest, crude and adjusted prevalence ratios (aPRs) were calculated using generalized linear models with Poisson family and logarithmic link function.

Results

We analyzed data from 31,028 women of childbearing age. The 11.3% reported having STIs in the last 12 months and 20.2% of the participants had an EOSI. After adjusting for potential confounders, we found that EOSI was associated with STIs (aPR: 1.27; 95% CI: 1.08-1.50; p = 0.005). When conducting stratified analysis by area of residence and number of sexual partners, this association was maintained in women living in urban areas (aPR: 1.36; 95% CI: 1.11-1.66; p = 0.003) those who did not report having a history of multiple sexual partners (aPR: 1.27; 95% CI: 1.08-1.51; p = 0.005), and those in the middle (aPR: 1.42; 95% CI: 1.03-1.97; p = 0.034) and highest (aPR: 2.12; 95% CI: 1.33-3.39; p = 0.002) wealth quintiles.

Conclusion

Among reproductive-age women from Peru, EOSI was associated with STIs, especially in women living in urban areas, with no history of multiple sexual partners, and belonging to the middle to higher wealth index. The implementation of measures to prevent EOSI and fostering appropriate sexual health counseling for women with EOSI is advised.

Changes in HPV prevalence, incidence, and clearance following the use of HIV pre-exposure prophylaxis (PrEP) among MSM in Xinjiang, China: An observational cohort study

The association between HIV pre-exposure prophylaxis (PrEP) and the natural history of human papillomavirus (HPV) has not been well documented. Our objective was to evaluate the impact of PrEP on the prevalence, incidence, and clearance of anal HPV among men who have sex with men (MSM). Sexually active, HIV-negative MSM aged 18 years and older in Xinjiang, China since September 1, 2016, were enrolled in an ongoing observational cohort study of HPV. At baseline and every 6 months, an anal swab was taken to test for HPV and a questionnaire on sociodemographic characteristics and sexual behaviors was collected. Those who consented to receive PrEP were enrolled in an open-label PrEP intervention study from November 1, 2019, to June 30, 2021. This study analyzed data from participants present in the HPV cohort between November 1, 2019, and June 30, 2021. We compared the prevalence, incidence, and clearance of anal HPV between men who received PrEP (PrEP users) and those who did not (non-PrEP users), and compared men before and after initiating PrEP. We calculated prevalence ratios (PRs), incidence rate ratios (IRRs), and clearance rate ratios (CRRs) for both comparisons. Of the 870 participants present in the HPV cohort during the period between November 1, 2019, and June 30, 2021, 859 had adequate β-globin for HPV genotype testing and were included in our study. Among them, 429 were PrEP users, while 430 were non-PrEP users. Median age was 32 years (interquartile range [IQR]: 26-38). Among PrEP users, 217 were tested for anal HPV before PrEP initiation. PrEP users had lower prevalence of HPV 45, 51, and 54 (PRs: 0.27 [95% CI: 0.09-0.80], 0.42 [0.21-0.85], and 0.41 [0.17-0.99], respectively) and lower clearance of HPV 16 (CRR: 0.31 [0.10-0.91]) compared with non-PrEP users. PrEP users exhibited lower prevalence of HPV 51 (PR: 0.31 [0.12-0.84]), lower incidence of HPV 6, 11, 16, 39 and 61 (IRRs: 0.34 [0.13-0.90], 0.26 [0.08-0.87], 0.44 [0.21-0.91], 0.21 [0.05-0.93], and 0.19 [0.04-0.82], respectively), as well as higher clearance of HPV 52 (CRR: 2.17 [1.08-4.35]) after PrEP initiation. PrEP use may lower the risk of HPV infection among MSM in Xinjiang, China. Our findings further extend the knowledge of the impact of PrEP on sexually transmitted infections.

Incidence and Prevalence of Hepatitis C Virus Among HIV-Negative Gay and Bisexual Men Using HIV Pre-exposure Prophylaxis (PrEP): A Systematic Review and Meta-analysis

Background

Gay and bisexual men using HIV pre-exposure prophylaxis (PrEP) are at increased risk for sexually transmissible infections. Hepatitis C virus (HCV) risk among PrEP users is less clear. We explored HCV prevalence and incidence among cohorts of gay and bisexual men using PrEP and sources of heterogeneity across studies.

Methods

This was a systematic review and meta-analysis of open-label PrEP studies to April 2022 reporting HCV prevalence at baseline or incidence during follow-up among gay and bisexual men using PrEP. Pooled prevalence and incidence estimates were calculated using random-effects meta-analysis, and subgroup analyses were performed by study- and country-level characteristics, including availability of HCV direct-acting antiviral (DAA) therapy at time of study.

Results

Twenty-four studies from 9 countries were included, with a total sample of 24 733 gay and bisexual men. Pooled HCV antibody baseline prevalence was 0.97% (95% CI, 0.63%-1.31%), and pooled HCV RNA baseline prevalence was 0.38% (95% CI, 0.19%-0.56%). Among 19 studies reporting HCV incidence, incidence ranged from 0.0 to 2.93/100 person-years (py); the pooled estimate was 0.83/100py (95% CI, 0.55-1.11). HCV incidence was higher in 12 studies that began follow-up before broad DAA availability (1.27/100py) than in 8 studies that began follow-up after broad DAA availability (0.34/100py) and higher in studies in Europe compared with North America and Australia.

Conclusions

Early reports of high HCV incidence among PrEP-using cohorts likely reflect enrollment of individuals based on specific risk-based eligibility criteria for smaller studies and enrollment before DAA scale-up. In contexts where both DAAs and PrEP have been implemented at scale, studies report lower HCV incidence. PrEP-specific HCV testing guidelines should be guided by local epidemiology.

Characteristics of Kenyan women using HIV PrEP enrolled in a randomized trial on doxycycline postexposure prophylaxis for sexually transmitted infection prevention

INTRODUCTION

The global incidence of sexually transmitted infections (STIs) has been rapidly increasing over the past decade, with more than one million curable STIs being acquired daily. Young women in sub-Saharan Africa have a high prevalence and incidence of both curable STIs and HIV. The use of doxycycline as a prophylaxis to prevent STIs is promising; however, clinical trials, to date, have only been conducted among men who have sex with men (MSM) in high-income settings. We describe the characteristics of participants enrolled in the first trial to determine the efficacy of doxycycline post-exposure prophylaxis (PEP) to reduce STI incidence among women taking daily, oral HIV pre-exposure prophylaxis (PrEP).

METHODS

This is an open-label 1:1 randomized clinical trial on the efficacy of doxycycline PEP compared with standard of care (e.g., quarterly STI screening and treatment) to reduce incident bacterial STIs - Neisseria gonorrhoeae, Chlamydia trachomatis, and Treponema pallidum - among Kenyan women aged ≥18 and ≤30 years. All were also taking HIV pre-exposure prophylaxis (PrEP). We describe the baseline characteristics, STI prevalence, and STI risk perception of participants.

RESULTS

Between February 2020 and November 2021, 449 women were enrolled. The median age was 24 years (IQR 21-27), the majority were never married (66.1%), 370 women (82.4%) reported having a primary sex partner, and 33% had sex with new partners in the three months prior to enrolment. Two-thirds (67.5%, 268 women) did not use condoms, 36.7% reported transactional sex, and 43.2% suspected their male partners of having sex with other women. Slightly less than half (45.9%, 206 women) were recently concerned about being exposed to an STI. The prevalence of STIs was 17.9%, with C. trachomatis accounting for the majority of infections. Perceived risk of STIs was not associated with the detection of an STI.

CONCLUSION

Young cisgender women using HIV PrEP in Kenya and enrolled in a trial of doxycycline postexposure prophylaxis had a high prevalence of curable STIs and represent a target population for an STI prevention intervention.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

HIV pre-exposure prophylaxis and diagnoses of sexually transmitted infections - observational data from German checkpoints, 01/2019-08/2021

BACKGROUND

The impact of starting HIV pre-exposure prophylaxis (PrEP) on diagnoses of sexually transmitted infections (STI) remains unclear. We used data from German HIV/STI Checkpoints collected from 01/2019 to 08/2021 to determine the impact of PrEP use on syphilis, gonorrhoea and chlamydia diagnoses.

METHODS

We used self-reported data on demographics, sexual behaviour, testing and PrEP use, as well as lab-confirmed diagnoses from visits to HIV/STI Checkpoints in Germany. PrEP use was categorized as (1) never used; (2) intention to use; (3) former use; (4) current on-demand use; (5) daily use. In multivariate regression analyses (MRA) with gonorrhoea, chlamydia, and syphilis diagnoses as outcomes, we controlled for age, number of sexual partners, number of condomless anal intercourse (CAI) partners in the last six months, and testing recency.

RESULTS

For the analysis, we included 9,219 visits for gonorrhoea and chlamydia testing and 11,199 visits for syphilis testing conducted at checkpoints from 01/2019 to 08/2021. MRA identified age (aOR 0.98; 95%CI 0.97-0.99), number of sexual partners in the past six months (aOR 4.90; 95%CI 2.53-9.52 for 11 + partners), and use of chemsex substances (aOR 1.62; 95%CI 1.32-2.00) as risk factors for gonorrhoea, while age (aOR 0.99; 95%CI 0.98-1.00), number of CAI partners (aOR 3.19; 95%CI 2.32-4.41 for 5 + partners), partner sorting (aOR 1.30; 95%CI 1.09-1.54), and use of chemsex substances (aOR 1.29; 95%CI 1.05-1.59) were risk factors for chlamydia infections. For syphilis, the number of CAI partners (aOR 3.19; 95%CI 1.60-6.34 for 5 + partners) was found to be the only significant risk factor. There was a strong association between PrEP use and the number of sexual partners (≤ 5 vs.>5: aOR 3.58; 95%CI 2.15-5.97 for daily PrEP use), the number of CAI partners in the past six months (≤ 1 vs.>1: aOR 3.70; 95%CI 2.15-6.37 for daily PrEP use), and the number of STI tests performed (suggesting higher testing frequency). Both outcomes were also related to partner sorting, chemsex, and selling sex.

CONCLUSIONS

Checkpoint visits reporting current PrEP use or intention to start PrEP correlated with eligibility criteria for PrEP, i.e. high partner numbers, inconsistent condom use during anal intercourse, and use of chemsex drugs. Use of HIV-specific prevention methods such as HIV serosorting, PrEP sorting, and viral load sorting was reported more frequently. (Daily) PrEP use was an independent risk factor for a chlamydia diagnosis only.

Determining the screening frequency for sexually transmitted infections for people who use HIV pre-exposure prophylaxis: a systematic review and meta-analysis

OBJECTIVES

Although the World Health Organization recommends 'frequent' screening of sexually transmitted infections (STI) for people who use pre-exposure prophylaxis for HIV, there is no evidence for optimal frequency.

METHODS

We searched five databases and used random-effects meta-analysis to calculate pooled estimates of STI test positivity. We narratively synthesized data on secondary outcomes, including adherence to recommended STI screening frequency and changes in STI epidemiology.

RESULTS

Of 7477 studies, we included 38 for the meta-analysis and 11 for secondary outcomes. With 2-3 monthly STI screening, the pooled positivity was 0.20 (95% confidence interval [CI]: 0.15-0.25) for chlamydia, 0.17 (95% CI: 0.12-0.22) for gonorrhea, and 0.07 (95% CI: 0.05-0.08) for syphilis. For chlamydia and gonorrhea, the positivity was approximately 50% and 75% lower, respectively, in studies that screened 4-6 monthly vs 2-3 monthly. There was no significant difference in the positivity for syphilis in studies that screened 4-6 monthly compared to 2-3 monthly. Adherence of clients to recommended screening frequency varied significantly (39-94%) depending on population and country. Modeling studies suggest more frequent STI screening could reduce incidence.

CONCLUSION

Although more frequent STI screening could reduce delayed diagnoses and incidence, there remain significant knowledge gaps regarding the optimal STI screening frequency.

Update on the Epidemiology, Screening, and Management of Chlamydia trachomatis Infection

Chlamydia trachomatis infection ("chlamydia") is the most commonly diagnosed bacterial sexually transmitted infection globally, occurring in the genitals (urethra or vagina/cervix), rectum, or pharynx. If left untreated in women, genital chlamydia can ascend into the upper genital tract causing pelvic inflammatory disease, increasing their risk for ectopic pregnancy, infertility, and chronic pelvic pain. In men, chlamydia can cause epididymitis and proctitis. However, chlamydia is asymptomatic in over 80% of cases. This article provides an update on the epidemiology, natural history, and clinical manifestations of chlamydia in adults and discusses the current approaches to its management and control policy.

Prevalence of Mycoplasma genitalium infection among HIV PrEP users: a systematic review and meta-analysis

OBJECTIVES

To summarise the prevalence of Mycoplasma genitalium (MG) and antibiotic-resistant MG infection among HIV pre-exposure prophylaxis (PrEP) users.

METHODS

We searched MEDLINE, Embase, Web of Science and Global Index Medicus up to 30 September 2022. We included studies reporting the prevalence of MG and/or antibiotic-resistant MG infection among PrEP users. Two reviewers independently searched for studies and extracted data. A systematic review with random-effects meta-analysis was performed to quantitatively summarise the results of included studies. The critical appraisal of included studies was conducted with the Joanna Briggs Institute checklist for prevalence studies and the quality of evidence was assessed with Grading of Recommendations Assessment, Development and Evaluation (GRADE).

RESULTS

A total of 15 studies were included in the systematic review, with 2341 individuals taking PrEP. Studies were conducted in high-income level countries between 2014 and 2019. Median age of participants varied from 23.5 to 40 years. The majority were men (85%) and among them, 93% were men who have sex with men. To identify MG, urine samples were analysed in 14 studies, rectal or anal swabs in 12 studies, oral or pharyngeal swabs in 9 studies, and urethral or vaginal in 3 studies. The pooled point prevalence of MG among PrEP users was 16.7% (95% CI 13.6% to 20.3%; 95% prediction interval (95% PI) 8.2% to 31.1%). The pooled point prevalence of macrolide-resistant infections was 82.6% (95% CI 70.1% to 90.6%; 95% PI 4.7% to 99.8%) and the prevalence of fluoroquinolone-resistant infections was 14.3% (95% CI 1.8% to 42.8%). Individuals taking PrEP have a higher chance of being infected with MG compared with those not taking PrEP (OR 2.30; 95% CI 1.6 to 3.4). The quality of evidence was very low to moderate.

CONCLUSION

We observed a high prevalence of MG and its macrolide resistance among PrEP users, highlighting the need to reinforce prevention strategies against sexually transmitted infections in this population.

PROSPERO REGISTRATION NUMBER

CRD42022310597.

Very High Incidence of Chlamydia trachomatis, Neisseria gonorrhoeae, and Treponema pallidum among Low-Risk MSM in an Outpatient Clinic in Wroclaw, Poland in 2019-2020

BACKGROUND

The rise in sexually transmitted infections and chemsex has led to syndemy with HIV, partly due to common routes of transmission and clustered transmissions. Despite this, barriers to STI care and PrEP still remain. We sought to determine whether MSM at low risk for HIV infection were also at low risk for other STIs.

METHODS

The study group was tested for HIV, HCV, and Treponema pallidum, as well as had urethral, rectal, and oropharyngeal smears performed for Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) six months apart. The control group was tested once to define the background incidence.

RESULTS

Treponema pallidum, CT, and NG prevalence was very high at both time points and was similar to the control group. CT was especially common in the control group (20.58%) and the study group at the rectal site at the second time point (9.37%). NG dominated the oropharyngeal site (15.87%), with urethral site sparing. NG infection was associated with an increased number of partners, not condom use (OR, 1.082 [95% CI; 1.009-1.171]). Risk behavior did not change between the time points. Treponema pallidum, CT, and NG incidence was exceptionally high (12.5/100PY, 25.39/100PY, 34.92/100PY, respectively; pooled 87.5/100PY) and was comparable to other studies of high-risk MSM.

CONCLUSIONS

Despite a lower risk for HIV acquisition, the study group was at a very high risk for other STIs, and this risk remained high throughout the study. Patients and medical professionals should be aware of syphilis, gonorrhea, and chlamydiosis transmission risks, and screening should be performed accordingly. Prophylactic programs need to be updated to specifically include lower-risk individuals.

Incidence and Risk Factors for Early Syphilis Among Men Who Have Sex With Men in Australia, 2013-2019: A Retrospective Cohort Study

Background

We aimed to examine the incidence of syphilis in men who have sex with men (MSM) and identify subgroups of MSM at a higher risk of syphilis infection.

Methods

We conducted a retrospective cohort study of MSM attending a sexual health clinic in Australia, during 2013-2019, who had at least 2 syphilis serological tests during the study period. The incidence of syphilis was expressed as per 100 person-years. A cox regression analysis was conducted to identify risk factors for syphilis.

Results

A total of 24 391 individual MSM (75 086 consultations) were included. A total of 1404 new syphilis cases were diagnosed with an incidence of 3.7/100 person-years (95% confidence interval, 3.5-3.9). Syphilis incidence was higher in MSM with human immunodeficiency virus ([HIV] 9.3/100 person-years) than in MSM taking HIV pre-exposure prophylaxis (PrEP) (6.9/100 person-years) or HIV-negative MSM not taking PrEP (2.2/100 person-years). Risk factors associated with high incidence of syphilis included the following: MSM with HIV (adjusted hazard ratio [aHR] 2.7), MSM taking HIV PrEP (aHR 2.1), past history of syphilis infection (aHR 2.4), injecting drug use (aHR 2.7), condomless anal sex (aHR 1.7), >4 sexual partners in the last 12 months (aHR 1.2), and concurrent sexually transmitted infection (chlamydia and gonorrhoea) (aHR 1.6).

Conclusions

The incidence of syphilis remains high among MSM, particularly in subgroups with associated risk factors for syphilis infections. These data highlight the need for biomedical and behavioral interventions to be targeted to subgroups of MSM at the highest risk of syphilis infection.

An overview of programmatic indicators to monitor the roll-out of HIV preexposure prophylaxis

Preexposure prophylaxis (PrEP) is increasingly implemented in national HIV prevention programmes through routine care. Monitoring will be vital to understand whether programmes succeed in engaging people into using PrEP appropriately, and in reducing the HIV epidemic. Yet, it is currently unclear which indicators are most suited to monitor PrEP programmes' performance. We therefore aimed to identify and map indicators that are currently used or suggested for monitoring PrEP programmes. We conducted a scoping review based on the framework by Arksey and O'Malley. We combined a systematic search in the peer-reviewed literature with hand-searching grey literature documents describing indicators and strategies that are used or suggested for PrEP monitoring. Only literature published after 2012 was included. No geographical restrictions were set. We charted data on indicator definitions, data sources used, reported experiences with monitoring and any relevant contextual factors. Ultimately, 35 peer-reviewed and 14 grey literature records were included. We identified indicators related to preuptake stages of PrEP, uptake and coverage, and programme impact. The indicators most commonly suggested for national-level monitoring were the number of new and current PrEP users, the number of HIV seroconversions among PrEP users and some variably defined indicators related to continuation and discontinuation of PrEP. Despite its perceived high relevance, studies reported several challenges to routinely monitor the population in need of PrEP and track prevention-effective PrEP use. In conclusion, a variety of indicators is currently used or suggested for monitoring PrEP programmes. Implementing proxy measures that track different aspects of PrEP use over time, and making synergies with research more explicit, could be used as strategies to obtain more granular insights into trends revealed by routine monitoring.

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.

HIV pre-exposure prophylaxis (PrEP) should be free across Canada to those meeting evidence-based guidelines

HIV pre-exposure prophylaxis (PrEP) should be free across Canada for all those who meet evidence-based guidelines. PrEP is a highly effective tool for preventing HIV acquisition that has been approved for use in Canada since 2016. However, without public drug plans or private insurance, generic PrEP costs approximately $200 to $250 CAD monthly. Current PrEP programs across Canada are a confusing patchwork system with variability in coverage and prohibitive co-payments, making PrEP too expensive for many equity-deserving groups. However, publicly funded PrEP programs are demonstrated to be cost-effective and even cost-saving by reducing the long-term healthcare expenditures associated with managing HIV. PrEP is not just an individual-level clinical tool. It is a public health intervention. Alongside “treatment as prevention,” PrEP is an important population-level strategy for eliminating new HIV infections in Canada and can play a role in helping to address complex health inequities affecting communities highly affected by HIV. Navigating drug coverage for patients consumes time and resources among healthcare providers that could be spent helping to improve other social determinants of health. Affordability will remain the foremost barrier to PrEP access until PrEP is made free to all those who meet evidence-based guidelines.

The relationship between HIV pre-exposure prophylaxis, sexually transmitted infections, and antimicrobial resistance: a qualitative interview study of men who have sex with men

BACKGROUND

HIV pre-exposure prophylaxis (PrEP) is a medication that prevents the acquisition of HIV. It has been targeted towards men who have sex with men (MSM). Since its introduction there have been concerns raised around changes in sexual behaviour such as increased condomless anal intercourse (CAI), leading to an elevation in sexually transmitted infections (STIs). With antimicrobial resistant strains of STIs rising, there are concerns that PrEP may be contributing to this growth. This study aims to understand how MSM conceptualise the relationship between PrEP, STIs and antimicrobial resistance (AMR).

METHODS

Twenty semi-structured interviews were conducted online using Zoom. Participants include a mix of PrEP related experiences (never used, currently use, previously used). Reflexive thematic analysis was undertaken by the lead author with 10% of transcripts double coded.

RESULTS

MSM in Wales have positive views and a good knowledge of PrEP and awareness of bacterial STIs. PrEP is perceived by many to lead to a reduction in condom use and increase in STIs but reported condom use behaviours presented to be stable in terms of PrEP initiation. PrEP use is influenced by increased concern for HIV and minimal concern for bacterial STIs. Awareness of AMR STIs was lacking.

CONCLUSIONS

There is a belief that PrEP use will lead to an increase in STI rates through reduced condom use, despite reported behaviours often being stable in relation to PrEP initiation, PrEP stigma may be influencing this dichotomy. Concern and awareness for resistant STIs is low, with little association to PrEP.

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.

Non-conventional interventions to prevent gonorrhea or syphilis among men who have sex with men: A scoping review

Objectives

We assessed nonconventional interventions that did not traditionally focus on increasing condom use and/or testing among men who have sex with men (MSM) and the evidence for these interventions.

Methods

Guided by the Participants, Concept and Context (PCC) framework, we searched five online databases from inception to 9 August 2021 for original research on interventions that do not focus on increasing condom use and/or testing to prevent gonorrhea and/or syphilis in MSM. Two researchers screened titles and abstracts to assess eligibility, reviewed articles' full text and resolved discrepancies through discussion. We charted relevant study information, and the included studies were critically appraised.

Results

Of 373 articles retrieved, 13 studies were included. These studies were conducted in Australia (n = 3), Belgium (n = 2), China (n = 3), the Netherlands (n = 1) and the US (n = 4). Two randomized controlled trials (RCTs) of doxycycline as pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) reduced any STI incidence (gonorrhea, syphilis, or chlamydia), but only doxycycline PEP significantly reduced syphilis incidence. Six studies of interventions that facilitated self-collection, self-examination, and self-testing, found varied evidence for gonorrhea and/or syphilis prevention. Four RCTs and one single-arm trial examined the efficacy of mouthwash, but the evidence remains inconclusive on whether mouthwash use can prevent transmission between men.

Conclusion

We found evidence for doxycycline PEP in reducing syphilis incidence, evidence on the use of mouthwash to prevent gonorrhea transmission between men remains inconclusive. More evidence is needed for interventions that do not focus on increasing condom use and/or testing to prevent gonorrhea and/or syphilis.

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.

Point-of-Care Diagnostics for Diagnosis of Active Syphilis Infection: Needs, Challenges and the Way Forward

Syphilis, a curable sexually transmitted infection, has re-emerged as a global public health threat with an estimated 5.6 million new cases every year. Pregnant women and men who have sex with men are key target populations for syphilis control and prevention programs. Frequent syphilis testing for timely and accurate diagnosis of active infections for appropriate clinical management is a key strategy to effectively prevent disease transmission. However, there are persistent challenges in the diagnostic landscape and service delivery/testing models that hinder global syphilis control efforts. In this commentary, we summarise the current trends and challenges in diagnosis of active syphilis infection and identify the data gaps and key areas for research and development of novel point-of-care diagnostics which could help to overcome the present technological, individual and structural barriers in access to syphilis testing. We present expert opinion on future research which will be required to accelerate the validation and implementation of new point-of-care diagnostics in real-world settings.

Prevalence, Anatomic Distribution, and Correlates of Chlamydia trachomatis and Neisseria gonorrhoeae Infections Among a Cohort of Men Who Have Sex With Men in Hanoi, Vietnam

BACKGROUND

Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) disproportionately affect men who have sex with men (MSM). Data on the prevalence, anatomical distribution, and correlates of NG and CT infections among MSM in Vietnam are limited.

METHODS

Between July 2017 and April 2019, MSM 16 years or older without HIV were enrolled into an observational cohort study. Baseline data, including sociodemographics, sexual behavior, and HIV status, were collected. Testing for NG and CT were performed on urine, rectal, and pharyngeal specimens. Multivariate logistic regression models identified factors associated with NG and CT infections at baseline.

RESULTS

In total, 1489 participants underwent NG/CT testing. The median age was 22 years (interquartile range, 20-26 years). There were 424 (28.5%) NG or CT infections: 322 (21.6%) with CT and 173 (11.6%) with NG. Rectal infections were most common for CT (73.9%), whereas pharyngeal infections were most common for NG (70.5%). Independent risk factors for CT or NG infection included ≥2 sex partners in the prior month (adjusted odds ratio [aOR], 2.04; 95% confidence interval [CI], 1.44-2.91), condomless anal sex (aOR, 1.44; 95% CI, 1.12-1.86), and meeting sex partners online (aOR, 1.35; 95% CI, 1.03-1.76). Recent genitourinary or rectal symptoms were not associated with infections.

CONCLUSIONS

The overall and extragenital prevalences of NG and CT infections were high within this sample of young MSM without HIV in Hanoi. Testing limited to urethral specimens would have missed nearly three-quarters of CT and NG infections, supporting the need for routine testing at multiple anatomic sites.

HIV Pre-Exposure Prophylaxis (PrEP) in a Brazilian Clinical Setting: Adherence, Adverse Events, Sexual Behavior, and Sexually Transmitted Infections

Tenofovir/emtricitabine (TDF/FTC) has been used as pre-exposure prophylaxis (PrEP) in preventing HIV infection. PrEP is an effective prevention tool as demonstrated in clinical trials and studies in clinical practice and was incorporated into the Brazilian public health system in December 2017. The present study was a prospective cohort that included 219 PrEP users monitored over a 10 month follow-up period in a capital city in Northeastern Brazil. Data were collected from the PrEP users' electronic medical records platform made available by the Brazilian Health Ministry. During the observation period, there was good user retention to the prevention program (84%) and there was high adherence to medication (90%). Almost half the users (49%) presented an adverse event, although these were mild and transient, 30 days after starting prophylaxis. There was a significant reduction in creatinine clearance (p < .001), from 104.9 to 83.5 mL/min; however, there was no need for drug discontinuation. Throughout the cohort, there was no significant change in the number of sexual partners, but the use of condoms during sexual intercourse decreased (p < .001). There was a non-significant increase in the incidence of syphilis (p = .08), and there was a 50% decrease in reporting signs and symptoms of sexually transmitted infections. No cases of HIV infection were observed. PrEP proved to be an effective tool in HIV prevention, presenting few complications of adverse events.

PrEP use and HIV seroconversion rates in adolescent girls and young women from Kenya and South Africa: the POWER demonstration project

INTRODUCTION

HIV incidence remains high among African adolescent girls and young women (AGYW). The primary objective of this study is to assess pre-exposure prophylaxis (PrEP) initiation, use, persistence and HIV acquisition among African AGYW offered PrEP in order to inform PrEP scale-up.

METHODS

POWER was a prospective implementation science evaluation of PrEP delivery for sexually active HIV-negative AGYW ages 16-25 in family planning clinics in Kisumu, Kenya and youth and primary healthcare clinics in Cape Town and Johannesburg, South Africa. Follow-up visits occurred at month 1 and quarterly for up to 36 months. PrEP users were defined based on the month 1 refill. PrEP persistence through month 6 was assessed using Kaplan-Meier survival analysis among AGYW with a month 1 visit, defining non-persistence as an ≥15 day gap in PrEP availability for daily dosing. PrEP execution was evaluated in a subset with PrEP supply from the prior visit sufficient for daily dosing by measuring blood tenofovir diphosphate (TFV-DP) levels.

RESULTS

From June 2017 to September 2020, 2550 AGYW were enrolled (1000 in Kisumu, 787 in Cape Town and 763 in Johannesburg). Median age was 21 years, 66% had a sexual partner of unknown HIV status, and 29% had chlamydia and 10% gonorrhoea. Overall, 2397 (94%) initiated PrEP and 749 (31%) had a refill at 1 month. Of AGYW who could reach 6 months of post-PrEP initiation follow-up, 128/646 (20%) persisted with PrEP for 6 months and an additional 92/646 (14%) had a gap and restarted PrEP. TFV-DP levels indicated that 47% (91/193) took an average of ≥4 doses/week. Sixteen HIV seroconversions were observed (incidence 2.2 per 100 person-years, 95% CI 1.2, 3.5); 13 (81%) seroconverters either did not have PrEP dispensed in the study interval prior to seroconversion or TFV-DP levels indicated <4 doses/week in the prior 6 weeks.

CONCLUSIONS

In this study of PrEP integration with primary care and reproductive health services for African AGYW, demand for PrEP was high. Although PrEP use decreased in the first months, an important fraction used PrEP through 6 months.  Strategies are needed to simplify PrEP delivery, support adherence and offer long-acting PrEP options to improve persistence and HIV protection.

Prevalence and incidence of hepatitis C infection amongst men who have sex with men in a population-based pre-exposure prophylaxis program in British Columbia, Canada

BACKGROUND

Men who have sex with men (MSM) are at risk for sexually-transmitted hepatitis C (HCV). Evidence for HCV infection in the context of pre-exposure prophylaxis (PrEP) use in North America is limited. We sought to characterize baseline HCV prevalence and incidence in MSM receiving PrEP in British Columbia (BC), Canada.

METHODS

We followed individuals in the BC PrEP program from January 2018 to August 2019. We evaluated baseline prevalence and incident seroconversions (newly positive HCV antibody). A multivariable logistic regression model was performed in MSM for factors associated with HCV prevalence at enrollment, including reported prior sexually transmitted infection (STI), HIV Incidence Risk Index for MSM score, PrEP use because of a partner living with HIV, and location of residence.

RESULTS

The median age of the cohort was 33 years, 98.3% male, with 3058 person years (PY) of follow-up. Baseline HCV prevalence was 0.82% (31/3907 MSM enrollees) and HCV incidence (n = 3) was 0.15 per 100 PY (95% confidence interval [CI] 0.03-0.45). In multivariable analysis, initiating PrEP because of a partner living with HIV (adjusted odds ratio [aOR] 5.02; 95% CI 1.87-13.47) and prior STI (aOR 2.34; 95% CI 1.04-5.24) were associated with positive HCV status.

CONCLUSIONS

Baseline HCV prevalence and incidence was low amongst MSM in a population-based PrEP program in BC, Canada. HCV was associated with bridging from populations living with HIV and evidence of a reported prior STI as a PrEP indicator condition amongst MSM. PrEP initiation may be an opportunity for linkage to HCV screening and treatment.

Trends in Sexual Behavior and Sexually Transmitted Infections After Initiating Human Immunodeficiency Virus Pre-Exposure Prophylaxis in Men Who Have Sex with Men from Amsterdam, the Netherlands: A Longitudinal Exposure-Matched Study

Men who have sex with men (MSM) initiating human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) may increase condomless anal sex (CAS) and number of partners, and, consequently, more often acquire sexually transmitted infections (STIs). Using data from the Amsterdam Cohort Studies, we compared sexual behavior and STI among MSM after PrEP-initiation with controls not initiating PrEP. The MSM reported on sexual behavior and were tested for HIV, chlamydia, gonorrhea, and syphilis semi-annually. We matched MSM who initiated PrEP between January 1, 2015 and December 31, 2019 1:1 to MSM who did not use time-dependent propensity scores based on age, sexual behavior, and STI. Primary end-points were number of casual partners, and proportion with CAS and receptive CAS (rCAS) with casual partners, sexualized drug use (SDU), any STI, and anal STI. We modeled end-points during the 4 years before and 2 years after PrEP-initiation or matched PrEP-initiation timepoint by using logistic regression (dichotomous end-points) or negative binomial regression (count end-point), adjusted for calendar year. Two hundred twenty-eight out of the 858 (26.6%) MSM initiated PrEP. We matched 198 out of 228 (86.8%) to a control. Before PrEP-initiation, end-points increased over time in both groups, with no statistically significant difference. The odds of CAS, rCAS, and anal STI were on average higher after than before PrEP-initiation in PrEP initiators, whereas after versus before differences were not observed in controls. After PrEP-initiation, PrEP initiators had statistically significantly more casual partners, and higher odds of CAS, rCAS, SDU, any STI, and anal STI than controls. These findings support frequent STI screening and counseling in MSM using PrEP.

Latent Class Analysis of Sexual Behaviours and Attitudes to Sexually Transmitted Infections Among Gay and Bisexual Men Using PrEP

Gay and bisexual men (GBM) who use pre-exposure prophylaxis (PrEP) are at increased risk of sexually transmitted infections (STIs) compared to those who don't use PrEP. Since the implementation of PrEP in Australia, it is possible that attitudes towards STIs have shifted in line with changes in risk and transmission dynamics in the context of increased screening. As the extent to which GBM utilise STI prevention strategies likely depends on their attitudes towards STIs and STI prevention, the aims of this study were to use latent class analysis (LCA) to classify GBM using PrEP on the basis of their attitudes towards STIs and reported risk behaviours, and examine how these categorisations relate to risk of STI acquisition. 1225 GBM who were previously enrolled in a PrEP implementation study (The PrEPX Study) completed a survey focused on sexual behaviours and attitudes towards STIs 1 year post-study follow-up. Data on chlamydia, gonorrhoea and syphilis testing and positivity were available through a sentinel network of participating study clinics. Using LCA, participants were allocated into four classes; Class 1, "Some concern and lowest risk"; Class 2, "Low concern and lower risk"; Class 3, " High concern and higher risk"; and Class 4, "Low concern and highest risk". The majority (78%) of participants were classified into Class 3 or Class 4, two groups which were distinguished by highly disparate attitudes towards STIs but with a similar proportion of participants diagnosed with a bacterial STI in the last 12 months (48% and 57%, respectively). Findings suggest that attitudes towards STIs among GBM using PrEP in Australia vary considerably, and this will likely influence their receptivity to different STI prevention strategies.

The 'Viennese epidemic' of acute HCV in the era of direct-acting antivirals

The recently reported epidemic of acute hepatitis C virus (HCV) infections -observed predominantly among men who have sex with men (MSM)-may now decline due to wide availability of direct-acting antivirals (DAAs). This study aimed to investigate the current trends of acute hepatitis C in Vienna. Patients presenting with acute hepatitis C between 01/2007 and12/2020 at the Vienna General Hospital were retrospectively enrolled and followed after virologic clearance/eradication. The introduction of unrestricted DAA access after 09/17 defined the 'DAA era', as compared to the 'pre-DAA era' prior to 09/17. We identified 134 acute hepatitis C cases in 119 patients with a mean age of 39 ± 9 years at inclusion. The majority of patients were male (92%), HIV-positive (88%) and MSM (85%). In the DAA era, a history of prior chronic HCV infection at inclusion was found in 24% (11/46) compared to 7% (5/73) in the pre-DAA era (p = .012). The annual rate of acute hepatitis C cases increased in the DAA era (17.11 per year) compared to the pre-DAA era (7.76 per year). The DAA era included an AHC-genotype-2 cluster and more HIV-negative acute hepatitis C cases (0% (0/73) vs. 30% (14/46), p < .001). Patients were followed after spontaneous clearance or sustained virologic treatment response (SVR) for a total of 251.88 patient-years (median 1.39 years per patient). In the DAA era, we recorded 15 acute hepatitis C-reinfections - corresponding to an incidence rate of 5.96 (95% CI: 3.57-9.66) reinfections per 100-patient-years. We continue to observe a high incidence of acute hepatitis C in Vienna in the DAA era-primarily among HIV-positive MSM, but increasingly also in HIV-negative MSM.

HTLV-1 Transmission and HIV Pre-exposure Prophylaxis: A Scoping Review

HIV pre-exposure prophylaxis (HIV-PrEP) is effective in reducing the likelihood of HIV acquisition in HIV-negative people at high risk of exposure. Guidelines recommend testing for sexually transmitted infections (STIs) before starting, and periodically on PrEP, including bacterial infections, HIV, hepatitis C virus, and, for those who are non-immune, hepatitis B virus. Diagnosed infections can be promptly treated to reduce onward transmission. HTLV-1 is not mentioned; however, it is predominantly sexually transmitted, causes adult T-cell leukaemia/lymphoma (ATL) or myelopathy in 10% of those infected, and is associated with an increased risk of death in those without any classically HTLV-associated condition. The 2021 WHO Technical Report on HTLV-1 called for the strengthening of global public health measures against its spread. In this scoping review, we, therefore, (1) discuss the epidemiological context of HIV-PrEP and HTLV-1 transmission; (2) present current knowledge of antiretrovirals in relation to HTLV-1 transmission prevention, including nucleos(t)ide reverse transcriptase inhibitors (NRTIs) and integrase strand transfer inhibitors (INSTIs); and (3) identify knowledge gaps where data are urgently required to inform global public health measures to protect HIV-PrEP users from HTLV-1 acquisition. We suggest that systematic seroprevalence studies among PrEP-using groups, including men who have sex with men (MSM), people who inject drugs (PWIDs), and female sex workers (FSWs), are needed. Further data are required to evaluate antiretroviral efficacy in preventing HTLV-1 transmission from in vitro studies, animal models, and clinical cohorts. PrEP delivery programmes should consider prioritizing the long-acting injectable INSTI, cabotegravir, in HTLV-1 endemic settings.

Perceptions on HIV Pre-Exposure Prophylaxis Among Urgent Care Clinicians in the Southern United States

Background:

Underutilization of HIV pre-exposure prophylaxis (PrEP) in the Southern United States (US) is well-documented. Urgent care (UC) centers are positioned as community-facing access points to PrEP, but the feasibility of integrating PrEP services into this setting is unclear. We conducted a survey of UC clinicians in the Southern US to better understand their perceptions of the feasibility of providing PrEP in their practice setting.

Objective:

The study aims to determine the feasibility and acceptability of providing PrEP services in the UC setting through a cross-sectional survey of UC clinicians.

Methods:

We conducted a 48-item cross-sectional survey of UC clinicians in the Southern US, between July and September 2020. The survey was distributed through the Urgent Care Association (UCA) and American Academy of Urgent Care Medicine (AAUCM) professional listservs as well as directly to publicly listed e-mail addresses.

Results:

Eighty-two clinicians responded to the survey. Most clinicians had familiarity with PrEP (97%). All respondents rated PrEP as an effective way to prevent HIV. However, less than half felt UC facilities were an appropriate place to prescribe PrEP. Few respondents (8%) expressed doubts that expansion of PrEP access would decrease the incidence of HIV in their community.

Conclusion:

These findings show UC clinicians are familiar with PrEP, and many believe it would benefit their patients; however, provider opinions on the appropriateness of providing PrEP in the UC setting differ. Further studies on PrEP implementation in UC centers are needed.

M2HepPrEP: study protocol for a multi-site multi-setting randomized controlled trial of integrated HIV prevention and HCV care for PWID

Background

Opioid use is escalating in North America and comes with a multitude of health consequences, including HIV and hepatitis C virus (HCV) outbreaks among persons who inject drugs (PWID). HIV pre-exposure prophylaxis (PrEP) and HCV treatment regimens have transformative potential to address these co-occurring epidemics. Evaluation of innovative multi-modal approaches, integrating harm reduction, opioid agonist therapy (OAT), PrEP, and HCV treatment is required. The aim of this study is to assess the effectiveness of an on-site integrated care model where delivery of PrEP and HCV treatment for PWID takes places at syringe service programs (SSP) and OAT programs compared with referring PWID to clinical services in the community through a patient navigation model and to examine how structural factors interact with HIV prevention adherence and HCV treatment outcomes.

Methods

The Miami-Montreal Hepatitis C and Pre-Exposure Prophylaxis trial (M²HepPrEP) is an open-label, multi-site, multi-center, randomized, controlled, superiority trial with two parallel treatment arms. A total of 500 persons who injected drugs in the prior 6 months and are eligible for PrEP will be recruited in OAT clinics and SSP in Miami, FL, and Montréal, Québec. Participants will be randomized to either on-site care, with adherence counseling, or referral to off-site clinics assisted by a patient navigator. PrEP will be offered to all participants and HCV treatment to those HCV-infected. Co-primary endpoints will be (1) adherence to pre-exposure prophylaxis medication at 6 months post-randomization and (2) HCV sustained virological response (SVR) 12 weeks post-treatment completion among participants who were randomized within the HCV stratum. Up to 100 participants will be invited to participate in a semi-structured interview regarding perceptions of adherence barriers and facilitators, after their 6-month assessment. A simulation model-based cost-effectiveness analysis will be performed to determine the comparative value of the strategies being evaluated.

Discussion

The results of this study have the potential to demonstrate the effectiveness and cost-effectiveness of offering PrEP and HCV treatment in healthcare venues frequently attended by PWID. Testing the intervention in two urban centers with high disease burden among PWID, but with different healthcare system dynamics, will increase generalizability of findings.

Trial registration

Clinicaltrials.gov NCT03981445. Trial registry name: Integrated HIV Prevention and HCV Care for PWID (M2HepPrEP). Registration date: June 10, 201.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06085-3.

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.

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.