Gonorrhoea and chlamydia screening in HIV clinics: time for new tools and targets

Incidence, Reinfection, and Discrepancy Between Sexual Practice and Anatomic Site Positivity of Sexually Transmitted Infections in Youth With HIV

BACKGROUND

This study aimed to determine the overall incidence and reinfection rates of sexually transmitted infections (STIs) and the discrepancy between self-reported exposure history and anatomic site positivity of STIs among adolescents and young adults (AYAs) with HIV in Atlanta, GA.

METHODS

Retrospective chart review was conducted on all patients 13-24 years of age at the Grady Ponce and Family Youth Clinic from January 1, 2009 to December 31, 2018. Data were collected on patient demographics, self-reported sexual history and STI events. First STI incidence and incidence of reinfections were calculated by dividing new cases over corresponding person follow-up time.

RESULTS

A total of 626 sexually active AYAs with HIV were included in analysis. The mean age at first observation was 18.9 (SD: ±2.8) years; 72% were male, 92% were Black and 80% were horizontally infected. The cumulative first STI incidence rate was 45.49 cases per 100 person-years, and the recurrent STI incidence rate was 119.86 cases per 100 person-years. Among all Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT) cases, the most common site of infection was the rectum (48.6% and 49.6%, respectively). Disagreement between exposure history and presence of GC or CT infection was statistically significant for nearly all anatomic sites and types of intercourse.

CONCLUSIONS

AYAs with HIV in Atlanta have disproportionately high first and recurrent incidence rates of STIs, with many patients not reporting exposure at their site of infection. There is considerable need to increase screening for STIs, including routine extragenital testing for GC and CT, among AYAs with HIV regardless of self-reported exposure history.

Gonorrhoea and chlamydia diagnosis as an entry point for HIV pre-exposure prophylaxis: a modelling study

OBJECTIVES

Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) increase the risk of HIV transmission among men who have sex with men (MSM). Diagnosis of NG/CT may provide an efficient entry point for prevention of HIV through the delivery of pre-exposure prophylaxis (PrEP); however, the additional population-level impact of targeting PrEP to MSM diagnosed with NG/CT is unknown.

DESIGN

An agent-based simulation model of NG/CT and HIV cocirculation among MSM calibrated against census data, disease surveillance reports and the US National HIV Behavioral Surveillance study.

SETTING

Baltimore City, Maryland, USA.

INTERVENTIONS

PrEP implementation was modelled under three alternative scenarios: (1) PrEP delivery at NG/CT diagnosis (targeted delivery), (2) PrEP evaluation at NG/CT screening/testing and (3) PrEP evaluation in the general community (untargeted).

MAIN OUTCOME

The projected incidence of HIV after 20 years of PrEP delivery under two alternatives: when equal numbers of MSM are (1) screened for PrEP or (2) receive PrEP in each year.

RESULTS

Assuming 60% uptake and 60% adherence, targeting PrEP to MSM diagnosed with NG/CT could reduce HIV incidence among MSM in Baltimore City by 12.4% (95% uncertainty range (UR) 10.3% to 14.4%) in 20 years, relative to no PrEP. Expanding the coverage of NG/CT screening (such that individuals experience a 50% annual probability of NG/CT screening and evaluation for PrEP on NG/CT diagnosis) can further increase the impact of targeted PrEP to generate a 22.0% (95% UR 20.1% to 23.9%) reduction in HIV incidence within 20 years. When compared with alternative implementation scenarios, PrEP evaluation at NG/CT diagnosis increased impact of PrEP on HIV incidence by 1.5(95% UR 1.1 to 1.9) times relative to a scenario in which PrEP evaluation happened at the time of NG/CT screening/testing and by 1.6 (95% UR 1.2 to 2.2) times relative to evaluating random MSM from the community.

CONCLUSIONS

Targeting MSM infected with NG/CT increases the efficiency and effectiveness of PrEP delivery. If high levels of sexually transmitted infection screening can be achieved at the community level, NG/CT diagnosis may be a highly effective entry point for PrEP initialisation.

Syphilis incidence in men who have sex with men with human immunodeficiency virus comorbidity and the importance of integrating sexually transmitted infection prevention into HIV care

INTRODUCTION

Syphilis continues to be a growing epidemic among men who have sex with men (MSM), particularly for those living with the human immunodeficiency virus (HIV). In 2016, MSM accounted for 80% of primary and secondary syphilis diagnoses in men in the United States; almost half of who were also HIV-infected. The synergistic relationship between HIV and syphilis has significant implications not only for HIV patient management, but also for sexually transmitted infection (STI) control among MSM. Areas covered: We review the literature on STI screening and treatment barriers at the patient-, provider-, and health system-levels, and present strategies to incorporate STI prevention into HIV care settings. Expert commentary: Integration of STI prevention into HIV care is paramount to stop the epidemic of not only syphilis, but also other curable STIs like gonorrhea and chlamydia. Although guidelines have been established for STI testing in HIV-infected MSM, screening rates continue to be lower than desired. Gonorrhea and chlamydia screening is below 50% in HIV-infected MSM; interventions that improve testing of those two infections must be implemented. For syphilis control, other additional strategies such as chemoprophylaxis should be considered given syphilis screening is above 50% in HIV-infected MSM.

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.

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.

Chlamydia trachomatis, Neisseria gonorrhoeae and syphilis among men who have sex with men in Brazil

BACKGROUND

Sexually transmitted diseases (STD) are frequently asymptomatic and increase the likelihood of transmitting and acquiring HIV. In Brazil, the guidelines for STDs diagnosis and treatment are based on the syndromic approach. Nucleic acid amplification tests (NAAT) has been recommended as routine STDs screening in some countries, especially for men who have sex with men (MSM). Limited data are available about how to best define target groups for routine screening by NAATs within this population. We aimed to assess the prevalence of rectal and urethral Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections and syphilis, and the factors associated with having at least one STD among HIV-infected and uninfected MSM in Rio de Janeiro, Brazil.

METHODS

From August 2010 to June 2012, 391 MSM were enrolled into the Evandro Chagas National Institute of Infectious Diseases-INI-Fiocruz cohort, and 292 MSM (HIV-infected:211 and HIV-uninfected:81) were included in this study. NAATs were performed on the rectal swabs and urine for CT and NG. The rapid plasma reagin test and microhemagglutination assay for Treponema pallidum were performed for syphilis diagnosis.

RESULTS

The overall prevalence of STD was 20.0% (95%CI:15.7-25.1): 10% anorectal chlamydia; syphilis 9.9%; anorectal gonorrheae 2.5%; and urethral chlamydia 2.2%; no case of urethral gonorrheae was detected. The proportion of HIV-positive MSM who had at least one STD was nearly two times that of HIV-negative MSM (22.6% vs 13.2%; P = 0.09). The frequency of each STD, except for anorectal NG (1.5% vs.5.2%), was higher among HIV-positive than HIV-negative individuals. Among the 211 asymptomatic participants, 17.5% (n = 37) were identified as having at least one STD; 10.4% (n = 22/211) tested positive for anorectal chlamydia. Sixty five percent of HIV-positive MSM were asymptomatic at the time of the STD diagnosis, while 100.0% of the HIV-negative MSM. Age (APR = 0.78; 95%CI:0.60-1.00 for each additional ten years) and a positive-HIV serostatus (APR = 2.05; 95%CI:1.03-4.08) were significantly associated with STD diagnosis.

CONCLUSION

An overall high STD-prevalence rate was observed, especially among HIV-infected and in younger individuals, and the majority of STDs were asymptomatic. STD screening using NAATs among asymptomatic MSM is a potentially cost-effective intervention for the prevention of HIV infection among MSM.