Self-screening for Neisseria gonorrhoeae and Chlamydia trachomatis in the human immunodeficiency virus clinic--high yields and high acceptability

Sexually Transmitted Infections in People with Human Immunodeficiency Virus

Sexually transmitted infections (STIs) are more commonly seen in patients with human immunodeficiency virus (PWH). Routine sexual history taking and appropriate multisite screening practices support prompt identification and treatment of patients, which in turn reduces morbidity and spread of STIs including HIV. Nucleic acid amplification testing has high accuracy for diagnosing many of the major STIs. Diagnosis of syphilis remains complex, requiring 2 stage serologic testing, along with provider awareness of the myriad symptoms that can be attributable to this disease. Prevention through mechanisms such as vaccines and postexposure prophylaxis hold promise to reduce the burden of STIs in PWH.

Impact of education and clinic site champion on extragenital testing for sexually transmitted infections

BACKGROUND

Sexually transmitted infections (STIs) are on the rise in the United States. Infections at extragenital (EG) sites (throat or rectum) may serve as an overlooked reservoir for STIs. The aims of this project were to determine the proportion of patients receiving EG testing and to observe the impact of an educational intervention.

METHODS

Phase I included four urgent care clinics and baseline data for adults receiving STI testing (Chlamydia trachomatis and Neisseria gonorrhoeae). Clinics received access to an educational presentation regarding the importance of EG testing. Two of these clinics served as pilot sites for the implementation of self-collection kits. Phase II involved further expansion and utilization of clinic site champions.

RESULTS

Phase I baseline data indicated that less than 1% of samples from patients receiving STI testing were from EG sites. There was an increase in EG testing after the educational intervention and implementation of self-collection kits. A larger increase in EG testing was seen after utilization of a site champion in Phase II.

CONCLUSION

EG infections serve as a potential source for STI transmission which makes multi-site testing necessary. Our interventions to improve EG testing were most effective in Phase II after implementing a clinic site champion.

Acceptability of rectal self-sampling in non-clinical venues for chlamydia and gonorrhea testing among men who have sex with men: A cross-sectional study in Shenzhen, China

Background

Rectal Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections among men who have sex with men (MSM) have become an increasingly important concern. The study aimed to explore (1) the acceptability of rectal self-sampling for chlamydia and gonorrhea testing among MSM in non-clinical venues in Shenzhen city, China; (2) factors associated with the acceptability of rectal self-sampling; and (3) factors associated with rectal CT and NG infections, respectively.

Methods

This cross-sectional study was conducted in two non-clinical settings in Shenzhen, China, from April 2021 to October 2021. Mixed-effects logistic regression analysis was performed to explore the factors associated with acceptance of rectal self-collection for CT and NG testing.

Results

Of the 306 MSM who were offered to perform rectal self-sampling, 133 (43.46%) accepted, and 96.24% (128/133) of them successfully provided a valid rectal sample. The prevalence of urogenital CT and NG infections among 303 MSM was 4.29 and 0.66%, respectively. The prevalence of rectal CT and NG infections among 128 participants was 31.25 and 9.38%, respectively. Participants having been diagnosed with HIV infection showed a higher acceptance of rectal self-collection for CT and NG testing.

Conclusion

This study reported that rectal self-sampling in non-clinical venues for CT and NG testing among MSM was barely acceptable and feasible in China. Most CT and NG infections would have been missed if urethral screening was offered alone, which implies that the CT and NG screening should be scaled up in the above setting. Integrating free CT tests into regular STI interventions for MSM could also be considered.

Community perspectives on ideal bacterial STI testing services for gay, bisexual, and other men who have sex with men in Toronto, Canada: a qualitative study

BACKGROUND

Innovation is needed to produce sustained improvements in bacterial sexually transmitted infections (STI) testing given suboptimal access and uptake among sexually active gay, bisexual or other men who have sex with men (GBM). Yet, the STI testing processes and technologies that best address local testing barriers among GBM in Toronto is unknown. We aimed to explore men's perspectives regarding STI testing services for GBM to identify and prioritize new STI testing interventions in Toronto, Ontario, Canada.

METHODS

We conducted four focus groups with twenty-seven GBM in 2017: two with cisgender men living with HIV, one with cisgender HIV-negative men, and one with transgender men. Twenty-seven men participated in the focus groups with 40% 18-30 years of age, 48% self-identifying as white, and the remainder self-identifying as Middle Eastern, Latino/Hispanic, Asian/Pacific Islander, South Asian, First Nations, African/Caribbean/Black, or mixed race. 59% of participants self-identified as living with HIV. Participants were asked about their STI testing experiences in Toronto, barriers and facilitators to testing, and ideal STI testing process. Focus groups were audio recorded, transcribed verbatim, and analyzed using thematic analysis.

RESULTS

Core concepts included how clinical context, bacterial STI testing delivery, and interactions with healthcare providers can create barriers and recommendations for ways to improve. Regarding clinical context, participants desired more clinics with accessible locations/hours; streamlined testing that minimized use of waiting rooms and wait times; and improved clinic ambience. Bacterial STI testing delivery recommendations included standardization to ensure consistency in sexual history intake, tests offered, follow-up and public health reporting between clinics. Men also recommended reducing the multistep process testing by offering components such as lab requisitions and results online. Participants also recommended interactions with healthcare providers be professional and non-judgmental, offer compassionate and competent care with destigmatizing and lesbian, gay, bisexual and trans (LGBT) affirming communication.

CONCLUSION

Concrete and practical solutions for improving existing sexual health services and facilitating optimal STI testing include streamlining testing options and providing patient-centred, LGBT-affirming care to enable optimal STI testing.

College students' comfort with and intention to use self-collection services for STI testing

Objective: Sexually transmitted infections (STIs) are at unprecedented levels; yet most college students have never been tested. Offering asymptomatic individuals the option to collect their own samples for STI testing is an effective strategy to increase testing coverage. This study explores students' perceptions of self-collection services. Participants: Four hundred and thirty-four (434) students from a large public university completed an online survey in February 2018. Methods: The cross-sectional survey assessed students' human immunodeficiency virus (HIV)/STI testing behaviors, comfort with self-collection procedures, and intention to use self-collection services if offered on campus. Results: Most students (88%) said they would use self-collection test kits they could take home, followed by self-collection in a private room at student health services (59%). Students were most comfortable with testing procedures involving less human interaction and collecting specimens themselves. Cost, accuracy, confidentiality of tests, and provision of clear "how to" instructions, topped students' concerns. Conclusion: Offering self-collection options may increase STI testing among asymptomatic college students.

A Missed Opportunity: Extragenital Screening for Gonorrhea and Chlamydia Sexually Transmitted Infections in People with HIV in a Southeastern Ryan White HIV/AIDS Program Clinic Setting

Background

Guidelines recommend annual screening for gonorrhea/chlamydia in sexually active people with HIV at multiple sites (urogenital, oropharyngeal, rectal). In the first year of multisite screening at our Ryan White HIV/AIDS Program clinic, we studied (1) sexual history documentation rate, (2) sexually transmitted infection (STI) screening rate, (3) characteristics associated with STIs, (4) the percentage of extragenital STIs that would have been missed without multisite screening.

Methods

Participants were ≥14 years old with ≥1 in-person medical visit at our clinic in 2019. Descriptive analyses were performed, and adjusting for number of sites tested, a log-binomial model was used to estimate the association between characteristics and STI diagnosis in men.

Results

In this cohort (n = 857), 21% had no sexual history recorded. Almost all STI diagnoses were among males (99.3%). 68% (253/375) received appropriate urogenital testing, 63% (85/134) received appropriate oropharyngeal testing, and 69% (72/105) received appropriate rectal testing. In male participants with ≥1 STI test (n = 347), Hispanic ethnicity and detectable HIV viral load were associated with an STI diagnosis. Of those diagnosed with an STI who had multisite testing, 96% (n = 25/26) were positive only at an extragenital site.

Conclusions

Screening rates were similar across all anatomical sites indicating no obvious bias against extragenital testing. In males, STIs were more frequently diagnosed in people who identify as Hispanic and those with detectable viral loads which may indicate more condomless sex in these populations. Based on infections detected exclusively at extragenital sites, our clinic likely underdiagnosed STIs prior to implementation of multisite screening.

HIV-1 Nucleic Acids Identify Rectal HIV Exposures in Self-Collected Rectal Swabs, Whereas Y-Chromosome Single Tandem Repeat Mixtures Are Not Reliable Biomarkers of Condomless Receptive Anal Intercourse

BACKGROUND

To focus interventions, biomarkers of HIV-1 exposure could help in identifying subpopulations at highest risk of acquisition. We assessed whether Y-chromosome single tandem repeat (YSTR) mixtures obtained from rectal swabs could serve as a biomarker of condomless receptive anal intercourse (CRAI) among men who have sex with men and transgender women and evaluated the feasibility of detecting HIV-1 virions to assess exposures.

METHODS

Twenty-nine sexually active HIV-seronegative men who have sex with men and one transgender woman from New York City answered on-site and mobile app sexual behavior questionnaires. They were randomized to collecting self-administered rectal swabs every morning or after receptive anal intercourse (RAI). YSTR profiles were assessed from blood sample and swabs; HIV-1 exposure was measured by conducting quantitative polymerase chain reaction in swabs.

RESULTS

After 2 months, the daily mobile survey had 135%-201% more instances of anal sex acts and 170%-193% more RAI than on-site surveys. Daily mobile reporting had 11%-35% less CRAI events than those reported on-site (Pdaily = 0.001; Pper-sex = 0.047). The daily swabbing arm reported less RAI (P < 0.001) and CRAI (P < 0.038) and had 2.95 lower odds of detecting YSTR mixtures (P = 0.021) than the per-sex-event arm. Surprisingly, YSTR detection was not significantly modified by report of bowel movements and lubricant, enema, or condom use. No participant became HIV-1 infected, yet HIV-1 total nucleic acids were detected in 6 independent episodes of CRAI in 2 participants taking pre-exposure prophylaxis.

CONCLUSIONS

YSTR mixtures demonstrated 80% specificity but only 30% sensitivity as a biomarker of CRAI in self-collected rectal swabs. However, detection of HIV-1 exposures in self-collected swabs may help in identifying those needing further HIV risk reduction strategies.

Exploring the attitudes of men who have sex with men on anal self-examination for early detection of primary anorectal syphilis: a qualitative study

BACKGROUND

Studies show men who have sex with men (MSM) practising receptive anal sex are more likely to present with secondary syphilis, suggesting anorectal primary lesions are being missed. Regular anal self-examination might be able to detect anorectal syphilis lesions, hence potentially reducing transmission. This study aimed to explore the attitudes of MSM on performing anal self-examination to detect primary syphilis.

METHODS

In this qualitative study, 20 MSM over 18 years of age were purposively sampled from a sexual health clinic to participate in semi-structured interviews. Interviews were recorded, transcribed verbatim and data analysed thematically.

RESULTS

Four major themes and 12 sub-themes were generated from the study: (1) reasons for performing anal self-examination, (2) preferred educational resources for anal self-examination, (3) attitudes towards partner anal examination, and (4) acceptability of anal self-examination. Most participants had performed some form of anal self-examination in the past, and, just over half performed regularly for mostly health-related concerns. Most participants who infrequently or never performed anal self-examination were agreeable to perform regularly if it was recommended by health professionals with appropriate guidance. Participants preferred education on anal self-examination from health professionals and trusted online learning resources.

CONCLUSION

Our study showed MSM were agreeable to anal self-examination however would like to receive education and training to gain more confidence in conducting anal self-examination as a screening tool. Further studies are required to explore the adherence and acceptability of anal self-examination for syphilis prior to studies examining efficacy. The study provides foundation for any future policy aiming at utilising anal self-examination as a screening tool for syphilis among MSM.

Pilot implementation of a home-care programme with chlamydia, gonorrhoea, hepatitis B, and syphilis self-sampling in HIV-positive men who have sex with men

Background

Not all men who have sex with men (MSM) at risk for sexually transmitted infections (STIs) and human immunodeficiency virus (HIV) infection currently receive sexual healthcare. To increase the coverage of high-quality HIV/STI care for MSM, we developed a home-care programme, as extended STI clinic care. This programme included home sampling for testing, combined with treatment and sexual health counselling. Here, we pilot implemented the programme in a hospital setting (HIV-positive MSM) to determine the factors for the successful implementation of STI home sampling strategies.

Methods

Healthcare providers from the HIV hospital treatment centre (Maastricht) were invited to offer free STI sampling kits (syphilis, hepatitis B, [extra]genital chlamydia and gonorrhoea laboratory testing) to their HIV-positive MSM patients (March to May 2018). To evaluate implementation of the program, quantitative and qualitative data were collected to assess adoption (HIV care providers offered sampling kits to MSM), participation (MSM accepted the sampling kits) and sampling-kit return, STI diagnoses, and implementation experiences.

Results

Adoption was 85.3% (110/129), participation was 58.2% (64/110), and sampling-kit return was 43.8% (28/64). Of the tested MSM, 64.3% (18/28) did not recently (< 3 months) undergo a STI test; during the programme, 17.9% (5/28) were diagnosed with an STI. Of tested MSM, 64.3% (18/28) was vaccinated against hepatitis B. MSM reported that the sampling kits were easily and conveniently used. Care providers (hospital and STI clinic) considered the programme acceptable and feasible, with some logistical challenges. All (100%) self-taken chlamydia and gonorrhoea samples were adequate for testing, and 82.1% (23/28) of MSM provided sufficient self-taken blood samples for syphilis screening. However, full syphilis diagnostic work-up required for MSM with a history of syphilis (18/28) was not possible in 44.4% (8/18) of MSM because of insufficient blood sampled.

Conclusion

The home sampling programme increased STI test uptake and was acceptable and feasible for MSM and their care providers. Return of sampling kits should be further improved. The home-care programme is a promising extension of regular STI care to deliver comprehensive STI care to the home setting for MSM. Yet, in an HIV-positive population, syphilis diagnosis may be challenging when using self-taken blood samples.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-020-05658-4.

Oral sex practices among men who have sex with men and transgender women at risk for and living with HIV in Nigeria

Background

Men who have sex with men (MSM) and transgender women (TGW) are at risk for sexually transmitted infections (STIs), including those of the oropharynx. We estimated the prevalence and factors associated with oral sex practices and characterized oropharyngeal STIs among a cohort of MSM and TGW in Nigeria.

Methods

From 2013 to 2018, TRUST/RV368 recruited MSM and TGW into HIV/STI diagnosis and treatment at community-based clinics in Nigeria. Participants who completed HIV testing and oral sex questions at enrollment were selected. Cross-sectional analyses with bivariate and multivariable logistic regression models estimated odds ratios (ORs) and 95% confidence intervals (CIs). Oropharyngeal swab testing for Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) began in 2014 and for those with diagnostic results at enrollment, the unadjusted association of oral sex practices with oropharyngeal STIs was conducted.

Results

A total of 1342 participants had a median age of 25 years (interquartile range: 22–29), 58% were living with HIV, and 69% reported oral sex practices. Factors associated with increased odds of engaging in oral sex included living with HIV (adjusted [a]OR: 1.4, 95% CI: 1.1–1.8), self-identifying as a woman (aOR:1.8, 95% CI: 1.1–2.8), mobile phone ownership (aOR:2.3, 95% CI: 1.3–3.9), receptive anal sex (aOR:1.7, 95% CI:1.3–2.3) and multiple male sexual partners (2 to 4 vs. ≤1, aOR:1.5, 95% CI: 1.0–2.2; 5+ vs ≤1, aOR:2.9, 95% CI:1.9–4.3). Oropharyngeal STI prevalence was 7% (52/752) and higher among those who engaged in oral sex compared to those who did not (unadjusted OR: 2.5, 95% CI:1.2–5.3).

Conclusions

Oral sex was common and associated with an increased odds of oropharyngeal STIs among MSM and TGW from Nigeria. In the absence of screening and treatment guidelines, condoms continue to be the mainstay for oral STI prevention. A pre-exposure prophylaxis for bacterial STIs would complement current prevention strategies to curb transmission.

Body Parts Matter: Social, Behavioral, and Biological Considerations for Urethral, Pharyngeal, and Rectal Gonorrhea and Chlamydia Screening Among MSM in Lima, Peru

BACKGROUND

Gonorrhea (Neisseria gonorrhoeae [GC]) and chlamydia (Chlamydia trachomatis [CT]) disproportionately affect men who have sex with men (MSM), and public health implications vary by anatomic site and bacterial agent. Urethral and rectal GC and CT can increase risk of HIV transmission, whereas pharyngeal GC may be a reservoir for antimicrobial resistance. To define screening priorities in Latin America, we compare differences in the prevalence and correlates of urethral, pharyngeal, and rectal GC and CT among MSM in Peru.

METHODS

A cross-sectional sample of 787 MSM from Lima was screened between 2012 and 2014. We described prevalence of urethral, pharyngeal, and rectal GC and CT infection and conducted bivariate analyses of associations with social, behavioral, and biological characteristics. Poisson regression analyses assessed the correlates of each infection at each anatomic site.

RESULTS

The most commonly symptomatic infection (urethral GC; 42.1%) was the least prevalent (2.4%). The most prevalent infections were rectal CT (15.8%) and pharyngeal GC (9.9%). Rectal CT was the least commonly symptomatic (2.4%) infection, and was associated with younger age (adjusted prevalence ratio [95% confidence interval], 0.96 [0.94-0.98]), HIV infection (1.46 [1.06-2.02]), and pasivo (receptive; 3.59 [1.62-7.95]) and moderno (versatile; 2.63 [1.23-5.60]) sexual roles.

CONCLUSIONS

Results highlight limitations of current syndromic screening strategies for sexually transmitted diseases in Peru, wherein urethral CT and rectal GC and CT may be missed due to their frequently asymptomatic presentations. Successful management of GC and CT infections among MSM in low-resource settings requires differentiating between bacterial agent, symptomatic presentation, associated risk factors, and public health implications of untreated infection at different anatomic sites.

Health Care Provider Perceptions of a Sexually Transmitted Infection Self-testing Program in an HIV Care Clinic

BACKGROUND

Sexually transmitted infections (STIs) disproportionately affect men who have sex with men. Although clinical practice guidelines recommend routine STI screening of men who have sex with men who have high-risk behaviors, extragenital STI testing rates have been low in HIV clinics across the nation. The University of Washington STD Prevention Training Center implemented an STI self-testing program at a large HIV primary care clinic in Seattle, WA, to facilitate extragenital STI testing.

METHODS

We performed a mixed-methods program evaluation to assess health care provider acceptability of the program at 9 months after implementation. Twenty-eight clinicians were invited to complete an online survey. We conducted one-on-one, semistructured interviews with 6 clinicians and a focus group with 7 members of the clinic nursing staff. Survey responses were tallied. Conventional content analysis was performed on survey comments and transcripts from the interviews and focus group.

RESULTS

Ninety-one percent of clinicians were either satisfied or very satisfied with the program. Perceived advantages of the program included saving time for clinicians, overcoming patient discomfort, and increasing patient access to testing. Perceived program disadvantages included unclear responsibility of directing patients through the self-testing process and incorrect sample collection and labeling.

CONCLUSIONS

Despite perceived disadvantages, the self-testing program was acceptable to clinicians and nursing staff, key population for successful program adoption. Implementation of STI self-testing programs in clinic settings could help to increase extragenital STI testing rates by removing provider and patient barriers to testing.

Optimizing Screening for Sexually Transmitted Infections in Men Using Self-Collected Swabs: A Systematic Review

BACKGROUND

Sexually transmitted infection (STI) rates are increasing in the United States while funding for prevention and treatment programs has declined. Sample self-collection for STI testing in men may provide an acceptable, easy, rapid, and potentially cost-effective method for increasing diagnosis and treatment of STIs.

METHODS

We conducted a systematic review of articles assessing self-collection of anal, oral, or genital swab samples among adult men for detection of STIs and/or human papillomavirus-related dysplasia. We searched for English-language articles in which men 18 years or older were recruited to participate.

RESULTS

Our literature search resulted in 1053 citations, with 20 meeting inclusion criteria. Self-collection methods were highly sensitive and comparable with clinician collection for detection of multiple STI pathogens. However, self-collected samples were less likely to be of adequate quality for anorectal cytology and less sensitive for detection of anal intraepithelial neoplasia than clinician-collected samples. Self-collection was highly acceptable. Overall, studies were small and heterogeneous and used designs providing lower levels of evidence.

CONCLUSIONS

Self-collection methods are a viable option for collecting samples for STI testing in adult men based on their high feasibility, acceptability, and validity. Implementation of self-collection procedures in STI testing venues should be performed to expand opportunities for STI detection and treatment.

Gonorrhoea and chlamydia in persons with HIV: number needed to screen

OBJECTIVES

Current guidelines recommend screening sexually active persons with HIV (PWH) for Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) at least annually. Yet, screening rates in many HIV clinics remain low. In this study, we estimated the number needed to screen (NNS) to detect a NG and/or CT infection at each anatomic site among different subpopulations of PWH. NNS provides a concrete, practical measure to aid in assessing the practical impact of screening. METHODS : We included adults in care at three HIV Research Network sites in 2011-2014. Restricting to first tests within each year, annual NNS was defined as number of persons tested divided by number positive. We computed urogenital and extragenital NNS by age and risk group (women, men who have sex with women (MSW) and men who have sex with men (MSM)). RESULTS : A total of 16 864 NG/CT tests were included. Among patients aged ≤25 years, urogenital NNS was similar among women (15 (95% CI 6 to 71)), MSW (21 (95% CI 6 to 167)) and MSM (20 (95% CI 12 to 36)). Over 25, urogenital NNS increased to a greater extent for women (363 (95% CI 167 to 1000)) and MSW (160 (95% CI 100 to 333)) than MSM (46 (95% CI 38 to 56)). The increase for women versus MSM >25 remained significant (p<0.01) in multivariable analysis. Among MSM, rectal NNS was 5 (95% CI 3 to 7) and 10 (95% CI 9 to 12) for ≤25 and for >25 years and pharyngeal NNS values were 8 (95% CI 5 to 13) and 20 (95% CI 16 to 24).

CONCLUSIONS

These findings suggest the importance of regular, at least annual NG/CT screening, particularly extragenital, of HIV positive MSM of all ages. They provide some support for age-based cutoffs for women and MSW (eg, universal screening for those aged ≤25 and targeted screening for those aged >25 years).

Acceptability of testing for anorectal sexually transmitted infections and self-collected anal swabs in female sex workers, men who have sex with men and transgender women in Papua New Guinea

BACKGROUND

Papua New Guinea (PNG) has some of the highest prevalence of urogenital sexually transmitted infections (STIs) in Pacific Asia, but to date, anorectal STI prevalence data do not exist, and diagnosis of anorectal STIs does not occur. The purpose of this study was to document the acceptability of anorectal STI testing and self-collection of anorectal swabs for testing among populations at risk of anorectal STIs, in advance of a large bio-behavioural survey during which this approach to specimen collection was planned among key populations in PNG.

METHODS

Four focus groups were conducted, collecting data from a purposive sample of 35 members of two civil society groups representing female sex workers, men who have sex with men and transgender women in Port Moresby and Goroka.

RESULTS

All participants were in favour of anorectal STI testing in PNG. Reasons given for willingness to undertake anorectal STI testing included that anal sex is practised; that anorectal STIs are not perceived to exist; there are self-reported experiences of anorectal symptoms indicative of anorectal STIs; that anorectal STI testing will enhance personal health; and that anorectal STI testing is not currently available in PNG. All participants were confident they could obtain self-collected specimens, although several stated that support from trained health workers should be available for community members who may not feel comfortable with self-collection.

CONCLUSIONS

This qualitative research is the first study of acceptability of anorectal STI testing and specimen self-collection procedures in PNG, and Pacific Asia more broadly. Our qualitative findings show support for anorectal STI testing including the use of self-collected swabs among key populations in PNG. Study findings informed the inclusion of anorectal STI testing in a large bio-behavioural survey to be used to estimate anorectal STI prevalence among key populations in PNG for the first time.

Gonorrhea and Chlamydia Case Detection Increased When Testing Increased in a Multisite US HIV Cohort, 2004-2014

OBJECTIVES

Annual screening for gonorrhea [Neisseria gonorrhoeae (NG)] and chlamydia [Chlamydia trachomatis (CT)] is recommended for all sexually active persons living with HIV but is poorly implemented. Studies demonstrating no increases in NG and/or CT (NG/CT) case detection in clinics that successfully expanded NG/CT screening raise questions about this broad screening approach. We evaluated NG/CT case detection in the HIV Research Network during 2004-2014, a period of expanding testing.

METHODS

We analyzed linear time trends in annual testing (patients tested divided by all patients in care), test positivity (patients positive divided by all tested), and case detection (the number of patients with a positive result divided by all patients in care) using multivariate repeated measures logistic regression. We determined trends overall and stratified by men who have sex with men (MSM), men who have sex exclusively with women, and women.

RESULTS

Among 15,614 patients (50% MSM, 26% men who have sex exclusively with women, and 24% women), annual NG/CT testing increased from 22% in 2004 to 60% in 2014 [adjusted odds ratio (AOR) per year 1.22 (1.21-1.22)]. Despite the increase in testing, test positivity also increased [AOR per year 1.10 (1.07-1.12)], and overall case detection increased from 0.8% in 2004 to 3.9% in 2014 [AOR per year 1.20 (1.17-1.22)]. Case detection was highest among MSM but increased over time among all 3 groups.

CONCLUSIONS

NG/CT case detection increased as testing expanded in the population. This supports a broad approach to NG/CT screening among persons living with HIV to decrease transmission and complications of NG/CT and of HIV.

2016 United Kingdom national guideline on the sexual health care of men who have sex with men

This guideline is intended for use in UK Genitourinary medicine clinics and sexual health services but is likely to be of relevance in all sexual health settings, including general practice and Contraception and Sexual Health (CASH) services, where men who have sex with men (MSM) seek sexual health care or where addressing the sexual health needs of MSM may have public health benefits. For the purposes of this document, MSM includes all gay, bisexual and all other males who have sex with other males and both cis and trans men. This document does not provide guidance on the treatment of particular conditions where this is covered in other British Association for Sexual Health and HIV (BASHH) Guidelines but outlines best practice in multiple aspects of the sexual health care of MSM. Where prevention of sexually transmitted infections including HIV can be addressed as an integral part of clinical care, this is consistent with the concept of combination prevention and is included. The document is designed primarily to provide guidance on the direct clinical care of MSM but also makes reference to the design and delivery of services with the aim of supporting clinicians and commissioners in providing effective services. Methodology This document was produced in accordance with the guidance set out in the BASHH CEG's document 'Framework for guideline development and assessment' published in 2010 at http://www.bashh.org/guidelines and with reference to the Agree II instrument. Following the production of the updated framework in April 2015, the GRADE system for assessing evidence was adopted and the draft recommendations were regraded. Search strategy (see also Appendix 1) Ovid Medline 1946 to December 2014, Medline daily update, Embase 1974 to December 2014, Pubmed NeLH Guidelines Database, Cochrane library from 2000 to December 2014. Search language English only. The search for Section 3 was conducted on PubMed to December 2014. Priority was given to peer-reviewed papers published in scientific journals, although for many issues evidence includes conference abstracts listed on the Embase database. In addition, for 'Identification of problematic recreational drug and alcohol use' section and 'Sexual problems and dysfunctions in MSM' section, searches included PsycINFO. Methods Article titles and abstracts were reviewed and if relevant the full text article was obtained. Priority was given to randomised controlled trial and systematic review evidence, and recommendations made and graded on the basis of best available evidence. Piloting and feedback The first draft of the guideline was circulated to the writing group and to a small group of relevant experts, third sector partners and patient representatives who were invited to comment on the whole document and specifically on particular sections. The revised draft was reviewed by the CEG and then reviewed by the BASHH patient/public panel and posted on the BASHH website for public consultation. The final draft was piloted before publication. Guideline update The guidelines will be reviewed and revised in five years' time, 2022.

Internet recruitment for sexually transmitted infection screening among men who have sex with men in Eastern Europe

Men who have sex with men (MSM) face negative health outcomes such as sexually transmitted infections (STIs) at disproportionate rates. Nonetheless, infections may be underestimated due to limited uptake in testing. To increase testing, screening interventions have been utilized in the past; however, some have resulted in limitations such as poor recruitment. To increase recruitment for screening of MSM in Estonia, two different recruitment strategies were examined. Recruitment was separated into two promotional periods: passive and active. Passive consisted of banners on gay-related sites, while active also placed banners on websites to the general public such as Facebook linked to specific thematic pages and users self-identifying as men. More men were recruited during the active period of five weeks (n = 134) than the passive period of 46 weeks (n = 126). Active promotion was so successful in that the number of home sampling kit orders far exceeded what was projected, forcing promotion to the general public to be closed after 13 days. Recruiting MSM through a combination of general public and gay-related websites and applications has the ability to quickly recruit for testing interventions. This method can recruit a large number in a short amount of time; therefore, a budget must be planned accordingly to support testing for all that participate.

Implementation and Operational Research: Effectiveness and Patient Acceptability of a Sexually Transmitted Infection Self-Testing Program in an HIV Care Setting

BACKGROUND

Rates of screening for bacterial sexually transmitted infections (STI) among men who have sex with men in HIV care settings remain low despite high prevalence of these infections. STI self-testing may help increase screening rates in clinical settings.

METHODS

We implemented an STI self-testing program at a large, urban HIV care clinic and evaluated its effectiveness and acceptability. We compared measures obtained during the first year of the STI self-testing program (Intervention Year, April 1, 2013-March 31, 2014) to Baseline Year (January 1, 2012-December 31, 2012) to determine: (1) overall clinic change in STI testing coverage and diagnostic yield and; (2) program-specific outcomes including appropriate anatomic site screening and patient-reported acceptability.

RESULTS

Overall, testing for gonorrhea and chlamydia increased significantly between Baseline and Intervention Year, and 50% more gonococcal and 47% more chlamydial infections were detected. Syphilis testing coverage remained unchanged. Nearly 95% of 350 men who participated in the STI self-testing program completed site-specific testing appropriately based on self-reported exposures, and 92% rated their self-testing experience as "good" or "very good."

CONCLUSIONS

STI self-testing in HIV care settings significantly increases testing coverage and detection of gonorrhea and chlamydia, and the program is acceptable to patients. Additional interventions to increase syphilis screening rates are needed.

An express sexual health service: in and out in a jiffy

Objectives The aims of the present study were to assess client satisfaction with existing services, gauge the interest in an express service option and to compare waiting times before and after the introduction of an express service. Methods A survey evaluating satisfaction with existing services, waiting times and interest in an express service was offered to all clients attending the Western Sydney Sexual Health Centre in May 2013. A pilot of the express service ran from May to December 2013, and a follow-up survey was conducted in December 2013. Results There was a high level of interest in the express service. Median waiting times and satisfaction with waiting times improved following introduction of the express clinic. A high level of satisfaction was reported in those who had used the express service. Conclusions The express service was well received by clients and has the potential to improve client waiting times, increase clinic capacity and improve the overall client journey through the clinic. What is known about the topic? Express service options for testing for sexually transmitted infections (STIs) are being introduced both in Australia and overseas. Express services have been shown to increase clinic capacity and can create cost savings. They appear to be acceptable to clients. What does this paper add? This paper demonstrates that an express service option can be successfully introduced in an at-risk multicultural population. What are the implications for practitioners? The present study helps show that new models can be successfully introduced into long-standing traditional service models. Such models can help improve efficiency, clinic capacity and may produce cost savings. An express clinic is an option for screening asymptomatic clients for STIs. Clients complete a self-collected history and take self-collected specimens, and clinician-collected blood tests and throat swabs are advised accordingly.

Efficacy and acceptability of rectal and perineal sampling for identifying gastrointestinal colonization with extended spectrum β-lactamase Enterobacteriaceae

OBJECTIVES

We evaluated 'pre-laboratory' factors associated with the detection of extended spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E) colonization including anatomical site, and staff and patient factors.

METHODS

All admissions to a large London hospital over 3 months were approached to provide rectal and perineal swabs, which were cultured for ESBL-E using chromogenic media. ESBL-E detection rates for patient- or staff-collected rectal or perineal swabs were compared using McNemar tests. Binary logistic regression was used to explore factors associated with patients declining to provide a rectal swab. The impact of simplifying the verbal study description to patients to improve the participation rate was evaluated.

RESULTS

Carriage of ESBL-E was significantly higher in rectal swabs than perineal swabs (7.8% of 4006 versus 3.8% of 4006, p <0.001), whether collected by staff or patients; 31.9% of 869 patients did not provide a rectal swab before the change in study description compared with 7.6% of 3690 patients afterwards (p <0.001). In multivariable analysis, factors associated with patients declining to provide a rectal swab were younger age (OR 0.99, 95% CI 0.99-1.00), female gender (OR 1.26, 95% CI 1.04-1.52), transfers from other hospitals (OR 1.77, 95% CI 1.07-2.93) or an unknown admission route (OR 1.61, 95% CI 1.09-2.37), being admitted before the change in study description (OR 0.39, 95% CI 0.31-0.48), and the staff member who consented the patient (p <0.001); ethnicity was not a significant factor.

CONCLUSIONS

Rectal swabs are recommended for the detection of ESBL-E colonization. Staff and patient factors influence whether patients participate in prevalence studies, which may skew their findings.

Impact of rectal gonorrhoea and chlamydia on HIV viral load in the rectum: potential significance for onward transmission

The aim of this study was to investigate the effect of asymptomatic rectal bacterial sexually transmitted infections (STIs) on rectal HIV viral load (VL). A prospective cohort study of HIV-positive men who have sex with men attending a tertiary centre in London, UK, for their routine HIV care was performed. Forty-two HIV-positive men who have sex with men were recruited between January and August 2014. In participants on antiretroviral therapy (ART), there was no significant difference in rectal VL in those with and without STI ( p = 0.4). All rectal HIV VLs were below the limit of detection (<100 copies/µg of total RNA) whether an STI was present or not. In those not on ART, rectal HIV VL was on average 0.6log₁₀ lower post STI treatment. The presence of asymptomatic rectal chlamydia and gonorrhoea was not associated with increased rectal HIV VL in those fully suppressed on ART. In the context of effective ART, the presence of rectal gonorrhoea or chlamydia does not appear to increase rectal HIV VL and the risk of increased viral infectivity.

Extragenital Infections Caused by Chlamydia trachomatis and Neisseria gonorrhoeae: A Review of the Literature

In the United States, sexually transmitted diseases due to Chlamydia trachomatis and Neisseria gonorrhoeae continue to be a major public health burden. Screening of extragenital sites including the oropharynx and rectum is an emerging practice based on recent studies highlighting the prevalence of infection at these sites. We reviewed studies reporting the prevalence of extragenital infections in women, men who have sex with men (MSM), and men who have sex only with women (MSW), including distribution by anatomical site. Among women, prevalence was found to be 0.6–35.8% for rectal gonorrhea (median reported prevalence 1.9%), 0–29.6% for pharyngeal gonorrhea (median 2.1%), 2.0–77.3% for rectal chlamydia (median 8.7%), and 0.2–3.2% for pharyngeal chlamydia (median 1.7%). Among MSM, prevalence was found to be 0.2–24.0% for rectal gonorrhea (median 5.9%), 0.5–16.5% for pharyngeal gonorrhea (median 4.6%), 2.1–23.0% for rectal chlamydia (median 8.9%), and 0–3.6% for pharyngeal chlamydia (median 1.7%). Among MSW, the prevalence was found to be 0–5.7% for rectal gonorrhea (median 3.4%), 0.4–15.5% for pharyngeal gonorrhea (median 2.2%), 0–11.8% for rectal chlamydia (median 7.7%), and 0–22.0% for pharyngeal chlamydia (median 1.6%). Extragenital infections are often asymptomatic and found in the absence of reported risk behaviors, such as receptive anal and oral intercourse. We discuss current clinical recommendations and future directions for research.

Brief Report: Gonorrhea and Chlamydia Testing Increasing but Still Lagging in HIV Clinics in the United States

Screening persons living with HIV for gonorrhea and chlamydia has been recommended since 2003. We compared annual gonorrhea/chlamydia testing to syphilis and lipid testing among 19,368 adults (41% men who have sex with men, 30% heterosexual men, and 29% women) engaged in HIV care. In 2004, 22%, 62%, and 70% of all patients were tested for gonorrhea/chlamydia, syphilis, and lipid levels, respectively. Despite increasing steadily [odds ratio per year (95% confidence interval): 1.14 (1.13 to 1.15)], gonorrhea/chlamydia testing in 2010 remained lower than syphilis and lipid testing (39%, 77%, 76%, respectively). Interventions to improve gonorrhea/chlamydia screening are needed. A more targeted screening approach may be warranted.

Screening for asymptomatic lymphogranuloma venereum co-infection in men who have sex with men newly diagnosed with HIV, hepatitis C or syphilis

Patients diagnosed with lymphogranuloma venereum have high rates of co-infection with HIV, syphilis and hepatitis C. The aim of this enhanced surveillance was to screen all men who have sex with men (MSM) newly diagnosed with HIV, syphilis or hepatitis C for co-infection with asymptomatic lymphogranuloma venereum as part of the recommended sexual health screen. Of the 145 patients screened, 21 patients were diagnosed with rectal Chlamydia trachomatis, one with both rectal and urethral chlamydia and six with urethral chlamydia. One rectal chlamydia-positive sample, when tested, was equivocal for lymphogranuloma venereum. Our data suggested that there was not a pool of asymptomatic lymphogranuloma venereum infection in MSM recently diagnosed with HIV, hepatitis C and syphilis. However, there have been recent reports of an increased incidence of asymptomatic lymphogranuloma venereum, raising the question whether lymphogranuloma venereum should be screened for in high risk asymptomatic MSM. The prevalence of asymptomatic rectal chlamydia infections was 19%.

Screening for Asymptomatic Extragenital Gonorrhea and Chlamydia in Men Who Have Sex with Men: Significance, Recommendations, and Options for Overcoming Barriers to Testing

Men who have sex with men (MSM) have a disproportionately greater risk than other populations of acquiring Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC), the two most commonly reported notifiable diseases in the United States according to the Centers for Disease Control and Prevention (CDC). The presence of either of these diseases is a significant risk factor for the acquisition and transmission of human immunodeficiency virus (HIV). Recent studies have shown that significant rates of asymptomatic GC and CT infection are found at the extragenital oropharygeal and rectal sites in MSM, with or without concurrent urogenital infection. However, extragenital sites are not being routinely screened and, thus, many asymptomatic GC and CT infections at the oropharyngeal and rectal sites may go undiagnosed. This review will begin with the current evidence-based screening recommendations for extragenital GC and CT in MSM. This will be followed by recently reported extragenital GC and CT infection rates in asymptomatic MSM, and a discussion of the risks and potential implications of undiagnosed extragenital GC and CT infections. Finally, a discussion on the frequency of, and potential barriers to, screening will be presented with a summary of potential interventions for increasing screening frequency found in the literature. The scope of this review will focus primarily on U.S. recommendations, infection rates, and screening frequencies, with the inclusion of relevant international recommendations and studies for comparative and illustrative purposes.

Can an asymptomatic screening pathway for men who have sex with men be introduced safely at a level 3 sexual health service in the UK?

Summary

To manage the rising demand on sexual health services in the UK, many clinics have introduced asymptomatic screening pathways for heterosexuals, which omit examination. In men who have sex with men however the screening of extragenital sites poses additional challenges. This study aimed to establish whether omitting examination of asymptomatic men who have sex with men would lead to clinically significant diagnoses being missed. The notes of all men who have sex with men who attended a UK level 3 sexual health clinic between 1 July 2011 and 30 June 2012 were retrospectively reviewed. Exclusion criteria included HIV-positive patients attending for HIV-related care, attendances for follow-up consultations not requiring a full sexual health screen, symptomatic patients, contacts of sexually transmitted infections and patients requesting an examination or a repeat prescription of a regularly used medication. In all, 920 consultations occurred during 12 months, of which 893 were reviewed; 476 (53.3%) consultations would have been eligible for screening on an asymptomatic pathway and, of these, 21 (4.4%) had abnormalities found at examination. Findings included genital warts, minor dermatological conditions and three cases of minor asymptomatic urological conditions. There were no clinically significant findings on examination of asymptomatic men who have sex with men requiring treatment, indicating that examination in this cohort may be of little benefit.

Rationale and design of REACT: a randomised controlled trial assessing the effectiveness of home-collection to increase chlamydia retesting and detect repeat positive tests

BACKGROUND

Repeat infection with Chlamydia trachomatis is common and increases the risk of sequelae in women and HIV seroconversion in men who have sex with men (MSM). Despite guidelines recommending chlamydia retesting three months after treatment, retesting rates are low. We are conducting the first randomised controlled trial to assess the effectiveness of home collection combined with short message service (SMS) reminders on chlamydia retesting and reinfection rates in three risk groups.

METHODS/DESIGN

The REACT (retest after Chlamydia trachomatis) trial involves 600 patients diagnosed with chlamydia: 200 MSM, 200 women and 200 heterosexual men recruited from two Australian sexual health clinics where SMS reminders for retesting are routine practice. Participants will be randomised to the home group (3-month SMS reminder and home-collection) or the clinic group (3-month SMS reminder to return to the clinic). Participants in the home group will be given the choice of attending the clinic if they prefer. The mailed home-collection kit includes a self-collected vaginal swab (women), UriSWAB (Copan) for urine collection (heterosexual men), and UriSWAB plus rectal swab (MSM). The primary outcome is the retest rate at 1-4 months after a chlamydia diagnosis, and the secondary outcomes are: the repeat positive test rate; the reinfection rate; the acceptability of home testing with SMS reminders; and the cost effectiveness of home testing. Sexual behaviour data collected via an online survey at 4-5 months, and genotyping of repeat infections, will be used to discriminate reinfections from treatment failures. The trial will be conducted over two years. An intention to treat analysis will be conducted.

DISCUSSION

This study will provide evidence about the effectiveness of home-collection combined with SMS reminders on chlamydia retesting, repeat infection and reinfection rates in three risk groups. The trial will determine client acceptability and cost effectiveness of this strategy.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ACTRN12611000968976.

High prevalence of asymptomatic sexually transmitted infections in HIV-infected men who have sex with men: A stimulus to improve screening

In Ireland the incidence of sexually transmitted infections (STIs) is steadily increasing while the number of new HIV-diagnoses in men who have sex with men has more than doubled in the past decade. This study investigated the prevalence of STIs in asymptomatic HIV-infected men who have sex with men (MSM) attending a clinic for routine HIV care in the largest HIV-centre in Ireland. Fifty HIV-infected MSM were included in the study (mean age [SD] 38years [9], 66% Irish). Sixteen per cent of HIV-infected MSM screened were diagnosed with a STI. Thirty-eight per cent reported always using condoms while 4% reported never using condoms, 46% used condoms inconsistently and 10% reported no sexual contacts in the preceding 12 months. Recognising the need to optimise STI screening, a pilot self-screening programme was subsequently introduced to our HIV clinic as a quality improvement initiative. Asymptomatic MSM attending for routine HIV care were invited to have an opportunistic STI screen either provider performed or by self-screening. Seventy-one patients were included in the pilot. Sixty-five (92%) opted for self-collected rectal swabs. Ten STIs were detected in eight patients. This study supports guidelines recommending routine screening for STIs in the care of HIV-infected patients and highlights opportunities to provide relevant screening and education interventions targeting unsafe sexual behaviours.

Australian sexually transmissible infection and HIV testing guidelines for asymptomatic men who have sex with men 2014: a review of the evidence

Men who have sex with men (MSM) in Australia and overseas are disproportionately affected by sexually transmissible infections (STIs), including HIV. Many STIs are asymptomatic, so regular testing and management of asymptomatic MSM remains an important component of effective control. We reviewed articles from January 2009–May 2013 to inform the 2014 update of the 2010 Australian testing guidelines for asymptomatic MSM. Key changes include: a recommendation for pharyngeal chlamydia (Chlamydia trachomatis) testing, use of nucleic acid amplification tests alone for gonorrhoea (Neisseria gonorrhoeae) testing (without gonococcal culture), more frequent (up to four times a year) gonorrhoea and chlamydia testing in sexually active HIV-positive MSM, time required since last void for chlamydia first-void urine collection specified at 20 min, urethral meatal swab as an alternative to first-void urine for urethral chlamydia testing, and the use of electronic reminders to increase STI and HIV retesting rates among MSM.

Improved sexual history taking in the 2012 BASHH asymptomatic screening re-audit

Effective asymptomatic screening for sexually transmitted infections is an important public health service because a significant proportion of sexually transmitted infections do not present with symptoms. In 2009, the National Audit Group of the British Association of Sexual Health and HIV (BASHH) audited the management of asymptomatic patients and recommended increased documentation about oral and anal sex, regional strategies for nucleic acid amplification test (NAAT) use for gonorrhoea, improved screening for hepatitis B in men who have sex with men and an increase in screening for HIV. The 2012 audit used web-based forms to collect submissions from 180 consultant-led centres (65% response rate) that included episodes of care from 6669 asymptomatic patients. An improvement was demonstrated for all the areas measured during the 2009 audit. A doubling of gonorrhoea testing using NAATs was seen and yet 10% of asymptomatic patients continued to have microscopy despite these tests not being recommended by BASHH guidelines. This audit recommends universal adoption of gonorrhoea NAATs across the United Kingdom.

Improving sexual health for HIV patients by providing a combination of integrated public health and hospital care services; a one-group pre- and post test intervention comparison

BACKGROUND

Hospital HIV care and public sexual health care (a Sexual Health Care Centre) services were integrated to provide sexual health counselling and sexually transmitted infections (STIs) testing and treatment (sexual health care) to larger numbers of HIV patients. Services, need and usage were assessed using a patient perspective, which is a key factor for the success of service integration.

METHODS

The study design was a one-group pre-test and post-test comparison of 447 HIV-infected heterosexual individuals and men who have sex with men (MSM) attending a hospital-based HIV centre serving the southern region of the Netherlands. The intervention offered comprehensive sexual health care using an integrated care approach. The main outcomes were intervention uptake, patients' pre-test care needs (n=254), and quality rating.

RESULTS

Pre intervention, 43% of the patients wanted to discuss sexual health (51% MSM; 30% heterosexuals). Of these patients, 12% to 35% reported regular coverage, and up to 25% never discussed sexual health topics at their HIV care visits. Of the patients, 24% used our intervention. Usage was higher among patients who previously expressed a need to discuss sexual health. Most patients who used the integrated services were new users of public health services. STIs were detected in 13% of MSM and in none of the heterosexuals. The quality of care was rated good.

CONCLUSIONS

The HIV patients in our study generally considered sexual health important, but the regular counselling and testing at the HIV care visit was insufficient. The integration of public health and hospital services benefited both care sectors and their patients by addressing sexual health questions, detecting STIs, and conducting partner notification. Successful sexual health care uptake requires increased awareness among patients about their care options as well as a cultural shift among care providers.