HIV status and viral loads among men testing positive for rectal gonorrhoea and chlamydia, Maricopa County, Arizona, USA, 2011-2013

Engaging hard-to-reach men-who-have-sex-with-men with sexual health screening: Qualitative interviews in an Australian sex-on-premises-venue and sexual health service

CONTEXT

Compared with the general population in Australia, men-who-have-sex-with-men (MSM) have higher rates of HIV and sexually transmissible infections (STIs). Despite widespread advice to test regularly, a minority of these men remain "hard to reach." We undertook qualitative interviews with a group of such men in Sydney to better understand their views and experiences in relation to sexual health screening.

METHODS

We conducted semi-structured interviews with men engaging with HIV/STI screening services at a sex-on-premises-venue and the local Sexual Health Service in Greater Western Sydney. We analyzed these data for content and themes.

RESULTS

Sexual behaviors and identities were diverse, often discordant and compartmentalized from everyday lives. Overall, reported HIV/STI knowledge was poor and men did not see themselves at risk of HIV/STIs regardless of sexual behavior. Men took calculated risks and balanced with pleasure and escapism. Reasons for avoidance of testing included fear, unwillingness to disclose behavior, privacy concerns, and perceived low risk. Men viewed sexual health care as distinct from general health care. Service delivery preferences varied by service venue. Participants highlighted convenience, confidentiality, and trust as critical factors for a testing service.

CONCLUSION

A variety of testing options are needed to engage hard-to-reach MSM. Opportunities to enhance testing may include expanding health messaging, demystifying testing, and delinking sexual identity from sexual behavior and risk, thus promoting advantages of testing and establishing testing as standard of care.

Anatomic site-specific gonorrhea and chlamydia testing and incidence among people with HIV engaged in care at four United States clinical centers, 2014-2018

Background

The incidence of Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) is increasing in the United States; however, there are limited data on anatomic site-specific GC/CT among people with HIV (PWH).

Methods

We reviewed records of all PWH in care between January 1, 2014 and November 16, 2018 at four sites in the CFAR Network of Integrated Clinical Systems Cohort (CNICS; N = 8455). We calculated anatomic site-specific GC/CT testing and incidence rates and used Cox proportional hazards models modified for recurrent events to examine sociodemographic and clinical predictors of GC/CT testing and incidence at urogenital, rectal, and pharyngeal sites. We also calculated site-specific number needed to test (NNT) to detect a positive GC/CT test.

Results

Of 8455 PWH, 2460 (29.1%) had at least yearly GC/CT testing at any anatomic site. The rates of urogenital, rectal, and pharyngeal GC were 1.7 (95%CI:1.6, 1.9), 3.2 (95%CI:3.0, 3.5), and 2.7 (95%CI:2.5, 2.9) infections per 100 person-years, respectively. The rates of urogenital, rectal, and pharyngeal CT were 1.9 (95%CI:1.7, 2.1), 4.3 (95%CI:4.0, 4.5), and 0.9 (95%CI:0.8, 1.0) infections per 100 person-years, respectively. PWH 16-39 years old experienced greater GC/CT rates at all anatomic sites while MSM experienced greater rates of extragenital infections. NNTs for urogenital, rectal, and pharyngeal GC/CT were 20 (95%CI:19, 21), 5 (95%CI:5, 5), and 9 (95%CI:8, 9), respectively.

Conclusion

Many PWH are not tested annually for GC/CT and rates of GC/CT infection, particularly rates of extragenital infections, are high. We identified groups of PWH who may benefit from increased site-specific GC/CT testing.

Gonorrhoea: a systematic review of prevalence reporting globally

BACKGROUND

The World Health Organization (WHO) recommends periodic gonorrhoea prevalence assessments in the general population or proxies thereof (including pregnant women, women attending family planning clinics, military recruits, and men undergoing employment physicals for example) and in population groups at increased risk, including men-who-have-sex-with-men (MSM) and sex workers.

METHOD

We evaluated reported prevalence data, including estimates from proxy general population samples to reflect the WHO recommendations. We describe the outcomes from the general population country-by-country and extend previous reviews to include MSM, sex workers, and extragenital infections.

RESULT AND CONCLUSION

In our systematic search, 2015 titles were reviewed (January 2010-April 2019) and 174 full-text publications were included. National, population-based prevalence data were identified in only four countries (the United States of America, the United Kingdom, Peru, New Caledonia) and local population-based estimates were reported in areas within five countries (China, South Africa, Brazil, Benin, and Malawi). The remaining studies identified only reported test positivity from non-probability, proxy general population samples. Due to the diversity of the reviewed studies, detailed comparison across studies was not possible. In MSM, data were identified from 64 studies in 25 countries. Rectal infection rates were generally higher than urogenital or pharyngeal infection rates, where extragenital testing was conducted. Data on sex workers were identified from 41 studies in 23 countries; rates in female sex workers were high. Current prevalence monitoring was shown to be highly suboptimal worldwide. Serial prevalence monitoring of critical epidemiological variables, and guidelines to optimize prevalence study conduct and reporting beyond antenatal settings are recommended.

Inadequate Engagement in HIV Care Among People With HIV Newly Diagnosed With a Sexually Transmitted Disease: A Multijurisdictional Analysis

BACKGROUND

A key challenge of HIV surveillance-based HIV care reengagement is locating people living with HIV (PLWH) who seem to be out of care to reengage them in care. Providing reengagement services to PLWH diagnosed with a sexually transmitted disease (STD)-individuals who are in jurisdiction and connected to the health care system-could be an efficient means of promoting HIV treatment and reducing HIV transmission.

METHODS

Early and late syphilis (ES/LS) and gonorrhea (GC) cases diagnosed in 2016 and 2017 in Louisiana, Michigan, Mississippi, Oregon, Rhode Island, and Texas were matched to each state's HIV surveillance data to determine the proportion of PLWH with these infections who (1) did not have evidence of a CD4 count or viral load in the prior ≥13 months (out of care) or (2) had a viral load ≥1500 copies/mL on their most recent HIV RNA test before STD diagnosis (viremic).

RESULTS

Previously diagnosed HIV infection was common among persons diagnosed with ES (n = 6942; 39%), LS (n = 4329; 27%), and GC (n = 9509; 6%). Among these ES, LS, and GC cases, 26% (n = 1543), 33% (n = 1113), and 29% (n = 2391) were out of HIV medical care or viremic at the time of STD diagnosis.

CONCLUSIONS

A large proportion of STD cases with prior HIV diagnosis are out of care or viremic. Integrating relinkage to care activities into STD partner services and/or the use of matching STD and HIV data systems to prioritize data to care activities could be an efficient means for relinking patients to care and promoting viral suppression.

Sexually Transmitted Infections and Human Immunodeficiency Virus

The human immunodeficiency virus (HIV) and sexually transmitted infections (STIs) are considered epidemics in the United States. Research on the association between STIs and HIV infectiousness and susceptibility has shown that STIs promote HIV acquisition and transmission via mucosal inflammation and ulceration caused by viral or bacterial pathogens. Some of the most common STIs associated with HIV are chlamydia, gonorrhea, syphilis, and herpes simplex virus type 2. STIs are a major cause of morbidity and mortality, particularly if diagnosis or treatment is delayed. Prevention and treatment of both HIV and STIs is essential to ending these associated epidemics.

Gaps Along the HIV Care Continuum: Findings Among a Population Seeking Sexual Health Care Services in New York City

BACKGROUND

Linkage/relinkage to HIV care for virally unsuppressed people with new sexually transmitted infections is critical for ending the HIV epidemic. We quantified HIV care continuum gaps and viral suppression among HIV-positive patients attending New York City (NYC) sexual health clinics (SHCs).

METHODS

One thousand six hundred forty-nine HIV-positive patients and a 10% sample of 11,954 patients with unknown HIV status on clinic visit date (DOV) were matched against the NYC HIV registry. Using registry diagnosis dates, we categorized matched HIV-positive patients as "new-positives" (newly diagnosed on DOV), "recent-positives (diagnosed ≤90 days before DOV), "prevalent-positives" (diagnosed >90 days before DOV), and "unknown-positives" (previously diagnosed but status unknown to clinic on DOV). We assessed HIV care continuum outcomes before and after DOV for new-positives, prevalent-positives, and unknown-positives using registry laboratory data.

RESULTS

In addition to 1626 known HIV-positive patients, 5% of the unknown sample (63/1196) matched to the registry, signifying that approximately 630 additional HIV-positive patients attended SHCs. Of new-positives, 65% were linked to care after DOV. Of prevalent-positives, 66% were in care on DOV; 43% of the out-of-care patients were relinked after DOV. Of unknown-positives, 40% were in care on DOV; 21% of the out-of-care patients relinked after DOV. Viral suppression was achieved by 88% of in-care unknown-positives, 76% in-care prevalent-positives, 50% new-positives, 42% out-of-care prevalent-positives, and 16% out-of-care unknown-positives.

CONCLUSIONS

Many HIV-positive people, including those with uncontrolled HIV infection, attend SHCs and potentially contribute to HIV spread. However, HIV status often is not known to staff, resulting in missed linkage/relinkage to care opportunities. Better outcomes could be facilitated by real-time ascertainment of HIV status and HIV care status.

New Human Immunodeficiency Virus Diagnoses Among Men Who Have Sex With Men Attending Sexually Transmitted Disease Clinics, STD Surveillance Network, January 2010 to June 2013

To estimate new human immunodeficiency virus (HIV) diagnosis rates among HIV negative men who have sex with men (MSM) who are repeatedly tested for HIV in sexually transmitted disease (STD) clinics and assess the impact of demographic and disease-specific characteristics that are associated with higher HIV diagnosis rates.

STUDY DESIGN

Retrospective analysis using 2010 to 2013 data from the STD Surveillance Network (SSuN), a sentinel surveillance system comprised of health departments in 12 cities conducting sentinel surveillance in 40 STD clinics. We analyzed data from all MSM repeatedly (≥2 times) tested for HIV, with an initial negative HIV test required for staggered cohort entry. Follow-up time was accrued from the date of the first negative HIV test to the most recent negative test or the first positive HIV test. The STD diagnoses during the follow-up period were reviewed. We estimated HIV diagnoses rates (number of HIV diagnoses/total number of person-years [PY] at risk) by demographic and clinical characteristics with 95% confidence intervals (CI) using an inverse variance weighted random effects model, adjusting for heterogeneity between SSuN jurisdictions.

RESULTS

Overall, 640 HIV diagnoses occurred among 14,824 individuals and 20,951.6 PY of observation, for an adjusted incidence of HIV diagnosis of 3.0 per 100 PY (95% CI, 2.6-3.4). Rates varied across race/ethnicity groups with the highest rate among Blacks (4.7/100 PY; 95% CI, 4.1-5.3) followed by Hispanics, whites, and persons of other races/ethnicities. Men who have sex with men having a diagnosis of primary or secondary (P&S) syphilis on or after the first negative HIV test had a higher new HIV diagnosis rate (7.2/100 PY; 95% CI, 5.8-9.0) compared with MSM who did not have a P&S syphilis diagnosis (2.8/100 PY; 95% CI, 2.6-3.1). Men who have sex with men who tested positive for rectal gonorrhea (6.3/100 PY; 95% CI, 5.7-6.9) or rectal chlamydia (5.6/100 PY; 95% CI, 4.6-6.6) had higher rates of new HIV diagnosis when compared to those with negative test results.

CONCLUSIONS

Men who have sex with men attending SSuN STD clinics have high rates of new HIV diagnoses, particularly those with a previous diagnosis of P&S syphilis, rectal chlamydia, and/or gonorrhea. Sexually transmitted disease clinics continue to be important clinical setting for diagnosing HIV among MSM populations.

Sexually Transmitted Infections Detected During and After Incarceration Among People with Human Immunodeficiency Virus: Prevalence and Implications for Screening and Prevention

BACKGROUND

Incarceration and human immunodeficiency virus (HIV) are associated with sexually transmitted infections (STIs); however, little is known about STI prevalence among people living with HIV (PLWH) during and after incarceration.

METHODS

Electronic medical records from the Dallas County Jail and community HIV clinics were reviewed to determine the frequency and results of testing for gonorrhea, chlamydia, syphilis, and hepatitis B virus (HBV) among PLWH incarcerated in Dallas County Jail between 2010 and 2013. HIV viral loads (VL) and evidence of STI symptoms and treatment were also collected.

RESULTS

During 2473 incarcerations, 6 (3%) of 190 tests were positive for gonorrhea, 7 (4%) of 190 for chlamydia, 231 (21%) of 1082 for syphilis, of which 53 (23%) were new diagnoses, and 48 (5%) of 1005 for HBV surface antigen. Among 1631 releases to the community, 808 followed up in community clinics, where 21 (4%) 553 tests were positive for gonorrhea, 23 (4%) of 555 for chlamydia, 150 (19%) of 808 for syphilis, of which 31 (21%) were new diagnoses, and 24 (6%) of 421 for HBV surface antigen. The majority of new STI cases, 51 (80%) of 64 in jail and 43 (77%)of 56 in the community, had a concurrent detectable (>200 copies/mL) HIV VL.

CONCLUSIONS

Testing for gonorrhea and chlamydia was low, particularly in jail, which was attributed to testing protocols. High proportions of PLWH tested positive for syphilis and HBV infection in both settings. The majority of patients with active STIs had a detectable HIV VL. Routine, opt-out screening for STIs for PLWH during and after incarceration has the potential to identify a high proportion of STIs and improve secondary HIV prevention.

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.

Asymptomatic anal sexually transmitted infections in HIV-positive men attending anal cancer screening

BACKGROUND

HIV-positive men who have sex with men (HIV+MSM) have an increased risk for anal dysplasia and for sexually transmitted infections (STIs).

OBJECTIVES

We determined the positivity rates of Chlamydia trachomatis (CT), Neisseria gonorrhoea (NG), Mycoplasma genitalium (MG) and syphilis in HIV+MSM participating in an anal cancer screening programme.

METHODS

In total, 852 intra-anal swabs were collected from 503 HIV+MSM between 2012 and 2014. Anal cytology and polymerase chain reaction assays for human papillomavirus (HPV), CT, NG and MG detection were performed. The syphilis status was determined serologically. Risk factors for STIs were explored by multiple logistic regression analysis.

RESULTS

In total 20·7% (104 of 503) of the patients had an STI other than HPV within the study period. The most common was CT, found in 10·9%, followed by NG (8·9%) and MG (4·2%). Early syphilis was detected in 4·6% and past syphilis in 44·5% of the HIV+MSM. Eighteen patients (3·6%) had more than one STI episode, and 90·6% of the 127 cases of STIs were asymptomatic. Age, anal HPV infection, abnormal anal cytology and previous syphilis were risk factors for STI.

CONCLUSIONS

Anal STIs are frequent and mostly asymptomatic in HIV+MSM participating in anal cancer screening. STI screening should be incorporated into anal cancer screening programmes for HIV+MSM.