HIV and Syphilis Testing Among Patients Tested for Gonorrhea and Chlamydia in Emergency Departments.

HIV self-testing (HIVST) refers to the process in which individuals collect their own specimens (e.g. blood, saliva and urine), perform the test and interpret the results at a convenient time and place [1]. HIVST has been recognized as an innovative and promising approach to increase testing uptake, expand the HIV testing rate and enhance HIV testing coverage [1, 2]. Moreover, a large body of HIVST programmes and research worldwide also proved the feasibility, acceptability and effectiveness of HIVST in HIV prevention [1, 3]. Hence, the World Health Organization (WHO) recommended HIVST as the alternative and promising way to decentralize HIV testing and further increase the uptake of HIV testing, especially in low- and middle-income countries [4]. More importantly, the experiences learned from HIVST programmes can be utilized to facilitate other sexually transmitted infection (STI) prevention programmes. Although the STI epidemic has become a global public health issue, it was often overlooked and underfunded. Given the advantages of self-testing, scholars and health practitioners proposed STI self-testing as an alternative way to facilitate the STI testing rate and coverage outside clinical settings. However, previous self-testing research and implementation programmes focused on HIVST or STI self-testing separately [5], which lost the opportunity to promote HIV and STI testing simultaneously. Here, we advocate that integrating STI self-testing with HIVST may be useful for expanding STI testing. First, the high feasibility of HIVST has opened a pathway for STI self-testing. HIVST is easy, convenient [6] and less stigmatized [7]. By integrating STI self-testing with HIVST, the demand generated by HIVST can be leveraged to improve STI testing coverage. For example, a clinical trial conducted in China demonstrated that rapid dual self-testing for HIV and syphilis expanded syphilis testing uptake among men who have sex with men (MSM) in China [8]. Studies in several other countries (e.g. the United States and Australia) also confirmed this finding. As a result, the WHO recommended the dual HIV/syphilis rapid test as the alternative option to expand HIV and syphilis testing rate [4]. Second, the integration would be more cost-effective than HIV or STI self-testing alone. By integrating programmes, resources can be leveraged for multiple STI testing instead of HIVST alone. Since HIVST alone is already a cost-effective strategy for promoting HIV screening [9], integrating STI self-testing with HIVST would be more cost-effective. With the increasing burden of syphilis and other STIs globally, there is a strong need to promote STI testing [6]. The HIV-STI integrated model should be affordable in diverse settings, especially in low- and middle-income countries. Third, the integrated self-testing model can decentralize STI testing, improving the coverage of STI testing. Traditional STI testing mainly relies on clinic testing, which may be more stigmatized, centralized and hard to access for at-risk individuals [8]. With the shifting budgets and closure of clinics due to COVID-19 and other issues, a lack of access to STI testing may further exacerbate the STI epidemic [10]. This has been demonstrated in a study conducted in the United States [11]. To address this problem, decentralized STI testing and promoting a people-centred STI testing strategy is essential, while integrating STI self-testing with HIVST can empower and facilitate routine STI tests. More high-quality rapid test kits that can be used in diverse settings are needed. Many Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) rapid testing kits in many parts of the world have poor accuracy [12, 13], which thwarted the scale-up of the integrated self-testing model. Generally, those self-testing kits may have lower sensitivity than laboratory-based tests, which can produce false-negative results (Table 1). Therefore, we advocate that more high-quality rapid test kits are needed for the integrated model while acknowledging the important role of those rapid test kits in supplementing other’ screening approaches. Self-testing kits that can separate ongoing and past infections are needed to capture new infections of syphilis. This recommendation was derived from the evidence that dual HIV/syphilis self-testing kits may not distinguish new from old infections [8]. Some kits can only identify whether the patients are ever infected rather than separating new and past infections. Given its importance, we encourage research and development focusing on integrated self-testing kits, which can distinguish new from past infections. More innovative solutions are needed to link self-reported data with national surveillance. Integrated self-testing might reduce the opportunities for tracing people with positive results and linking them to care [6]. Furthermore, the self-testing relied on self-reported data, which generated missing national data, and might lead to insufficient evidence of shifts in patterns of HIV and STIs infection [6]. To tackle this issue, we suggest the establishment of a national digital reporting platform as a promising solution to incorporate more self-reported data into the national data repository. Individuals who undertake HIV and STI self-testing are encouraged to share their results on this platform, thereby enabling them to keep track of their HIV and STI status while assisting the Centers for Diseases Prevention and Control (CDC) in acquiring more individual-level data. Hence, more innovative ways can be adopted to link self-reported and national data in terms of HIV and STI self-testing results. In summary, given the experiences obtained from HIVST programmes, we are recommending integrated HIV and STI self-testing models to facilitate simultaneous HIV and STI testing. We propose that the integrated self-testing kit could be the alternative approach to address this issue. Our proposal relied on a series of advantages proffered by the integrated self-testing kit, including its high feasibility, cost-effectiveness and the decentralization of facilitating STI tests outside of clinical settings. Despite those benefits, there are still barriers inhibiting the scale-up of the integrated self-testing model. Hence, to roll out STI tests with HIVST, we call for high-quality rapid test kits on the one hand. On the other hand, we advocate conducting more empirical studies to provide substantial experience which will be beneficial for the future implementation of the integrated model. The authors declare no competing interests. DW drafted the manuscript. WT made revisions. RT, GM and JDT provided feedback on the draft and revision. All authors equally contributed to this response. All authors read and approved the final version. We would like to thank the journal editors for giving us the opportunity to discuss this important topic.

The objective of this study was to test the effect of a brief educational and counseling intervention on increasing the uptake of free testing for Chlamydia trachomatis (chlamydia) and Neisseria gonorrhea (gonorrhea) among young female emergency department (ED) patients. Women are particularly vulnerable to more serious consequences of these infections due to asymptomatic presentation. Increased testing is important to detect, treat, and halt the spread of these infections among asymptomatic women. This was a randomized controlled trial. Research assistants (RAs) approached female patients in two EDs. Eligible patients were between 18 and 35 years of age, who reported having sex with males, but were not attending the ED for either treatment of sexually transmitted infection (STI) or testing for possible STI exposure. Participants responded to survey questions about their lifetime and past 3-month substance use, number of recent sexual partners, condom use, and perception of risks for chlamydia and gonorrhea infections. Following the survey, the RAs randomized participants into study control or treatment arms. Each treatment arm participant received a brief educational/counseling intervention from the RA. The brief intervention focused on the woman's personal risks for chlamydia and gonorrhea and condoms attitudes and usage. As the primary outcome of this study, participants were offered free urine tests for chlamydia and gonorrhea infection postintervention or post-survey completion, depending on group assignment. A total of 171 women completed the baseline assessment and were offered chlamydia and gonorrhea testing. The mean (±SD) age was 26 (±4.76) years, 18% were Hispanic, and 12% were Spanish-speaking only. The brief intervention that was offered to increase these women's awareness of their STI risk did not result in increased acceptance of testing; 48% in the brief intervention group accepted testing (95% confidence interval [CI] = 32% to 64%) versus 36% in the control group (95% CI = 19% to 53%). In a multivariable logistic regression, only self-identifying as being Hispanic was associated with greater willingness to be tested. Of the asymptomatic women tested (n = 71), five tested positive for chlamydia. This represents a positivity rate of 7%. There were no positive test results for gonorrhea. Women who reported high-risk factors for STI, such as younger age (≤25 years), having sex in the past 90 days without using condoms, identified substance use, or previous STI, were not more likely to accept the offer of chlamydia and gonorrhea testing. The brief intervention used in this study did not increase the uptake of testing for chlamydia and gonorrhea infections in this sample, in comparison to receiving no intervention. Although Hispanic women were more likely to accept chlamydia and gonorrhea testing, it is concerning that those women who report STI risk factors were not more likely to accept the offer of chlamydia and gonorrhea testing. Future research should focus on the refinement of an intervention protocol to focus on prior STI and lack of condom use to increase the uptake of testing among this high-risk group.

BackgroundRegular HIV and sexually transmitted infection (STI) testing for men who have sex with men (MSM) is an important means of infection prevention, the adoption of which remains suboptimal in the community.ObjectiveOn the hypothesis that engagement plays an important role in sexual health monitoring, this study aimed to pilot-test internet-based HIV and STI testing with self-sampling to enhance engagement of MSM with regular testing.MethodsThis 1-year cohort study was conducted on HIV-negative MSM aged 18 years or older. A designated website was set up to enable participants to make appointments for baseline and follow-up visits at 3-monthly intervals. On-site blood sampling was performed for HIV and syphilis tests, along with self-collection of pharyngeal swabs, rectal swabs, and urine samples for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) testing. Full engagement, as defined by having made at least 3 visits over a 6-12 months’ follow-up period, was compared with partial engagement in the bivariable logistic regression model.ResultsBetween August 2019 and October 2020, 204 MSM were recruited, after the exclusion of 2 baseline HIV-positive MSM. The majority (189/204, 92.7%) were Chinese, the median age was 31 (IQR 26-39) years, and 58.0% (116/200) had experience with pre-exposure prophylaxis (PrEP) at baseline. Full engagement (146/204, 71.6%) was associated with incident STI during the follow-ups (odds ratio [OR] 4.23, 95% CI 1.63-10.94), seeking a medical referral after STI detection (OR 10.25, 95% CI 3.25-29.79), and a synchronized schedule of HIV and STI testing with PrEP visits (OR 51.85, 95% CI 19.30-139.34). No incident HIV was detected in the follow-up period. At baseline, the overall STI (CT, NG, or syphilis) prevalence was 30%, with CT at 18%, NG at 13%, and syphilis at 5%. During follow-up, the incidences were 59.08/100 person-years (py) for any STI, 33.05/100 py for CT, 29.86/100 py for NG, and 10.4/100 py for syphilis. The detection rates of CT and NG in urine samples were lower than with pharyngeal swabs and rectal swabs. The scores for convenience, confidence of correct sampling, and accuracy of self-sampling were high (7 to 8 out of 10).ConclusionsBoth baseline prevalence and incidence of STI were high among MSM engaged in regular testing. A high degree of engagement in regular STI and HIV testing was positively associated with incident STI, history of health-seeking behaviors, and perceived convenience of self-sampling. Self-sampling could be introduced as a means of enhancing engagement in regular HIV and STI testing.

Melendez, Johan H. PhD, MS; Hamill, Matthew M. MBChB, PhD; Armington, Gretchen S. MA; Gaydos, Charlotte A. DrPH, MS; Manabe, Yukari C. MD Author Information

HIV and other sexually transmitted infections (STIs) are on the rise nationally and internationally. The coronavirus 2019 (COVID-19) pandemic drove a shift toward telemedicine and prioritization of symptomatic treatment over asymptomatic screening. The impact in safety-net settings, which faced disproportionate baseline STI/HIV rates rooted in structural inequities, and where many patients lack telemedicine resources, is not yet known. This study describes the impact of COVID-19 on STI/HIV testing at an urban safety-net hospital. We used descriptive statistics to compare hospital-wide chlamydia, gonorrhea, syphilis, and HIV testing volume and positivity rates in the following periods: prepandemic (July 1, 2019-February 29, 2020), peak-pandemic (March 1, 2020-May 31, 2020), and postpeak (June 1, 2020-August 31, 2021). STI and HIV test volume dropped sharply in March 2020. STI testing during the peak-pandemic period was 42% of prepandemic baseline (mean 1145 vs. 2738 tests/month) and nadired in April 2020 (766 tests/month). Similarly, peak-pandemic HIV testing was 43% of prepandemic baseline (mean 711 vs. 1635 tests/month) and nadired in April 2020 with 438 tests/month, concentrated in emergency department and inpatient settings. STI and HIV testing rates did not return to baseline for a full year. STI and HIV test positivity rates were higher in the peak-pandemic period compared with the prepandemic baseline. Given the precipitous decline in STI and HIV testing during the pandemic, safety-net settings should develop low-barrier alternatives to traditional office-based testing to mitigate testing gaps, high positivity rates, and associated morbidity.

"Sex in the Time of COVID": Clinical Guidelines for Sexually Transmitted Disease Management in an Era of Social Distancing.

HIV and other sexually transmitted infections (STIs) have disproportionately affected communities of men who have sex with men (MSM). We describe HIV and STI prevalence and testing patterns among urban Vietnamese MSM. We conducted a cross-sectional community-based study of MSM in Hanoi, Vietnam in 2016. Participants self-reported experiences of social stigma in healthcare settings and previous HIV and STI testing. STI testing included HIV, herpes simplex virus-2 (HSV-2), syphilis, gonorrhea, and chlamydia. 205 MSM participated in the study. STI prevalence was HIV (10%), HSV-2 (4%), syphilis (13%), gonorrhea (34%), and chlamydia (19%). More than half (55%) of participants tested positive for at least one STI. Most participants had been previously tested for HIV or another STI (72%), with 24% previously receiving a positive result. Perceived and enacted social stigma in healthcare contexts was negatively associated with previous HIV or STI testing (adjusted prevalence odds ratio (aPOR): 0.22; 95% confidence interval (CI): 0.10-0.48). High prevalence of STIs was observed among Vietnamese MSM, and perceived and enacted stigma was related to HIV and STI testing. Our findings reaffirm the importance of regular STI screening among this population as well as additional outreach to promote safe HIV and STI healthcare engagement.

243 Emergency Department Sexually Transmitted Infection Testing and Compliance With CDC HIV Testing Guidelines in a National Sample of Emergency Departments

Gaps in syphilis screening for patients receiving sexually transmitted infection testing in the emergency department.

BackgroundWhile rates of HIV and sexually transmitted infections (STIs) are extremely high among adolescents and young adults in the United States, rates of HIV and STI testing remain low. Given the ubiquity of mobile phones and the saliency of peers for youths, text messaging strategies may successfully promote HIV or STI testing among youths.ObjectiveThis study aimed to understand the types of messages youths believe were motivating and persuasive when asked to text friends to encourage them to seek HIV or STI testing services at a neighborhood clinic.MethodsWe implemented an adolescent peer-based text messaging intervention to encourage clinic attendance and increase STI and HIV testing among youths (n=100) at an adolescent clinic in San Francisco, California. Participants were asked to send a text message to 5 friends they believed were sexually active to encourage their friends to visit the clinic and receive STI or HIV screening. Thematic analysis was used to analyze the content of the text messages sent and received during the clinic visit. Member checking and consensus coding were used to ensure interrater reliability and significance of themes.ResultsWe identified four themes in the messages sent by participants: (1) calls to action to encourage peers to get tested, (2) personalized messages with sender-specific information, (3) clinic information such as location and hours, and (4) self-disclosure of personal clinic experience. We found that nearly all text messages included some combination of 2 or more of these broad themes. We also found that youths were inclined to send messages they created themselves, as opposed to sending the same message to each peer, which they tailored to each individual to whom they were sent. Many (40/100, 40%) received an immediate response to their message, and most participants reported receiving at least 1 positive response, while a few reported that they had received at least 1 negative response. There were some differences in responses depending on the type of message sent.ConclusionsGiven the high rates of STI and HIV and low rates of testing among adolescents, peer-driven text messaging interventions to encourage accessing care may be successful at reaching this population. This study suggests that youths are willing to text message their friends, and there are clear types of messages they develop and use. Future research should use these methods with a large, more diverse sample of youths and young adults for long-term evaluation of care seeking and care retention outcomes to make progress in reducing HIV and STI among adolescents and young adults.

BackgroundEmergency Departments (EDs) are important sites for HIV testing. However, there is little guidance on how best to implement HIV testing in the ED. The purpose of this study was to evaluate HIV screening practices of high-risk individuals presenting to an ED in the absence (ED1) and in the presence (ED2) of an established HIV testing program within the same academic hospital.MethodsWe performed a retrospective chart review of all individuals 18 years or older presenting to either ED between January 1, 2016 and December 31, 2018. High-risk of HIV infection was determined by receipt of bacterial sexually transmitted infection (STI) testing for Neisseria gonorrhoeae or Chlamydia trachomatis. The primary outcome was receipt of any HIV test in the ED. Overall proportions of patients tested for HIV at the same time of STI testing were compared between sites by chi-square test. Predictors of HIV testing were analyzed by logistic regression.ResultsDuring the study period, 7,956 individuals received STI testing at ED1 and 10,815 received STI testing at ED2. The majority of individuals receiving STI testing at both sites were female, 81.2% at ED1 and 66.4% at ED2 (P <0.001). Only 4.0% of individuals received HIV testing at ED1 compared with 47.4% at ED2 (P <0.001). Individuals were significantly more likely to receive HIV testing at the time of STI testing in the ED with an HIV testing program (aOR 19.66, 95% CI 17.28–22.37). In the ED without an HIV testing program, individuals were more likely to receive HIV testing if they were male (aOR 3.57, 95% CI 2.78–4.55) and less likely if they were black (aOR 0.57, 95% CI 0.50–0.97). In the ED with an HIV testing program, individuals were more likely to receive HIV testing if they were male (aOR 2.17, 95% CI 1.92–2.44) and more likely if they were black (aOR 1.74, 95% CI 1.37–2.20).ConclusionOverall, the presence of an HIV testing program in the ED significantly increased the probability that individuals would receive an HIV test at the time of bacterial STI testing and mitigated disparities in care. The results of this study will help guide ongoing interventions to improve HIV screening among high-risk individuals in the emergency department.DisclosuresAll authors: No reported disclosures.

BackgroundGlobally, female sex workers (FSW) are disproportionately affected by HIV and other sexually transmitted infections (STIs). However, uptake of STI and HIV testing services among FSW in sub-Saharan Africa remains low. We aimed to assess the effect of FSW-led peer education and text message reminders on 3-monthly syphilis and HIV testing among FSW in Uganda.MethodsBetween September 2019 and February 2020, we implemented weekly peer education sessions and bi-monthly SMS reminders for FSW in Mbarara (intervention city). Peer education sessions were implemented by 20 FSW, who received five days of basic training as peer educators. We held monthly meetings with peer educators throughout the six-month implementation period. FSW in Mbale (control city) continued to receive standard of care consisting of HIV testing outreach campaigns, and facility-based testing. Using a quasi-experimental design in one intervention city, and one control city, we conducted pre- and post- questionnaire-based surveys on recent syphilis and HIV testing behavior among FSW in July-October 2018, and March 2020. We compared proportions and prevalence ratios at baseline and follow-up using chi-square tests and negative binomial regression.ResultsWe conducted 436 interviews (200 before/236 after) with FSW. At baseline similar proportions reported taking an HIV test (57 % vs. 54 %; p = 0.72), and a syphilis serology test (35 % vs. 39 %; p = 0.67) in the intervention and control cities, respectively, in the prior three months. After the intervention, this proportion increased to 82 % (95 % confidence interval [CI] 74.0-88.2) for HIV, and 81 % (95 % CI: 73.0–87.0) for syphilis in the intervention city. Relative to baseline in the control city, the proportion testing for HIV was unchanged (52 %) but decreased for syphilis (26 %).ConclusionsBi-monthly text message reminders with weekly peer education sessions increased uptake of 3-monthly syphilis and HIV testing in a Ugandan female sex work population and could help increase sex worker engagement in HIV/STI services in line with World Health Organization recommendations.

BackgroundPeriodic testing of female sex workers (FSW) for sexually transmitted infections (STIs) is a core component of global and national responses to achieve population-level STI elimination. We conducted a qualitative study to explore barriers and facilitators of regular syphilis and HIV testing among FSW in Uganda.MethodsWithin a quasi-experimental study among 436 FSW to assess the effect of peer education and text message reminders on uptake of regular STI and HIV testing among FSW, we conducted 48 qualitative interviews in four cities in Uganda from August–December 2018. We purposively selected FSW who tested for syphilis and HIV every 3–6 months; 12 FSW were interviewed in each city. Sex worker interviews explored: 1) reasons for periodic syphilis and HIV testing; 2) barriers and facilitators of testing; 3) experiences of testing; and 4) challenges faced while seeking testing services. Data were analyzed using thematic content analysis.ResultsThematic analysis revealed individual- and health system-level barriers and facilitators of testing. For syphilis, barriers were a) interpersonal stigma, low perceived severity of syphilis and testing misconceptions (individual); and b) judgmental provider attitudes, paucity of facilities offering syphilis testing, stockouts of test kits and high cost (health system). Facilitators were c) desire to remain healthy, get married and have children, knowing the benefits of early treatment, influence of male partners/clients and normative testing behaviors (individual); and d) sex worker clinics offering dual syphilis/HIV testing (health system). For HIV, barriers included: a) internalized stigma (individual); and b) unfavorable clinic hours, stigma, discrimination, and unfriendly provider (health system). Facilitators were a) motivations to stay healthy and attract clients, habitual testing, self-efficacy, doubts about accuracy of negative test results, and use of post-exposure prophylaxis (individual); and d) availability of testing facilities (health system). Syphilis and HIV had similar testing barriers and facilitators.ConclusionsHIV programs are likely to be important entry points for syphilis testing among FSW. Multi-level interventions to address testing barriers should consider focusing on these service delivery points. Extending the dual syphilis and HIV testing approach to FSW may improve testing uptake for both infections at public health facilities and decrease population-level incidence.

ObjectivesWe examined sexual behaviour, sexually transmitted infection (STI) and HIV testing and testing need, and identified associated factors, among gay, bisexual and other men who have sex with men (GBMSM)...

Cisgender men who have sex with men (MSM), transgender women, cisgender women and cisgender men who have sex with women only (MSW) have differential risk of acquiring Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC), the two most commonly reported bacterial sexually transmitted infections (STIs) in the USA. Similarly, MSM and transgender women have a higher number of syphilis infections in the USA than other groups. The presence of any of these three STIs is a significant risk factor for HIV acquisition and transmission, unless taking antiretroviral medication for HIV prevention (pre-exposure prophylaxis) or treatment (antiretroviral therapy). We sought to understand the prevalence rates of STIs in various vulnerable populations by anatomical site, sex and gender, which will inform the development of targeted prevention interventions and guide future updates to national testing guidelines. Participants are enrolled in the MACS (Multicenter AIDS Cohort Study)/WIHS (Women's Interagency HIV Study) Combined Cohort Study (MWCCS)-the longest-running observational study of both people living with HIV (PLWH) and sociodemographically similar people living without HIV (PLWOH) in the world-with a total of 13 clinical research sites across the USA; participants (N=5700) complete quantitative assessments related to a variety of behavioural and health-related factors every 6 months. Regardless of whether or not they were sexually active or symptomatic/asymptomatic, all enrolled participants (ie, cisgender MSM, transgender women, cisgender women and cisgender MSW) were asked to complete surveillance testing for bacterial STIs (ie, syphilis, CT and GC). In addition to urethral samples, cisgender MSM, transgender women and cisgender MSW collected samples to test for extragenital pharyngeal and rectal CT and GC. Using at-home testing kits, participants self-collected biospecimens (ie, dried blood spots (DBS)/ microtainer of blood, urine and rectal and pharyngeal swabs) which were mailed to a central laboratory for nucleic acid amplification testing (for CT/GC) and syphilis testing using the reverse algorithm. STI results were linked to participants' HIV testing data and self-administered surveys on sociodemographics, sexual behaviours and psychosocial factors. Among those tested, 24.6% of cisgender MSM, 25.8% of transgender women, 7.4% of cisgender women and 14.6% cisgender MSW tested positive for at least one STI. Multiple STIs/anatomical sites were detected in 3.9% of participants, with the highest prevalence among transgender women (9.7%). Current/past syphilis prevalence was 11.2% across all participants, with cisgender MSM (19.7%) and transgender women (19.4%) having a higher prevalence than cisgender women (6.4%) and cisgender MSW (12.6%). Regarding CT, 2.1% of the participants tested were positive at one anatomical site. Among those who had extragenital testing, rectal CT was the most prevalent (3.2%), including 3.4% among cisgender MSM, 8.9% among transgender women and 0.9% among cisgender MSW. For GC, 1.4% of participants tested positive at one site. Among those who tested for extragenital STIs, rectal GC was the most common site, with a prevalence of 2.2%, including 2.3% for cisgender MSM, 4.3% for transgender women and 1.4% among MSW. Overall, 7.1% of participants tested positive for CT or GC at one or more anatomical sites. Finally, PLWH had a significantly higher prevalence of syphilis (13.74%) compared with PLWOH (6.11%) (p<0.001). There is a high prevalence of bacterial STIs among participants in the MWCCS. Self-collection of DBS/microtainer of blood, urine and rectal and pharyngeal swabs provided a useful, cost-effective option for screening participants outside of the traditional clinical setting. Given the possible asymptomatic nature of all three STIs, regular testing and education can be key to detection and treatment. Culturally appropriate and locally derived community outreach and engagement can be highly effective in reducing stigma around HIV and STIs and help reduce barriers to testing and treatment.