Prevalence of Intimate Partner Violence, Substance Use Disorders and Depression among Incarcerated Women in Lima, Perú

Background: Globally, there is evidence supporting the co-occurrence of intimate partner violence (IPV), substance use disorders (SUD) and mental health disorders among women in prisons, however, there is limited research investigating these domains in the Andean region where rates of female incarceration have increased. The study objective was to explore the prevalence of IPV, SUD and depression among incarcerated women in a Peruvian prison and explore associations among these variables and related correlates. Methods: 249 incarcerated women responded to a questionnaire about IPV, substance use, depression, and sexual behavior, and were screened for HIV/sexually transmitted diseases (STDs). Univariate analysis and logistic regression were used to estimate relative risk and the influence of substance use and depression on IPV rates. Results: Twelve months prior to incarceration, of the women with sexual partners pre-incarceration (n = 212), 69.3% experienced threats of violence, 61.4% experienced ≥1 acts of physical violence, and 28.3% reported ≥1 act of sexual aggression. Pre-incarceration, 68.1% of drug-using women had a SUD, and 61.7% of those who consumed alcohol reported hazardous/harmful drinking. There were 20 (8.0%) HIV/STD cases; and 67.5% of the women reported depressive symptoms. Compared to women with no experiences of physical violence, a greater proportion of women who experienced least l violent act had depressive symptoms and engaged in sex work pre-incarceration. Depression was associated with physical violence (adjusted relative risk = 1.35, 95% confidence interval: 1.14–1.58). Recommendations: The findings provide evidence of a syndemic of IPV, substance abuse and depression among incarcerated women in a Peruvian prison. To help guide policy makers, further research is needed to determine if this is indicative of trends for other at-risk women in the region, and viable options to treat these women during incarceration to prevent recidivism and other long-term negative sequalae.

Is exclusive breastfeeding for six-months protective against pediatric tuberculosis?

Experts recommend exclusive breastfeeding from birth to six months because it protects against deadly childhood illness, including respiratory tract infections and diarrhea. We hypothesized that exclusive breastfeeding would decrease the risk of active tuberculosis (TB) in children. We analyzed cross-sectional data from 279 children in Lima, Peru aged 6 to 59 months with TB symptoms and a close adult contact with TB. Mothers self-reported breastfeeding, and children were evaluated for TB per national guidelines. To quantify the association between exclusive breastfeeding and TB, we estimated prevalence ratios using a generalized linear model with a log link, binomial distribution, and robust variance. Twenty-two percent of children were diagnosed with TB and 72% were exclusively breastfed for six months. We found no evidence that six months of exclusive breastfeeding was associated with TB disease in either bivariate analyses (prevalence ratio [PR] = 1.5; 95%CI = 0.8–2.5) or multivariable analyses adjusting for sex and socioeconomic status (adjusted PR = 1.6; 95%[CI] = 0.9–2.7). In post hoc analyses among children whose close TB contact was their mother, we found evidence of a weak positive association between breastfeeding and TB (aPR = 2.1; 95%[CI] = 0.9–4.9). This association was not apparent among children whose close contact was not the mother (aPR = 1.2; 95%[CI] = 0.6–2.4). Our results raise the possibility that children who are breastfed by mothers with TB may be at increased risk for TB, given the close contact. Due to the cross-sectional study design, these results should be interpreted with caution. If these findings are confirmed in longitudinal analyses, future interventions could aim to minimize TB transmission from mothers with TB to breastfeeding infants.

Quality Improvement to Address Surgical Burden of Disease at a Large Tertiary Public Hospital in Peru

BACKGROUND

In resource-limited settings, there is a unique opportunity for using process improvement strategies to address the lack of access to surgical care. By implementing organizational changes in the surgical admission process, we aimed to decrease wait times, increase surgical volume, and improve patient satisfaction for elective general surgery procedures at a public tertiary hospital in Lima, Peru.

METHODS

During the first phase of the intervention, Plan-Do-Study-Act (PDSA) cycles were performed to ensure the surgery waitlist included up-to-date clinical information. In the second phase, Lean Six Sigma methodology was used to adapt the admission and scheduling process for elective general surgery patients. After six months, outcomes were compared to baseline data using Wilcoxon rank-sum test.

RESULTS

At the conclusion of phase one, 87.0% (488/561) of patients on the new waitlist had all relevant clinical data documented, improved from 13.3% (2/15) for the pre-existing list. Time from admission to discharge for all surgeries improved from 5 to 4 days (p<0.05) after the intervention. Median wait times from admission to operation for elective surgeries were unchanged at 4 days (p=0.076) pre- and post-intervention. There was a trend toward increased weekly elective surgical volume from a median of 9 to 13 cases (p=0.24) and increased patient satisfaction rates for elective surgery from 80.5 to 83.8% (p=0.62), although these were not statistically significant.

CONCLUSION

The process for scheduling and admitting elective surgical patients became more efficient after our intervention. Time from admission to discharge for all surgical patients improved significantly. Other measured outcomes improved, though not with statistical significance. Main challenges included gaining buy-in from all participants and disruptions in surgical services from bed shortages.

The Application of Cytokine Expression Assays to Differentiate Active From Previously Treated Syphilis

To investigate the role of serum cytokine assays to distinguish between active from treated syphilis among serofast patients, we recruited individuals into a prospective cohort study. Participants underwent routine syphilis screening. We selected specimens from a majority cohort of serofast participants with treated and active syphilis. We analyzed specimens with a 62-cytokine multiplex bead-based enzyme-linked immunosorbent assay. Cytokines, brain-derived neurotrophic factor and tumor necrosis factor β, were most predictive. We built a decision tree that was 82.4% accurate, 100% (95% confidence interval, 82%-100%) sensitive, and 45% (18%-75%) specific. Our decision tree differentiated between serum specimens from serofast participants with treated syphilis versus active syphilis.

Cytokine expression in Treponema pallidum infection

BACKGROUND

Current syphilis tests cannot distinguish between active and past syphilis among patients with serofast rapid plasma reagin (RPR) titers. We investigated whether cytokine profiles might provide insight in the differentiation of active and treated syphilis.

METHODS

We collected quarterly serum samples from participants at risk for incident syphilis in a prospective cohort study of men and male-to-female transgender women. We defined incident syphilis as a new RPR titer ≥ 1:8 or a fourfold increase from a prior RPR titer and a positive Treponema pallidum particle agglutination assay. We measured cytokine expression using a 63-multiplex bead-based Luminex assay (eBiosciences/Affymetrix, San Diego, California, USA). We used tertile bins and Chi square tests to identify differences in proportions of cytokines between samples from patients with active and treated syphilis. We constructed a network of cytokine profiles from those findings. We used R software (R version 3.4.1, R, Vienna, Austria) to fit models.

RESULTS

We identified 20 pairs of cytokines (out of 1953 possible pairs) that differed between active and treated syphilis. From those, we identified three cytokine networks of interest: an Eotaxin-Rantes-Leptin network, a Mig-IL1ra-Trail-CD40L network, and an IL12p40-IL12p70 network.

CONCLUSIONS

Differences in cytokine profiles are present among men and male-to-female transgender women with active and treated syphilis. Cytokine assays may be a potentially useful tool for identifying active syphilis among patients with serologic syphilis reactivity.

Feasibility of the string test for tuberculosis diagnosis in children between 4 and 14 years old

BACKGROUND

The enteric string test can be used to obtain a specimen for microbiological confirmation of tuberculosis in children, but it is not widely used for this. The aim of this analysis to evaluate this approach in children with tuberculosis symptoms.

METHODS

We conducted a cross-sectional study to assess children's ability to complete the test (feasibility), and self-reported pain (tolerability). We examined caregivers' and children's willingness to repeat the procedure (acceptability) and described the diagnostic yield of cultures for diagnostic tools. We stratified estimates by age and compared metrics to those derived for gastric aspirate (GA).

RESULTS

Among 148 children who attempted the string test, 34% successfully swallowed the capsule. Feasibility was higher among children aged 11-14 than in children 4-10 years (83% vs 22% respectively, p < 0.0001). The string test was better tolerated than GA in both age groups; however, guardians and older children reported higher rates of willingness to repeat GA than the string test (86% vs. 58% in children; 100% vs. 83% in guardians). In 9 children with a positive sputum culture, 6 had a positive string culture. The one children with a positive gastric aspirate culture also had a positive string culture.

CONCLUSION

Although the string test was generally tolerable and accepted by children and caregivers; feasibility in young children was low. Reducing the capsule size may improve test success rates in younger children.

HIV and syphilis testing preferences among men who have sex with men and among transgender women in Lima, Peru

BACKGROUND

Men who have sex with men (MSM) and transgender women in Peru are at high risk for acquiring syphilis and HIV infection. The World Health Organization highly recommends screening for HIV and syphilis to reduce morbidity and mortality associated with untreated infections. We aimed to identify factors associated with dual testing preferences for HIV and syphilis infection among MSM and transgender women in Lima, Peru.

METHODS

We used conjoint analysis, an innovative method for systematically estimating consumer preferences. We created eight hypothetical test profiles varying across six dichotomous attributes: cost (free vs. $4), potential for false positive syphilis result (no false positive vs. some risk of false positive), time-to-result (20 minutes vs. 1 week), blood draw method (finger prick vs. venipuncture), test type (rapid vs. laboratory), and number of draws (1 vs. 2). We fit a conjoint analysis model for each participant using a simple main effects ANOVA. Attribute importance values were calculated using percentages from relative ranges in the attribute's utility values. Results were summarized across participants and averages were reported.

RESULTS

We recruited 415 MSM/transgender women over 18 years of age from two STD clinics in Lima, Peru. No potential for syphilis false positive result (no false positive vs. some potential for false positive) had the largest average impact on willingness to use the test and on average accounted for 23.8% of test type preference, followed by cost (free vs. ~USD$4; 21.6%), time to results (20 minutes vs. 1 week; 17.4%), number of blood draws (1 draw vs. 2 draws; 13.8%), method of blood draw (fingerprick vs. venipuncture; 13.7%), and test type (rapid POC vs. laboratory; 9.7%).

CONCLUSION

MSM/transgender women in Peru prioritized accuracy, cost, timeliness and number of blood draws for HIV and syphilis testing. Implementing a low cost, accurate, rapid and dual testing strategy for HIV and syphilis could improve screening uptake and accessibility of testing to accelerate time to treatment.

The Relationship Between Risk Perception and Frequency of HIV Testing Among Men Who Have Sex with Men and Transgender Women, Lima, Peru

HIV infections in Peru are concentrated among men who have sex with men (MSM) and transgender women (TW). HIV testing rates among them remain low, delaying entrance into care. We assessed the prevalence of frequent HIV testing (at least every 6 months) and associated factors among 310 MSM and TW who attend sexual health clinics in Lima, Peru, and who reported that they were HIV seronegative or unaware of their status. Only 39% of participants tested frequently, and 22% had never tested; 29% reported that they were at low or no risk for acquiring HIV. Reporting low or no risk for acquiring HIV was associated with frequent testing (adjusted prevalence ratio [aPR] = 1.53, 95% CI 1.13-2.08); those reporting unprotected anal sex were less likely to test frequently (aPR = 0.66, 95% CI 0.50-0.87). HIV prevalence was 12% and did not vary by risk perception categories. This at-risk population tests infrequently and may not understand the risk of having unprotected sex.

Barriers and facilitators to antiretroviral therapy adherence among Peruvian adolescents living with HIV: A qualitative study

AIDS deaths among adolescents are increasing globally. This qualitative study investigated the barriers and facilitators to cART adherence among Peruvian adolescents living with HIV. Guided by a social ecological model, we analyzed transcripts from 24 psychosocial support groups for HIV-positive adolescents aged 13–17 years and 15 individual, in-depth interviews with cART providers and caregivers to identify the barriers and facilitators to cART adherence at the individual, family/caregiver and hospital levels. Most barriers and facilitators to cART adherence clustered at the individual and family/caregiver levels, centering on support provided to adolescents; history of declining health due to suboptimal cART adherence; side effects from antiretroviral drugs; and cART misinformation. Interventions to support adolescent HIV cART adherence should begin at the individual and family/caregiver levels and include an educational component. No adolescent living with HIV should die from AIDS in an era of accessible cART.

High incidence of extra-genital gonorrheal and chlamydial infections among high-risk men who have sex with men and transgender women in Peru

Extra-genital Neisseria gonorrhoeae and Chlamydia trachomatis infections are associated with antimicrobial resistance and HIV acquisition. We analyzed data from a cohort of men who have sex with men (MSM) and transgender women followed quarterly for two years in Peru. Incident cases were defined as positive N. gonorrhoeae or C. trachomatis nucleic acid tests during follow-up. Repeat positive tests were defined as reinfection among those with documented treatment. We used generalized estimating equations to calculate adjusted incidence rate ratios (aIRRs). Of 404 participants, 22% were transgender. Incidence rates of rectal N. gonorrhoeae and C. trachomatis infection were 28.1 and 37.3 cases per 100 person-years, respectively. Incidence rates of pharyngeal N. gonorrhoeae and C. trachomatis infection were 21.3 and 9.6 cases per 100 person-years, respectively. Incident HIV infection was associated with incident rectal (aIRR = 2.43; 95% CI 1.66-3.55) N. gonorrhoeae infection. Identifying as transgender versus cisgender MSM was associated with incident pharyngeal N. gonorrhoeae (aIRR = 1.85; 95% CI 1.12-3.07) infection. The incidence of extra-genital N. gonorrhoeae and C. trachomatis infections was high in our population. The association with incident HIV infection warrants evaluating the impact of rectal N. gonorrhoeae screening and treatment on HIV transmission.

Do Subjective Alcohol Screening Tools Correlate with Biomarkers Among High-Risk Transgender Women and Men Who Have Sex with Men in Lima, Peru?

Alcohol abuse can influence sexual risk behavior; however, its measurement is not straightforward. This study compared self-reported alcohol use, via the AUDIT and CAGE, with levels of phosphatidylethanol (Peth), a phospholipid biomarker that forms with chronic, heavy drinking, among high-risk MSM and TW in Lima, Peru. Chi square, Fisher's exact, Wilcoxon ranksum tests compared the instruments. Receiver operating curves determined sensitivity and specificity of the self-reported measures. Among 69 MSM and 17 TW, PEth was positive for 86% (95% CI 77-93%) of participants, while 67% reported binge-drinking in the last 2 weeks. The AUDIT classified 25% as hazardous drinkers while CAGE identified 6% as problem drinkers. Self-reported binge drinking was more sensitive than the AUDIT for PEth positivity (71% vs. 27%, p = 0.022). Among high-risk MSM and TW in Lima, validated, self-report measures of alcohol abuse underestimated biological measures. Further research correlating bio-markers and self-reported alcohol abuse measures is needed.

Mental disorders and drug/alcohol use in patients commencing extensively drug-resistant tuberculosis treatment

Mental disorders and alcohol/drug use worsen treatment outcomes for multidrug-resistant tuberculosis (TB), but data are lacking for extensively drug-resistant (XDR) TB. We investigated the association of baseline mental disorders and alcohol/drug use on XDR-TB treatment outcomes in a retrospective study of 53 XDR-TB Peruvian patients during 2010-2012. Logistic regression estimated the odds ratios for unfavourable XDR-TB treatment outcomes. Overall treatment success was 25%. Mental disorders and drug/alcohol use were found in respectively 22.4% and 20.4% of patients; neither were associated with unfavourable treatment outcomes. Future research should explore the relationship between mental health and drug/alcohol use in XDR-TB treatment outcomes.

Transient aortitis documented by positron emission tomography in a case series of men and transgender women infected with syphilis

OBJECTIVES

Syphilis infection persists globally contributing to preventable and treatable morbidity and mortality. How extensive early syphilis disseminates is unknown. To better understand the relationship between early syphilis infection and inflammation over time, our study enrolled six individuals recently infected with syphilis for sequential positron emission tomography (PET) scans.

METHODS

We evaluated a case series of six individuals with high syphilis titres (two secondary, two early latent and two latent, unknown duration, but with high titre) who received sequential PET scans to assess inflammation over time and its response to treatment.

RESULTS

At time of PET scan, four of the six individuals were co-infected with HIV. One of the four was not on antiretroviral therapy and three of the four were not virally suppressed (viral load of >400 copies/mL). Baseline rapid plasma reagin (RPR) titres ranged from 1:64 to 1:256 (four of the six participants had prior non-reactive RPR results). Five of the six participants had mild to intense hypermetabolic PET scan activity consistent with cervical (n=5), axillary (n=4), inguinal (n=5) and retroperitoneal (n=1) adenopathy. Mild hypermetabolic activity in the thoracic aortic wall, suggesting aortitis, was present among the same five participants and resolved within 30 days for four of the five participants and 60 days for the other participant. However, widespread lymphadenopathy remained present in PET scans up to 3 months following treatment in two participants. We did not find any abnormal PET scan activity of the central nervous system.

CONCLUSION

We found abnormal aortic wall PET scan activity suggesting aortitis to be common in a case series of patients with early syphilis. In research settings, PET scans may be a sensitive tool to monitor inflammation associated with syphilis.

The PICASSO Cohort: baseline characteristics of a cohort of men who have sex with men and male-to-female transgender women at high risk for syphilis infection in Lima, Peru

BACKGROUND

Men who have sex with men (MSM) and male-to-female transgender women (transwomen) are disproportionately at risk of syphilis infection in Peru.

METHODS

From 2013 to 2014, MSM and transwomen seeking human immunodeficiency virus (HIV) or sexually transmitted infection (STI) testing and/or treatment were recruited into a 2-year observational cohort study to determine predictors of recently acquired syphilis infection (defined as a rapid plasma reagin [RPR] titer ≥1:16 and a reactive treponemal antibody test) in Lima, Peru. At baseline, interviewers collected sociodemographic, behavioral, and medical characteristics from participants. All cohort participants were tested for syphilis, HIV, Chlamydia trachomatis (CT), and Neisseria gonorrhoeae (NG) infection. Using cross-sectional analyses, bivariate and multivariate models were used to determine factors associated with recently acquired syphilis infection and calculate adjusted prevalence ratios.

RESULTS

We recruited 401 participants, 312 MSM and 89 transwomen, with median ages of 29.0 and 32.5 years old (interquartile ranges: 23.3, 37.4 and 27.2, 39.5, respectively). The prevalence of recently acquired syphilis infection at baseline was 16.8% for MSM and 6.7% for transwomen. Among MSM and transwomen, 30.1 and 33.7% were infected with HIV, 18.6 and 24.7% were infected with CT, and 14.2 and 19.1% were infected with NG, respectively. Co-infection rates among MSM with recently acquired syphilis infection included: 44.2% with HIV, 40.4% with CT (32.7% with anal CT and 7.7% with pharyngeal CT), and 19.2% with NG (11.5% with anal NG and 7.7% with pharyngeal NG). Co-infection rates among transwomen with recently acquired syphilis infection included: 66.7% with HIV, 0% with CT, and 16.7% with anal NG. In multivariate analysis among the entire cohort, recently acquired syphilis infection was independently associated with younger age (adjusted prevalence ratio [aPR] = 0.96, 95% confidence interval [CI] = 0.93-0.99), receptive role during anal sex (aPR = 2.56, 95% CI = 1.05-6.25), prior HIV diagnosis (aPR = 1.70, 95% CI = 1.11-2.61), anal CT or NG infection (aPR = 1.69, 95% CI = 1.09-2.60), and prior syphilis diagnosis (aPR = 3.53, 95% CI = 2.20-5.68).

CONCLUSIONS

We recruited a cohort of MSM and transwomen who had a high prevalence of recently acquired syphilis infection in Lima, Peru. Recently acquired syphilis infection was associated with socio-demographic characteristics, sexual risk, and sexually transmitted co-infections.

HIV Status Communication with Sex Partners and Associated Factors Among High-Risk MSM and Transgender Women in Lima, Peru

Men who have sex with men (MSM) and transgender women (TW) are key populations in the HIV epidemic. HIV status communication between sex partners can inform decisions regarding sexual behavior. MSM and TW were asked about HIV status communication with sex partners at baseline, 9- and 18-months. GEE models assessed associations with HIV status communication at baseline using prevalence ratios (PRs) and longitudinally using odds ratios (ORs). At baseline, those who had previously had an HIV test, disclosed their HIV status to 42 % of their sex partners. HIV status communication was associated with knowing their sex partner's HIV status at baseline (aPR 5.20) and longitudinally (aOR 1.86). HIV positivity at baseline was negatively associated with HIV status communication during follow-up (aOR 0.55). All reported aPRs and aORs have p < 0.05. Interventions promoting HIV status communication and more frequent HIV testing should be explored as current efforts are insufficient.

Risk Factors Associated with Incident Syphilis in a Cohort of High-Risk Men in Peru

BACKGROUND

Syphilis is concentrated among high-risk groups, but the epidemiology of syphilis reinfection is poorly understood. We characterized factors associated with syphilis incidence, including reinfection, in a high-risk cohort in Peru.

METHODS

Participants in the NIMH CPOL trial were assessed at baseline and 2 annual visits with HIV/STI testing and behavioral surveys. Participants diagnosed with syphilis also attended 4- and 9-month visits. All participants underwent syphilis testing with RPR screening and TPPA confirmation. Antibiotic treatment was provided according to CDC guidelines. Reinfection was defined as a 4-fold titer increase or recurrence of seroreactivity after successful treatment with subsequent negative RPR titers. The longitudinal analysis used a Possion generalized estimating equations model with backward selection of variables in the final model (criteria P <0.02).

RESULTS

Of 2,709 participants, 191 (7.05%) were RPR-reactive (median 1:8, range 1:1-1:1024) with TPPA confirmation. There were 119 total cases of incident syphilis, which included both reinfection and first-time incident cases. In the bivariate analysis, the oldest 2 quartiles of age (incidence ratio (IR) 3.84; P <0.001 and IR 8.15; P <0.001) and being MSM/TW (IR 6.48; P <0.001) were associated with higher risk of incident syphilis infection. Of the sexual risk behaviors, older age of sexual debut (IR 12.53; P <0.001), not being in a stable partnership (IR 1.56, P = 0.035), higher number of sex partners (IR 3.01; P <0.001), unprotected sex in the past 3 months (IR 0.56; P = 0.003), HIV infection at baseline (IR 3.98; P <0.001) and incident HIV infection during the study period (IR 6.26; P = 0.003) were all associated with incident syphilis. In the multivariable analysis, older age group (adjusted incidence ratio (aIR) 6.18; P <0.001), men reporting having sex with a man (aIR 4.63; P <0.001), and incident HIV infection (aIR 4.48; P = 0.008) were significantly associated.

CONCLUSIONS

We report a high rate of syphilis reinfection among high-risk men who have evidence of previous syphilis infection. Our findings highlight the close relationship between HIV incidence with both incident syphilis and syphilis reinfection. Further studies on syphilis reinfection are needed to understand patterns of syphilis reinfection and new strategies beyond periodic testing of high-risk individuals based on HIV status are needed.

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

Chlamydia trachomatis and Neisseria gonorrhoeae are among the most common sexually transmitted bacterial infections in the world. Data are limited, however, on the burden of extra-genital chlamydial and gonococcal infections among men who have sex with men and transgender women in Lima, Peru. Data were gathered from self-collected anal or pharyngeal swabs from participants in Lima, Peru, and analyzed via cross-sectional methods. Prevalence ratios for the association between extra-genital infection with socio-demographic and sexual behaviors were determined. Overall, 127 (32.8%) participants had anal or pharyngeal infections. On multivariate modeling, anal infection was positively associated with practicing both receptive and insertive anal sex, when compared to insertive alone (PR = 2.49; 95% CI = 1.32-4.71), and negatively associated with any antibiotic use in the prior three months (PR = 0.60; 95% CI = 0.39-0.91). Pharyngeal infection was negatively associated with age greater than 30 years compared to 18-30 years (PR = 0.54; 95% CI = 0.30-0.96), and positively associated with gender identity of transgender women (PR = 2.12; 95% CI = 1.20-3.73). This study demonstrates considerable burden of extra-genital chlamydial and gonococcal infections among men who have sex with men and transgender women in Lima, Peru.

Anogenital Human Papillomavirus Infection and HIV Infection Outcomes Among Peruvian Transgender Women: Results from a Cohort Study

Latin American transgender women are highly vulnerable to HIV infection, and although much is known about factors associated with HIV infection in this population, little is known about the association of human papilloma virus (HPV) with HIV infection. We investigated anogenital HPV and cumulative HIV incidence among 68, initially HIV uninfected, Peruvian transgender women enrolled into a 2-year, prospective cohort study: 95.6% had at least one anogenital HPV genotype at baseline, 19.1% had visible anogenital warts, and 6.0% became infected with HIV over the course of the study. Due to the high anogenital HPV prevalence, this population would likely benefit from early immunization with the HPV vaccine.

Impact of alcohol use on sexual behavior among men who have sex with men and transgender women in Lima, Peru

BACKGROUND

Alcohol use disorders (AUDs) may enhance the likelihood of risky sexual behaviors and the acquisition of sexually transmitted infections (STIs). Associations between AUDs with condomless anal intercourse (CAI) and STI/HIV prevalence were assessed among men who have sex with men (MSM) and transgender women (TW) in Lima, Peru.

METHODS

MSM and TW were eligible to participate based on a set of inclusion criteria which characterized them as high-risk. Participants completed a bio-behavioral survey. An AUDIT score ≥8 determined AUD presence. Recent STI diagnosis included rectal gonorrhea/chlamydia, syphilis, and/or new HIV infection within 6 months. Prevalence ratios (PR) were calculated using Poisson regression.

RESULTS

Among 312 MSM and 89 TW, 45% (181/401) had an AUD. Among those with an AUD, 164 (91%) were hazardous/harmful drinkers, and 17 (9%) had alcohol dependence. Higher CAI was reported by participants with an AUD vs. without, (82% vs. 72% albeit not significant). Reporting anal sex in two or more risky venues was associated with screening AUD positive vs. not (24% vs. 15%, p=0.001). There was no difference in recent STI/HIV prevalence by AUD status (32% overall). In multivariable analysis, screening AUD positive was not associated with CAI or recent STI/HIV infection.

CONCLUSIONS

In our sample AUDs were not associated with CAI or new HIV infection/recent STI. However higher prevalence of CAI, alcohol use at last sex, and anal sex in risky venues among those with AUDs suggests that interventions to reduce the harms of alcohol should be aimed toward specific contexts.

High prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae infections in anal and pharyngeal sites among a community-based sample of men who have sex with men and transgender women in Lima, Peru

OBJECTIVES

This study aimed to characterise the epidemiology of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections among men who have sex with men (MSM) and transgender women (TW) in Lima, Peru.

SETTING

Cross-sectional study in Lima, Peru.

PARTICIPANTS

We recruited a group of 510 MSM and 208 TW for a subsequent community-based randomised controlled trial. The presence of CT and NG were evaluated using Aptima Combo2 in pharyngeal and anal swabs. We also explored correlates of these infections.

PRIMARY AND SECONDARY OUTCOME MEASURES

Study end points included overall prevalence of C. trachomatis and N. gonorrhoeae in anal and pharyngeal sites.

RESULTS

Overall prevalence of CT was 19% (95% CI 16.1% to 22.1%) and 4.8% (95% CI 3.3% to 6.6%) in anal and pharyngeal sites, respectively, while prevalence of NG was 9.6% (95% CI 7.5% to 12.0%) and 6.5% (95% CI 4.8% to 8.5%) in anal and pharyngeal sites, respectively.

CONCLUSIONS

The prevalence of each infection declined significantly among participants older than 34 years (p<0.05). Efforts towards prevention and treatment of extraurogenital chlamydial and gonococcal infections in high-risk populations like MSM and TW in Lima, Peru, are warranted.

TRIAL REGISTRATION NUMBER

NCT00670163; Results.

Field evaluation of a dual rapid diagnostic test for HIV infection and syphilis in Lima, Peru

OBJECTIVES

Screening for HIV and syphilis in key populations is recommended by the WHO to reduce the morbidity, mortality and transmission associated with undiagnosed and untreated infections. Rapid point-of-care tests that can detect multiple infections with a single fingerprick whole blood specimen using a single device are gaining popularity. We evaluated the field performance of a rapid dual HIV and syphilis test in people at high risk of HIV and syphilis infections.

METHODS

Participants included men who have sex with men and transgender women recruited in Lima, Peru. Reference standard testing for detection of HIV and syphilis infections, conducted using blood samples from venipuncture, included Treponema pallidum particle agglutination and fourth-generation HIV enzyme immunoassay for which positive results had a confirmation HIV Western blot test. For the evaluation test, SD BIOLINE HIV/Syphilis Duo test (Standard Diagnostics, Korea), a fingerprick blood specimen was used. Sensitivity and specificity were calculated and the exact binomial method was used to determine 95% CIs.

RESULTS

A total of 415 participants were recruited for the study. The dual test sensitivity for detection of T. pallidum infection was 89.2% (95% CI 83.5% to 93.5%) and specificity 98.8% (95% CI 96.5% to 99.8%). For detection of HIV infection, the sensitivity of the dual test was 99.1% (95% CI 94.8% to 100%) and specificity 99.4% (95% CI 97.7% to 99.9%).

CONCLUSIONS

This high performing dual test should be considered for the use in clinical settings to increase uptake of simultaneous testing of HIV and syphilis and accelerate time to treatment for those who need it.

A prospective cohort study characterising the role of anogenital warts in HIV acquisition among men who have sex with men: a study protocol

INTRODUCTION

The HIV epidemic in Latin America is concentrated among men who have sex with men (MSM) and transgender women (TGW) with transmission predominately occurring during unprotected anal intercourse. This mode of transmission is also responsible for other sexually transmitted infections (STIs) such as herpes simplex, chlamydia and gonorrhoea, human papillomavirus (HPV)/genital warts and syphilis. Studies assessing the prevalence of HIV and HPV among MSM have not addressed the role of genital warts and HPV-related diseases in the acquisition of HIV infection. Community-based testing programmes are a potentially important way to remove barriers including stigma for individuals to learn about their STI status.

METHODS AND ANALYSIS

The prospective cohort study will recruit 600 MSM/TGW at a community centre in Lima, Peru, named Epicentro. Half of the participants will have a history of or have current anogenital warts (AGW), and the other half will have no history of AGW. We will measure the prevalence and acquisition of STIs including syphilis, HPV, chlamydia and gonorrhoea and the HIV-incidence in the two groups. To the best of our knowledge, it will be the first study that specifically examines the impact of genital warts on incident HIV infection. This study will help to understand the relationship between AGW and HIV infection among MSM/TGW in Peru. Furthermore, it may facilitate the development of preventive intervention strategies to reduce the prevalence of AGW and prevent incident HIV infection. HPV-related manifestations may be a good proxy for HIV risk.

ETHICS AND DISSEMINATION

This study was approved by institutional review boards at the University of California, Los Angeles (UCLA) in the USA and Impacta in Peru. Study findings will be shared with the Peruvian Ministry of Health as well as other international and national public health organisations. Study results will be translated into Spanish for participants.

TRIAL REGISTRATION NUMBER

The Clinicaltrials.gov registration number is NCT01387412.

Characterizing the syphilis epidemic among men who have sex with men in Lima, Peru to identify new treatment and control strategies

BACKGROUND

Syphilis is an important sexually transmitted infection (STI) with serious public health consequences. Among men who have sex with men (MSM) in Lima, the prevalence and incidence are extraordinarily high. Current syndromic approaches, however, fail to identify asymptomatic cases, and in settings where large proportions of individuals test positive again after treatment, it is frequently difficult to distinguish treatment failure from re-infection. Thus, new approaches are needed to improve treatment strategies and public health control efforts.

METHODS/DESIGN

Study participants will undergo baseline testing for syphilis infection along with a behavioral survey covering demographics, sexual behavior, drug and alcohol abuse and health-care seeking behavior. The cohort will be followed for 18 months at three-month intervals. Blood and earlobe scrapings will also be collected for T. pallidum DNA testing, to create molecular markers for subtyping. We will also perform cytokine testing on collected samples in order to create host immunologic profiles associated with recurrence, re-infection, treatment failure and success.

DISCUSSION

Advances in social epidemiology, molecular typing and characterization of host immune responses will offer promise in developing new understandings of syphilis management. We will share our findings with the Peruvian Ministry of Health and other public health organizations, to identify new approaches of case detection and successful treatment.

Problem drinking is associated with increased prevalence of sexual risk behaviors among men who have sex with men (MSM) in Lima, Peru

BACKGROUND

Alcohol use is an important but understudied HIV risk factor among men who have sex with men (MSM), particularly in Latin America. We studied the relationship between problem drinking and sexual risk among MSM in Lima, Peru.

METHODS

We recruited 718 participants from 24 neighborhoods for a study on sexually transmitted infections and community-building among MSM. Multivariate analysis was used to identify factors independently associated with problem drinking, which was defined via the CAGE Questionnaire.

RESULTS

Of 718 participants, 58% met criteria for problem drinking. In univariate analysis, problem drinkers were significantly more likely to report failing to always use condoms, use alcohol or drugs prior to their most recent sexual encounter, report a history of sexual coercion and to engage in transactional sex. Problem drinkers also reported significantly higher numbers of recent and lifetime sexual partners. In multivariate analysis, factors independently associated with problem drinking included a history of sexual coercion [OR 1.8 95%, CI 1.2-2.6], having consumed alcohol prior to the most recent sexual encounter [OR 2.1 95%, CI 1.5-2.9], receiving compensation for sex in the last six months [OR 1.6, 95% CI 1.1-2.2] or having reported a prior HIV+ test [OR 0.5, 95% CI 0.2-0.9].

DISCUSSION

We found a high prevalence of problem drinking among MSM in Lima, Peru, which was associated with increased sexual risk in our study. Of note, individuals who were already HIV-infected were less likely to be problem drinkers. Further studies and targeted interventions to reduce problem drinking among MSM are warranted.

Relationship between alcohol consumption prior to sex, unprotected sex and prevalence of STI/HIV among socially marginalized men in three coastal cities of Peru

This article presents data about the relationship between alcohol consumption prior to sex and unprotected sex and the prevalence of at least one sexually transmitted infection (STI) including HIV among socially marginalized men in three coastal Peruvians cities. During an epidemiological survey with 2,146 men, we assessed their STI prevalence, frequency of alcohol consumption prior to sex, unprotected sex and other sexual risk behaviors. The overall prevalence of at least one STI/HIV was 8.5 % (95 % CI 7.3-9.7), the prevalence of unprotected sex was 79.1 % (95 % CI 77.8-80.3) and alcohol consumption prior to sex with any of the last five sex partners in the previous 6 months was 68.9 % (95 % CI 66.9-70.9). Bivariate and multivariate analysis showed that alcohol consumption of participants or their partners prior to sex were associated with the prevalence of at least one STI, adjusted Prevalence Ratio (aPR) = 1.3 (95 % CI 1.01-1.68). Unprotected sex was significantly associated with alcohol consumption prior to sex when both partners used alcohol, aPR = 1.15 (95 % CI 1.10-1.20) or when either one of them used alcohol aPR = 1.14 (95 % CI 1.09-1.18). These findings concur with previous literature suggesting a relationship between alcohol consumption prior to sex and STI and HIV. These data improve our understanding of this relationship in this context and could be used to enhance STI and HIV prevention strategies for socially marginalized men in Peru.

Impact of international laboratory partnerships on the performance of HIV/sexually transmitted infection testing in five resource-constrained countries

To review a quality control and quality assurance (QC/QA) model established to ensure the validity and reliability of collection, storage and analysis of biological outcome data, and to promote good laboratory practices (GLPs) and sustained operational improvements in international clinical laboratories, we conducted a two-arm randomized community-level HIV behavioural intervention trial in five countries: China, India, Peru, Russia and Zimbabwe. The trial was based on diffusion theory utilizing a Community Popular Opinion Leaders (CPOLs) intervention model with behavioural and biological outcomes. The QC/QA model was established by the Biological Outcome Workgroup, which collaborated with the Data Coordinating Center and John Hopkins University Reference Laboratory. Five international laboratories conducted chlamydia/gonorrhoea polymerase chain reaction (PRC)-based assays, herpes simplex virus type 2 enzyme immunoassay (EIA), syphilis serology (rapid plasma regain and Treponema pallidum particle agglutination assay, HIV serology (EIA/Western blot) and Trichomonas vaginalis culture. Data were collected at baseline, 12 and 24 months. Laboratory performance and infrastructure improved throughout the trial. Recommendations for improvement were consistently followed. Quality laboratories in resource-poor settings can be established, operating standards can be improved and certification can be obtained with consistent training, monitoring and technical support. Building collaborative partnership relations can establish a sustainable network for clinical trials, and can lead to accreditation and international laboratory development.

Routine laboratory screening for acute and recent HIV infection in Lima, Peru

BACKGROUND

Before implementing screening programmes for acute HIV infection in developing countries, key issues, including cost, feasibility and public health impact, must be determined.

OBJECTIVE

Fourth-generation enzyme immunoassay (EIA) was compared with HIV-1 RNA PCR for the detection of acute and early HIV infection in counselling and testing populations in Lima, Peru.

METHODS

Adults presenting for HIV testing at designated clinics in Lima-Callao, Peru were offered additional screening for acute HIV infection. All serum samples were tested with fourth-generation Ag/Ab EIA and confirmed by line immunoassay. Negative specimens were combined into 50-sample pools for HIV-1 RNA screening by PCR analysis in standard pooling algorithms. RNA-positive samples were retested with a third-generation EIA to evaluate the relative sensitivity of standard testing procedures.

RESULTS

Between 2007 and 2008 1191 participants were recruited. The prevalence of HIV infection was 3.2% (38/1191; 95% CI 2.2% to 4.2%) overall and 10.5% (25/237; 95% CI 6.6% to 14.5%) among men who reported sex with men (MSM). The prevalence of acute or recent HIV infection was 0.2% (95% CI 0% to 0.4%) overall and 0.8% (95% CI 0% to 2.0%) among MSM. Compared with third-generation EIA testing, both fourth-generation EIA and RNA PCR increased the rate of HIV case identification by 5.3% overall and by 8.0% within the subpopulation of MSM.

CONCLUSIONS

Screening for acute HIV infection within Peru's resource-limited public health system was acceptable and detected a high prevalence of acute and recent HIV infection among MSM. Additional efforts are needed to screen for, and prevent, transmission of HIV among MSM in Peru during the acute seroconversion stage.

Risk factors for the spread of HIV and other sexually transmitted infections among men who have sex with men infected with HIV in Lima, Peru

OBJECTIVES

To assess the prevalence of sexually transmitted infections (STIs), the frequency of sexual risk behaviours, and the relation between knowledge of HIV infection status and sexual risk behaviour among men who have sex with men (MSM) infected with HIV attending an STI clinic in Peru.

METHODS

We recruited a convenience sample of 559 MSM from a municipal STI clinic in Lima, Peru. Participants completed a survey and provided blood for HIV, syphilis and HSV-2 antibody testing, and urine for gonorrhoea and chlamydia nucleic acid testing.

RESULTS

Among 124 MSM with HIV, 72.6% were aware that they were infected with HIV. Active syphilis (RPR> or =1:8) was diagnosed in 21.0% of men infected with HIV, HSV-2 in 79.8%, urethral gonorrhoea in 1.6% and chlamydia in 1.6%. Among 41 participants reporting insertive anal intercourse with their last sex partner, 34.2% did not use a condom. Of the 86 participants reporting receptive anal intercourse, 25.6% did not use a condom. At least one episode of insertive unprotected anal intercourse (UAI) with a partner uninfected with HIV during the past 6 months was reported by 33.6% (35/104) of participants, and receptive UAI with a partner uninfected by HIV was reported by 44.6% (45/101). There was no difference in frequency of UAI with partners infected or uninfected with HIV observed between men who knew their serostatus compared with those who were previously undiagnosed (all p values >0.05).

CONCLUSIONS

MSM with HIV in Peru engaged in high-risk behaviours for spreading HIV and STIs. Knowledge of whether someone was infected with HIV was not associated with a decreased frequency of UAI. Additional efforts to reduce risk behaviour after the diagnosis of HIV infection are necessary.

Prevalence of HIV, herpes simplex virus-2, and syphilis in male sex partners of pregnant women in Peru

BACKGROUND

Sexually active heterosexual men may represent an important risk factor for HIV infection and STI transmission to their female partners and unborn children, though little is known about the prevalence of STIs in this population. We sought to determine the prevalence of HIV, herpes simplex virus type 2 (HSV-2), and syphilis infection and associated risk behaviors among male sex partners of pregnant women in Peru.

METHODS

Survey and seroprevalence data were collected from 1,835 male partners of pregnant women in four cities in Peru. Serum was tested for antibodies to HIV, HSV-2, and syphilis.

RESULTS

Among the 1,835 male participants, HIV prevalence was 0.8% (95% CI = 0.5-1.4%), HSV-2 16.0% (95% CI = 14.3-17.8%), and syphilis 1.6% (95% CI = 1.0-2.2%). Additionally, 11.0% reported a lifetime history of intercourse with men, and 37.1% with female sex workers. Unprotected intercourse with men during the previous year was reported by 0.9% and with female sex workers by 1.2%.

CONCLUSION

Pregnant women's sex partners reported lifetime sexual contact with core risk groups, had an elevated prevalence of HSV-2, and demonstrated the potential to spread HIV and other STIs to their partners. Though the prevalence of HIV in the population was not significantly higher than observed in other samples of heterosexuals in Peru, the risk of HIV transmission to their female partners may be exacerbated by their increased prevalence of HSV-2 infection. Further study of heterosexual populations is necessary to fully understand the epidemiology of HIV/STIs in Latin America.

Prevalence of same-sex sexual behavior and associated characteristics among low-income urban males in Peru

BACKGROUND

Peru has a concentrated HIV epidemic in which men who have sex with men are particularly vulnerable. We describe the lifetime prevalence of same-sex sexual contact and associated risk behaviors of men in Peru's general population, regardless of their sexual identity.

METHODS AND RESULTS

A probability sample of males from low-income households in three Peruvian cities completed an epidemiologic survey addressing their sexual risk behavior, including sex with other men. Serum was tested for HSV-2, HIV, and syphilis. Urine was tested for chlamydia and gonorrhea. A total of 2,271 18-30 year old men and women were contacted, of whom 1,645 (72.4%) agreed to participate in the study. Among the sexually experienced men surveyed, 15.2% (85/558, 95% CI: 12.2%-18.2%) reported a history of sex with other men. Men ever reporting sex with men (MESM) had a lower educational level, had greater numbers of sex partners, and were more likely to engage in risk behaviors including unprotected sex with casual partners, paying for or providing compensated sex, and using illegal drugs. MESM were also more likely to have had previous STI symptoms or a prior STI diagnosis, and had a greater prevalence of HSV-2 seropositivity.

CONCLUSIONS

Many low-income Peruvian men have engaged in same-sex sexual contact and maintain greater behavioral and biological risk factors for HIV/STI transmission than non-MESM. Improved surveillance strategies for HIV and STIs among MESM are necessary to better understand the epidemiology of HIV in Latin America and to prevent its further spread.