Bacterial Sexually Transmitted Infections Research Articles

Syphilis Elimination: Lessons Learned Again

It is estimated that approximately 20 million new sexually transmitted infections (STIs) occur each year in the United States. The federally funded sexually transmitted disease prevention program implemented by Centers for Disease Control and Prevention is primarily focused on the prevention and control of the three most common bacterial STIs: syphilis, gonorrhea, and chlamydia. A range of factors facilitate the transmission and acquisition of STIs, including syphilis. In 1999, Centers for Disease Control and Prevention launched the National Campaign to Eliminate Syphilis from the United States. The strategies were familiar to public health in general and to sexually transmitted disease control in particular: (1) enhanced surveillance, (2) expanded clinical and laboratory services, ((3) enhanced health promotion, (4) strengthened community involvement and partnerships, and (5) rapid outbreak response. This national commitment to syphilis elimination was not the first effort, and like others before it too did not succeed. However, the lessons learned from this most recent campaign can inform the way forward to a more comprehensive approach to the prevention and control of STIs and improvement in the nation's health.

Sexual behaviours and sexually transmitted infection outcomes in a cohort of HIV-negative men who have sex with men attending sexual health clinics in England.

Men who have sex with men (MSM) attending sexual health (SH) clinics are at high risk for HIV acquisition and are disproportionately affected by sexually transmitted infections (STIs). We collected standardised behavioural data from MSM attending clinics to characterise sexual behaviours and identify predictors for HIV and STIs. In 2012–2013, HIV-negative MSM attending five SH clinics in England reported sexual behaviours in the previous three months via a self-administered questionnaire. Behaviours were linked to the individual’s clinical records using national surveillance. The prevalence and incidence of bacterial STIs (gonorrhoea, Chlamydia, lymphogranuloma venereum and syphilis) and incidence of HIV were calculated. Adjusted odds ratios and hazard ratios with 95% confidence interval (CI) were reported for significant predictors. Of 1278 HIV-negative MSM, 54% were of white ethnicity and UK-born and 43% were 25–34 years old. Almost all men reported at least one partner in the last three months. Half reported condomless anal sex and 36% condomless receptive anal intercourse (CRAI). Incidence of bacterial STIs was 46/100 (95%CI 39–54) person years (py) and of HIV was 3.1/100 (95%CI 1.7–5.6) py. A STI at baseline and CRAI with increasing numbers of partners were associated with both incident infections. In this cohort of MSM high-risk behaviours and STIs were prevalent. Engagement in CRAI increased the likelihood of subsequent infection, while men diagnosed with a bacterial STI were at increased risk of a future STI. Clinical and behavioural risk assessments to determine an individual’s risk of infection could allow a more nuanced prevention approach that has greater success in reducing transmission.

Identifying Solutions to Improve the Sexually Transmitted Infections Testing Experience for Youth Through Participatory Ideation.

Sexually transmitted infection (STI) services, including screening, treatment, and counseling among youth, remain suboptimal. In the midst of increasing incidence of bacterial STIs, alarming STI disparities, and persistently low testing rates among youth, solution-focused and action-oriented research with youth is needed. To identify solutions to STI testing barriers, we conducted three participatory ideation workshops with 18 youth, 10 key stakeholders who work with youth, and 8 social design graduate students. In response to prompt questions asking "How might we" address a testing barrier, participants generated as many ideas as they could on small pieces of paper. The brainstorming sessions produced 702 brainstorm idea sheets that were then qualitatively analyzed through pile sorting by three team members (including two youth) with each pile representing a priori themes (from the "How might we" probe) or emergent themes. Ten themes were identified corresponding to three domains: (1) improving the testing experience (improving transparency in the testing process, increasing trust in privacy, alternative testing options, and providing incentives/rewards for testing), (2) addressing the clinic space (multi-service spaces, appealing physical clinical space, and providing waiting room activities), and (3) reframing STI testing (normalizing STI testing, the clinic as a supportive environment, and youth leadership to promote and support STI testing). These findings move beyond identifying barriers and motivators to STI testing among youth and focus on the generation of possible solutions. By engaging youth in the development of solutions to STI testing, solutions that may be better-utilized and more acceptable to youth may be developed.

Anti-HIV-1 Activity of Lactic Acid in Human Cervicovaginal Fluid.

Women of reproductive age with a Lactobacillus-dominated vaginal microbiota have a reduced risk of acquiring and transmitting HIV and a vaginal pH of ~4 due to the presence of ~1% (wt/vol) lactic acid. While lactic acid has potent HIV virucidal activity in vitro, whether lactic acid present in the vaginal lumen inactivates HIV has not been investigated. Here we evaluated the anti-HIV-1 activity of native, minimally diluted cervicovaginal fluid obtained from women of reproductive age (n = 20) with vaginal microbiota dominated by Lactobacillus spp. Inhibition of HIVBa-L was significantly associated with the protonated form of lactic acid in cervicovaginal fluid. The HIVBa-L inhibitory activity observed in the <3-kDa acidic filtrate was similar to that of the corresponding untreated native cervicovaginal fluid as well as that of clarified neat cervicovaginal fluid subjected to protease digestion. These ex vivo studies indicate that protonated lactic acid is a major anti-HIV-1 metabolite present in acidic cervicovaginal fluid, suggesting a potential role in reducing HIV transmission by inactivating virus introduced or shed into the cervicovaginal lumen.IMPORTANCE The Lactobacillus-dominated vaginal microbiota is associated with a reduced risk of acquiring and transmitting HIV and other sexually transmitted infections (STIs). Lactic acid is a major organic acid metabolite produced by lactobacilli that acidifies the vagina and has been reported to have inhibitory activity in vitro against bacterial, protozoan, and viral STIs, including HIV infections. However, the anti-HIV properties of lactic acid in native vaginal lumen fluids of women colonized with Lactobacillus spp. have not yet been established. Our study, using native cervicovaginal fluid from women, found that potent and irreversible anti-HIV-1 activity is significantly associated with the concentration of the protonated (acidic, uncharged) form of lactic acid. This work advances our understanding of the mechanisms by which vaginal microbiota modulate HIV susceptibility and could lead to novel strategies to prevent women from acquiring HIV or transmitting the virus during vaginal intercourse and vaginal birth.

Alcohol retail sales licenses and sexually transmitted infections in Texas counties, 2008-2015

ABSTRACTBackground: Research suggests that reduced retail alcohol outlet density may be associated with lower prevalence of HIV and other sexually transmitted infections (STIs). On-premise sale of alcohol for immediate consumption is theorized as increasing social interactions that can lead to sexual encounters. Objective: We examined associations between on- and off-premise retail alcohol sales licenses and number of newly diagnosed HIV and STI cases in Texas counties. Methods: Retail alcohol sales license data were obtained from the Texas Alcoholic Beverage Commission. HIV and bacterial STI data were obtained from the Texas Department of State Health Services. Associations between retail alcohol sales licenses and STIs were estimated using spatial linear models and Poisson mixed effects models for over-dispersed count data. Results: Adjusting for county-specific confounders, there was no evidence of residual spatial correlation. In Poisson models, each additional on-premise (e.g., bar and restaurant) alcohol license per 10,000 population in a county was associated with a 1.5% increase (95% CI: 0.4%, 2.6%) in the rate of HIV and a 2.4% increase (95% CI: 1.9%, 3.0%) in the rate of bacterial STIs, adjusting for potential confounders. In contrast, number of off-premise licenses (e.g., take-out stores) was inversely associated with the incidence of STI and HIV, although the association with HIV was not statistically significant. Conclusions: This study adds to the limited literature on the association between retail alcohol availability and STIs. Additional research is needed on the role of alcohol availability (and policies affecting availability) in the spread of HIV and other STIs.

Chlamydia screening

Sexually transmitted infections (STIs) are a major public health problem worldwide, affecting quality of life, adding economic burden and causing serious morbidity. Chlamydia infection is the most common bacterial STI, making up a large proportion of the over 1 000 000 STIs acquired every day. Although easily cured with antibiotics, untreated chlamydial infection can have serious consequences affecting reproductive health and the unborn child. Since chlamydia infection is typically asymptomatic, screening provides an opportunity to prevent complications and reduce transmission. With long waits for genitourinary medicine appointments and busy sexual health clinics, screening in primary care can help to improve chlamydia detection and treatment rates.

Chemsex and new HIV diagnosis in gay, bisexual and other men who have sex with men attending sexual health clinics.

The aim of the study was to analyse associations between chemsex and new HIV and sexually transmitted infection (STI) diagnoses among gay, bisexual and other men who have sex with men (GBMSM) accessing sexual health clinics. A retrospective case note review was carried out for all GBMSM attending two London sexual health clinics between 1 June 2014 and 31 July 2015. Chemsex status was documented for 1734 of 1840 patients. Overall, 27.1% (n = 463) disclosed current recreational drug use, of whom 286 (16.5%) disclosed chemsex participation and 74 of 409 (18.1%) injected drugs. GBMSM who were already HIV positive were more likely to disclose chemsex participation [adjusted odds ratio (AOR) 2.55; 95% confidence interval (CI) 1.89-3.44; P < 0.001]. Those disclosing chemsex participation had higher odds of being newly diagnosed with HIV infection (AOR 5.06; 95% CI 2.56-10.02; P < 0.001), acute bacterial STIs (AOR 3.94; 95% CI 3.00-5.17; P < 0.001), rectal STIs (AOR 4.45; 95% CI 3.37-6.06; P < 0.001) and hepatitis C (AOR 9.16; 95% CI 2.31-36.27; P = 0.002). HIV-negative chemsex participants were also more likely to have accessed post-exposure prophylaxis for HIV in the study period and to report sex with a discordant HIV- or hepatitis C virus-infected partner (P < 0.001). Chemsex disclosure in sexual health settings is associated with higher rates of STI diagnoses, including HIV infection and hepatitis C. GBMSM attending sexual health services should therefore be assessed for chemsex participation and disclosure should prompt health promotion, harm minimization and wellbeing interventions.

An epidemiological study of sexually transmitted diseases cases at STD clinic, Gorakhpur

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Sexually transmitted diseases (STDs) have been considered as a major health problem, in developing countries like India. Knowledge regarding pattern and prevalence of different STIs is very important to implement proper strategies to control the STDs. The aim of this study is to understand the pattern and prevalence of different sexually transmitted infections (STIs) in eastern Uttar Pradesh.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; This is a retrospective observational study. Records of all the patients who had attended the STI clinic from January 2013 to December 2017 in Tertiary care Hospital, Gorakhpur have been analysed.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; The commonest STD was herpes genitalis 24.04% and condylomata acuminata 23.51% respectively. The prevalence of combined gonococcal/non gonococcal urethritis and bacterial vaginosis accounts for 23.84% and HIV was detected in 13.19% of the patients. There is a decline in occurrence of Syphilis with prevalence of 5.74%.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; There is increased prevalence of viral STIs and decline in bacterial STIs seen, probably due to easy access of antibiotics to common people.&lt;/p&gt;

Age difference between heterosexual partners in Britain: Implications for the spread of Chlamydia trachomatis

Heterosexual partners often differ in age. Integrating realistic patterns of sexual mixing by age into dynamic transmission models has been challenging. The effects of these patterns on the transmission of sexually transmitted infections (STI) including Chlamydia trachomatis (chlamydia), the most common bacterial STI are not well understood. We describe age mixing between new heterosexual partners using age- and sex-specific data about sexual behavior reported by people aged 16–63 years in the 2000 and 2010 British National Surveys of Sexual Attitudes and Lifestyles. We incorporate mixing patterns into a compartmental transmission model fitted to age- and sex-specific, chlamydia positivity from the same surveys, to investigate C. trachomatis transmission. We show that distributions of ages of new sex partners reported by women and by men in Britain are not consistent with each other. After balancing these distributions, new heterosexual partnerships tend to involve men who are older than women (median age difference 2, IQR −1, 5 years). We identified the most likely age combinations of heterosexual partners where incident C. trachomatis infections are generated. The model results show that in >50% of chlamydia transmitting partnerships, at least one partner is ≥25 years old. This study illustrates how sexual behavior data can be used to reconstruct detailed sexual mixing patterns by age, and how these patterns can be integrated into dynamic transmission models. The proposed framework can be extended to study the effects of age-dependent transmission on incidence in any STI.

Men who have sex with men more often chose daily than event-driven use of pre-exposure prophylaxis: baseline analysis of a demonstration study in Amsterdam.

IntroductionThe Amsterdam PrEP project is a prospective, open‐label demonstration study at a large sexually transmitted infection (STI) clinic. We examined the uptake of PrEP; the baseline characteristics of men who have sex with men (MSM) and transgender persons initiating PrEP; their choices of daily versus event‐driven PrEP and the determinants of these choices.MethodsFrom August 2015 through May 2016, enrolment took place at the STI clinic of the Public Health Service of Amsterdam, the Netherlands. MSM or transgender persons were eligible if they had at least one risk factor for HIV infection within the preceding six months. Participants were offered a choice between daily or event‐driven use of tenofovir/emtricitabine. Baseline data were analysed using descriptive statistics and multivariable analysis was employed to determine variables associated with daily versus event‐driven PrEP.ResultsOnline applications were submitted by 870 persons, of whom 587 were invited for a screening visit. Of them, 415 were screened for eligibility and 376 initiated PrEP. One quarter (103/376, 27%) chose event‐driven PrEP. Prevalence of bacterial STI was 19.0% and mean condomless anal sex (CAS) episodes in the preceding three months were 11. In multivariable analysis, older age (≥45 vs. ≤34, aOR 2.1, 95% CI 1.2 to 3.9), being involved in a steady relationship (aOR 1.7, 95% CI 1.0 to 2.7), no other daily medication use (aOR 0.6, 95% CI 0.3 to 0.9), and fewer episodes of CAS (per log increase aOR 0.7, 95% CI 0.6 to 0.9) were determinants for choosing event‐driven PrEP.DiscussionPrEP programmes are becoming one of the more important intervention strategies with the goal of reducing incident HIV‐infection and we were unable to accommodate many of the persons applying for this study. Offering a choice of dosing regimen to PrEP users may enable further personalization of HIV prevention strategies and enhance up‐take, adherence and cost‐effectiveness.ConclusionsThe majority of participants preferred daily versus event‐driven use. Within this majority, a high number of CAS episodes before PrEP initiation was reported and we observed a high prevalence of STI. Determinants of choosing event‐driven PrEP were older age, fewer CAS episodes, no other daily medication use, and involved in a steady relationship.

Sexualized drug use ('chemsex') and high-risk sexual behaviours in HIV-positive men who have sex with men.

ObjectivesThe incidence of sexually transmitted infections (STIs) and HIV infection remains high in gay, bisexual, and other men who have sex with men (MSM) in the UK, and sexualized drug use (“chemsex”) and injecting drug use (“slamsex”) may play a part in this. We aimed to characterize HIV‐positive MSM engaging in chemsex/slamsex and to assess the associations with self‐reported STI diagnoses and sexual behaviours.MethodsData from a 2014 survey of people attending HIV clinics in England and Wales were linked to clinical data from national HIV surveillance records and weighted to be nationally representative. Multivariable logistic regression assessed the associations of chemsex and slamsex with self‐reported unprotected anal intercourse (UAI), serodiscordant UAI (sdUAI) (i.e. UAI with an HIV‐negative or unknown HIV status partner), sdUAI with a detectable viral load (>50 HIV‐1 RNA copies/mL), hepatitis C, and bacterial STIs.ResultsIn the previous year, 29.5% of 392 sexually active participants engaged in chemsex, and 10.1% in slamsex. Chemsex was significantly associated with increased odds of UAI [adjusted odds ratio (AOR) 5.73; P < 0.001], sdUAI (AOR 2.34; P < 0.05), sdUAI with a detectable viral load (AOR 3.86; P < 0.01), hepatitis C (AOR 6.58; P < 0.01), and bacterial STI diagnosis (AOR 2.65; P < 0.01). Slamsex was associated with increased odds of UAI (AOR 6.11; P < 0.05), hepatitis C (AOR 9.39; P < 0.001), and bacterial STI diagnosis (AOR 6.11; P < 0.001).ConclusionsThree in ten sexually active HIV‐positive MSM engaged in chemsex in the past year, which was positively associated with self‐reported depression/anxiety, smoking, nonsexual drug use, risky sexual behaviours, STIs, and hepatitis C. Chemsex may therefore play a role in the ongoing HIV and STI epidemics in the UK.

Characteristics of Cases With Repeated Sexually Transmitted Infections, Massachusetts, 2014-2016.

Persons with prior sexually transmitted infections (STIs) are at high risk for reinfection. No recent studies have examined frequency with which persons are diagnosed and reported with multiple bacterial STIs over time. We conducted a retrospective, of confirmed syphilis, gonorrhea, and chlamydial infections reported to Massachusetts state surveillance system within a 2-year period, 28 July 2014-27 July 2016. Among Massachusetts population aged 13-65 years (4847510), 49142 (1.0%) were reported with ≥1 STIs; 6999 (14.2% of those with ≥1 STI) had ≥2 STIs, accounting for 27.7% of STIs. Of cases with ≥5 or more STIs (high-volume repeaters), 118 (74%) were men and 42 (26%) were women. Men spanned the age spectrum and were predominantly non-Hispanic white; 87% reported same-sex contacts. Women were younger, predominantly nonwhite, and without known same-sex contacts. Women were reinfected with gonorrhea and chlamydia or chlamydia alone; none had syphilis or human immunodeficiency virus (HIV) infection. All men with syphilis also had gonorrhea and/or chlamydia; 35% were diagnosed with HIV before, during, or within 10 months after study period. The majority (56%) of high-volume repeaters were seen at more than 1 care site/system. In Massachusetts, a large proportion of bacterial STIs are reported from a small subpopulation, many of whom have repeated infections and are likely to have higher impact on STI and HIV rates. Public health can play a crucial role in reaching high-volume repeaters whose STI histories may be hidden from clinicians due to fragmented care.

Partner notification and retesting for Chlamydia trachomatis and Neisseria gonorrhoeae: a case-note review in New Zealand primary care.

INTRODUCTION Bacterial sexually transmitted infections (STIs) contribute to a significant burden of ill-health despite being easy to diagnose and treat. STI management guidelines provide clinicians with evidence-based guidance on best-practice case management. AIM To determine the extent of adherence to STI management guidelines for partner notification, follow up and testing for reinfection following diagnosis of Chlamydia trachomatis and Neisseria gonorrhoeae. METHODS Retrospective review of electronic patient records for individuals diagnosed with chlamydia or gonorrhoea in eight primary care clinics in Wellington, New Zealand. At each clinic, 40 clinical records were reviewed (320 in total). Outcome measures were: overall numbers (%) of cases with documented evidence of reason for testing, sexual history, treatment, advice, partner notification and follow up. Partner notification outcomes were: n (%) with evidence of partner notification discussion and n (%) with partners advised, tested and treated. Proportions retested between 6 weeks and 6 months and n (%) positive on retesting were also determined. RESULTS Presenting features and treatment were generally well documented. Recent sexual history including number of partners was documented for half of cases reviewed (159/320). Partner notification discussion was documented for 74% (237/320) of cases, but only 24.4% (78/320) had documentation on numbers of partners notified and 17% (54/320) on numbers of partners treated. Testing for reinfection between 6 weeks and 6 months occurred for 24.7% (79/320), of whom 19% (15/79) re-tested positive. CONCLUSIONS This research suggests there are gaps in important aspects of patient care following bacterial STI diagnosis - a factor that may be perpetuating our high rates of infection. A more systematic approach will be needed to ensure people diagnosed with an STI receive the full cycle of care in line with best practice guidelines.

Post-exposure prophylaxis with doxycycline to prevent sexually transmitted infections in men who have sex with men: an open-label randomised substudy of the ANRS IPERGAY trial

Increased rates of sexually transmitted infections (STIs) have been reported among men who have sex with men. We aimed to assess whether post-exposure prophylaxis (PEP) with doxycycline could reduce the incidence of STIs. All participants attending their scheduled visit in the open-label extension of the ANRS IPERGAY trial in France (men aged 18 years or older having condomless sex with men and using pre-exposure prophylaxis for HIV with tenofovir disoproxil fumarate plus emtricitabine) were eligible for inclusion in this open-label randomised study. Participants were randomly assigned (1:1) at a central site to take a single oral dose of 200 mg doxycycline PEP within 24 h after sex or no prophylaxis. The primary endpoint was the occurrence of a first STI (gonorrhoea, chlamydia, or syphilis) during the 10-month follow-up. The cumulative probability of occurrence of the primary endpoint was estimated in each group with the Kaplan-Meier method and compared with the log-rank test. The primary efficacy analysis was done on the intention-to-treat population, comprising all randomised participants. All participants received risk-reduction counselling and condoms, and were tested regularly for HIV. This trial is registered with ClinicalTrials.gov number, NCT01473472. Between July 20, 2015, and Jan 21, 2016, we randomly assigned 232 participants (n=116 in the doxycycline PEP group and n=116 in the no-PEP group) who were followed up for a median of 8·7 months (IQR 7·8-9·7). Participants in the PEP group used a median of 680 mg doxycycline per month (IQR 280-1450). 73 participants presented with a new STI during follow-up, 28 in the PEP group (9-month probability 22%, 95% CI 15-32) and 45 in the no-PEP group (42%, 33-53; log-rank test p=0·007). The occurrence of a first STI in participants taking PEP was lower than in those not taking PEP (hazard ratio [HR] 0·53; 95% CI 0·33-0·85; p=0·008). Similar results were observed for the occurrence of a first episode of chlamydia (HR 0·30; 95% CI 0·13-0·70; p=0·006) and of syphilis (0·27; 0·07-0·98; p=0·047); for a first episode of gonorrhoea the results did not differ significantly (HR 0·83; 0·47-1·47; p=0·52). No HIV seroconversion was observed, and 72 (71%) of all 102 STIs were asymptomatic. Rates of serious adverse events were similar in the two study groups. Gastrointestinal adverse events were reported in 62 (53%) participants in the PEP group and 47 (41%) in the no-PEP group (p=0·05). Doxycycline PEP reduced the occurrence of a first episode of bacterial STI in high-risk men who have sex with men. France Recherche Nord & Sud Sida-HIV Hépatites (ANRS) and Bill & Melinda Gates Foundation.

Sexually Transmitted Infection Testing of HIV-Positive Medicare and Medicaid Enrollees Falls Short of Guidelines.

Men who have sex with men with HIV have high sexually transmitted infection (STI) incidence. Thus, the Centers for Disease Control and Prevention (CDC) recommends at least yearly STI screening of HIV-infected individuals. We calculated testing rates for syphilis, chlamydia, and gonorrhea among HIV-positive Californians with Medicare or Medicaid insurance in 2010. Logistic regressions estimated how testing for each bacterial STI relates to demographic and provider factors. Fewer than two-thirds of HIV-positive Medicare and fewer than three-quarters of Medicaid enrollees received a syphilis test in 2010. Screenings for chlamydia or gonorrhea were less frequent: approximately 30% of Medicare enrollees were tested for chlamydia or gonorrhea in 2010, but higher proportions of Medicaid enrollees were tested (45%-46%). Only 34% of HIV-positive Medicare enrollees who were tested for syphilis were also screened for chlamydia or gonorrhea on the same day. Nearly half of Medicaid enrollees were tested for all 3 STIs on the same day. Patients whose providers had more HIV experience had higher STI testing rates. Testing rates for chlamydia and gonorrhea infection are low, despite the increase in these infections among people living with HIV and their close association with HIV transmission. Interventions to increase STI testing include the following: prompts in the medical record to routinely conduct syphilis testing on blood drawn for viral load monitoring, opt-out consent for STI testing, and provider education about the clinical importance of STIs among HIV-positive patients. Last, it is crucial to change financial incentives that discourage nucleic acid amplification testing for rectal chlamydia and gonorrhea infections.

Chemsex Among Men Who Have Sex With Men: a Sexualized Drug Use Survey Among Clients of the Sexually Transmitted Infection Outpatient Clinic and Users of a Gay Dating App in Amsterdam, the Netherlands.

Chemsex (i.e., drug use during sex) is practiced by some men who have sex with men (MSM) and is associated with high-risk behavior. In a cross-sectional study at the sexually transmitted infection (STI) clinic of Amsterdam, we explored chemsex practices, risk behavior, and STI prevalence. A survey on chemsex (γ-hydroxybutyrate, crystal methamphetamine, and/or mephedrone) was offered to clinic clients during routine STI screening and to Amsterdam users of a gay online dating app. Associations were assed using χ test and multivariable regression. Chemsex in the past 6 months was practiced by 866 (17.6%) of 4925 MSM clients and by 159 (1.5%) of 10857 non-MSM clients. Among gay dating app users, the proportion that reported chemsex engagement was higher than among MSM visiting the STI clinic (29.3% [537/1832] vs. 17.6%; P < 0.001). Chemsex was a significant risk factor for bacterial STI in HIV-negative MSM visiting the STI clinic (adjusted odd ratio, 1.5; 95% confidence interval, 1.2-1.8), but not in HIV-positive MSM. A majority practiced chemsex once a month or less, and 87.0% reported sex without drug use in the past month. In Amsterdam, chemsex is frequently practiced and significantly associated with bacterial STI in HIV-negative MSM but not in HIV-positive MSM. Future prevention strategies to reduce STI incidence should especially target HIV-negative MSM engaging in chemsex.

The role of frequent HIV testing in diagnosing HIV in men who have sex with men

In the UK, quarterly HIV testing is recommended for high-risk men who have sex with men (MSM). In this manuscript we determined the risk of being newly diagnosed with HIV in MSM by their HIV testing history, considering both the frequency and periodicity of testing. Data on HIV incidence in MSM attending a sexual health clinic (SHC) in England in 2013-2014 with testing history (previous 2 years) were obtained from GUMCAD, the national sexually transmitted infection (STI) surveillance system in England. HIV testing patterns among MSM were defined using the frequency and periodicity of testing, based on 3 month intervals, in the year preceding the first attendance during the study period. Cox proportional hazards regression was used to determine the association between HIV testing pattern and time to HIV diagnosis with and without adjustment for demographic confounders. Analyses were stratified by risk stratum, with 'high risk' defined as a history of a bacterial STI in the past year. Adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs) are reported. Among the 37 702 HIV-negative MSM attending an SHC in 2013-2014, 1105 (3%) were diagnosed with HIV infection within 1 year of their first attendance. The probability of HIV diagnosis was highest in MSM who were tested quarterly compared with those who were not tested in the past year (aHR 2.51; 95% CI 1.33-4.74); this increased 1.8-fold among high-risk MSM (aHR 4.48; 95% CI 0.97-21.17). The probability of subsequent HIV diagnosis was greatest in high-risk MSM who were tested most frequently. Quarterly HIV testing increased the likelihood of identifying undiagnosed HIV infection and should remain a continued recommendation for high-risk MSM.

Sociodemographic and Clinical Factors Associated With Increasing Bacterial Sexually Transmitted Infection Diagnoses in Men Who Have Sex With Men Accessing Care at a Boston Community Health Center (2005-2015).

BackgroundThe reasons why bacterial sexually transmitted infections (BSTIs) are increasing in US men who have sex with men (MSM) have not been fully characterized.MethodsAn open cohort of MSM accessing medical care at a Boston community health center was used to assess secular trends in BSTI diagnoses. Frequency of infection and the estimated population size were used to calculate diagnosis rates. Poisson models were fit for multivariable analyses.ResultsBetween 2005 and 2015, 19 232 men had at least 1 clinic visit. Most (72.4%) were white; 6.0% were black, and 6.1% were Latino. Almost half had documented self-report of identifying as gay (42.6%) or bisexual (3.2%). Most had private health insurance (61.7%); 5.4% had Medicare, 4.6% had Medicaid, and 8.4% reported no insurance. Between 2005 and 2015, BSTI diagnoses increased more than 8-fold. In 2015, of 1319 men who were diagnosed with at least 1 BSTI; 291 were diagnosed with syphilis, 554 with gonorrhea (51.4% rectal, 31.0% urogenital), and 679 with chlamydia (69.1% rectal, 34.3% urogenital). In 2015, 22.7% of BSTIs were diagnosed among HIV-infected patients (15.4% of the clinic population), and 32.8% of BSTIs were diagnosed among HIV-uninfected patients using pre-exposure prophylaxis (PrEP; 10.1% of all men in care). In multivariable analyses, age 18 to 24 years, being HIV-infected, using PrEP, being nonwhite, or reporting Medicaid or not reporting having private insurance or Medicare were independently associated with being diagnosed with a new BSTI.ConclusionsOver the past decade, BSTI diagnosis rates increased in HIV-infected and uninfected MSM, with disproportionate increases in PrEP users, racial and ethnic minority MSM, those aged 25 to 34 years, and those without stable health insurance, warranting focused education, screening, and accessible services for these key subpopulations.

Modernizing Field Services for Human Immunodeficiency Virus and Sexually Transmitted Infections in the United States.

Public health field services for sexually transmitted infections (STIs) have not adequately evolved to address the expanding scale of the STI problem, its concentration among men who have sex with men, the emergence of new communication technologies and the availability of antiretroviral therapy as a cornerstone of human immunodeficiency virus (HIV) prevention. Field services need to modernize. Modernization should seek to expand field services objectives beyond sex partner STI testing and treatment to include: HIV testing of persons with bacterial STI and their partners, including efforts to promote frequent HIV/STI testing; increased condom access; linkage and relinkage to HIV care and promotion of viral suppression; preexposure prophylaxis promotion; linkage to long-acting contraception; and referral for health insurance. Field services programs cannot advance these new objectives while simultaneously doing all of the work they have traditionally done. Modernization will require a willingness to reconsider some longstanding aspects of field services work, including the centrality of face-to-face interviews and field investigations. Health departments seeking to modernize will need to carefully assess their ongoing activities and reorganize to align the use of field services resources with program priorities. In some instances, this may require reorganization to allow the staff greater specialization and closer integration with surveillance activities. Adapting programs will require new staff training, improvements in data management systems, and a greater investment in monitoring and evaluation. Although modernization is likely to evolve over many years, the time to start is now.

Efficacy, safety, and effect on sexual behaviour of on-demand pre-exposure prophylaxis for HIV in men who have sex with men: an observational cohort study

Data for on-demand pre-exposure prophylaxis (PrEP) are scarce. We implemented a cohort study to assess its efficacy, safety, and effect on sexual behaviour. We invited men and transgender women who have sex with men, previously enrolled in the randomised placebo-controlled ANRS IPERGAY trial at seven sites (six in France and one in Canada), to participate in an open-label extension with on-demand tenofovir disoproxil fumarate (300 mg) and emtricitabine (200 mg) to be taken before and after sexual intercourse. We assessed the incidence of HIV and other sexually transmitted infections (STIs), PrEP adherence, safety, and sexual behaviour. Statistical analyses included comparisons of proportions and incidence between the randomised phase of the ANRS IPERGAY trial and the open-label phase, and all participants were included in safety analyses. ANRS IPERGAY is registered with ClinicalTrials.gov, number NCT01473472. Between Nov 4, 2014, and Jan 27, 2015, we enrolled 361 participants. Median follow-up was 18·4 months (IQR 17·7-19·1). One participant who discontinued PrEP acquired HIV infection. HIV incidence was 0·19 per 100 person-years (95% CI 0·01-1·08), compared with 6·60 per 100 person-years (3·60-11·05) in the placebo group of the randomised study, indicating a relative reduction of 97% (95% CI 81-100) in the incidence of HIV with on-demand PrEP. Participants used a median of 18 pills of study drugs per month (IQR 11-25), and at the 6 month visit 240 (71%) of 336 participants had tenofovir detected in plasma. Drug-related gastrointestinal events were reported in 49 participants (14%) but were self-limited. Only four participants (1%) discontinued PrEP, three because of an increase in plasma creatinine. The proportion of participants reporting condomless sex at their last receptive anal intercourse significantly increased from 77% (136 of 176 participants) at baseline to 86% (66 of 77 participants) at 18 months' follow-up (p for trend=0·0004). The incidence of a first bacterial STI during this open-label phase did not change significantly compared with the randomised phase (59·0 vs 49·1 per 100 person-years, respectively; p=0·11). On-demand oral PrEP is highly effective at preventing HIV infection among high-risk men who have sex with men and therefore represents an alternative to daily PrEP, expanding choices for HIV prevention. High rates of STIs resulting from low condom use did not undermine PrEP efficacy, but warrant frequent testing. ANRS (France Recherche Nord and Sud Sida-HIV Hépatites), the Canadian HIV Trials Network, Fonds Pierre Bergé-Sidaction, Gilead Sciences, and the Bill & Melinda Gates Foundation.