Structural vulnerabilities and PrEP awareness among Boston heterosexuals and people who inject drugs at risk for HIV: findings from 2018 to 2019 cycles from the Boston, MA site of the NHBS

Little is known about biopsychosocial factors relating to pre-exposure prophylaxis (PrEP) awareness among people with either heterosexual or injection drug use HIV risk behaviors. Participants engaged in vaginal/anal sex with a person of the opposite sex (N = 515) or were people who injected drugs (PWID; N = 451) in the past 12 months from 2018-2019 in Boston, MA. We examined associations between PrEP awareness and: homelessness; perceived HIV-related stigma; country of birth; bacterial STDs, chlamydia, and/or gonorrhea in the past 12 months, lifetime hepatitis C virus (HCV) infection, sexual orientation, and poverty. More PWID (36.8%) were aware of PrEP than people with heterosexual HIV risk (28%; p = .001). Among people with heterosexual risk, homelessness (aOR = 1.99, p = .003), and among PWID: homelessness (aOR = 2.11, p = .032); bacterial STD (aOR = 2.96, p = .012); chlamydia (aOR = 6.14, p = .008); and HCV (aOR = 2.40, p < .001) were associated with increased likelihood of PrEP awareness. In the combined sample: homelessness (aOR = 2.25, p < .001); HCV (aOR = 2.18, p < .001); identifying as homosexual (aOR = 3.71, p = .036); and bisexual (aOR = 1.55, p = .016) were each associated with PrEP awareness. Although having an STD, HCV, identifying as homosexual or bisexual, and experiencing homelessness were associated with increased PrEP awareness, most participants were unaware of PrEP. Efforts to increase PrEP awareness could engage PWID and heterosexual HIV risk behavior.

Unravelling Delay in Care for Sexually Transmitted Infections-Related Symptoms in a Developing Country Setting (Jamaica)

BACKGROUND

Sexually transmitted infections (STIs) and STI treatment remain a challenge in public health. There is little understanding of related factors influencing health seeking behaviour and delay of care among clinic attendees in Jamaica.

AIM

To determine socio-demographic profile of clinic attendees with STI and identify factors associated with delay in seeking care for STI-related symptoms.

METHODS

A cross-sectional study was done. 201 adult patients presenting with STI symptoms from four health centres in Kingston and St Andrew were selected. A 24-item interviewer-assisted questionnaire was used to obtain data on socio-demographic characteristics, patients' symptoms and duration, previous STIs, knowledge of complications and seriousness of STIs, and factors influencing decision to seek medical care.

RESULTS

Almost 75% delayed seeking care for STIs. Recurrent STIs was identified in 41% of patients. 'Could not find time' was the most commonly reported reason for delay in seeking care (36%). Females were 3.4 times more likely to delay seeking care for STI symptoms than males (OR 3.42, 95% CI: 1.73-6.73). Those with primary level education and below were 5 times more likely to delay seeking care for STI symptoms than those with at least secondary level education (OR 5.05, 95% CI: 1.09-23.46). Participants viewed staff as confidential (68%) and 65% thought health-care workers spent adequate time during consultations.

CONCLUSION

Lower education level and the female gender are associated with delay in seeking care for STI-related symptoms. These factors should be considered when developing interventions to reduce delay in care for STI-related symptoms.

Laboratory Data Timeliness and Completeness Improves Following Implementation of an Electronic Laboratory Information System in Côte d'Ivoire: Quasi-Experimental Study on 21 Clinical Laboratories From 2014 to 2020

BACKGROUND

The Ministry of Health in Côte d'Ivoire and the International Training and Education Center for Health at the University of Washington, funded by the United States President's Emergency Plan for AIDS Relief, have been collaborating to develop and implement the Open-Source Enterprise-Level Laboratory Information System (OpenELIS). The system is designed to improve HIV-related laboratory data management and strengthen quality management and capacity at clinical laboratories across the nation.

OBJECTIVE

This evaluation aimed to quantify the effects of implementing OpenELIS on data quality for laboratory tests related to HIV care and treatment.

METHODS

This evaluation used a quasi-experimental design to perform an interrupted time-series analysis to estimate the changes in the level and slope of 3 data quality indicators (timeliness, completeness, and validity) after OpenELIS implementation. We collected paper and electronic records on clusters of differentiation 4 (CD4) testing for 48 weeks before OpenELIS adoption until 72 weeks after. Data collection took place at 21 laboratories in 13 health regions that started using OpenELIS between 2014 and 2020. We analyzed the data at the laboratory level. We estimated odds ratios (ORs) by comparing the observed outcomes with modeled counterfactual ones when the laboratories did not adopt OpenELIS.

RESULTS

There was an immediate 5-fold increase in timeliness (OR 5.27, 95% CI 4.33-6.41; P<.001) and an immediate 3.6-fold increase in completeness (OR 3.59, 95% CI 2.40-5.37; P<.001). These immediate improvements were observed starting after OpenELIS installation and then maintained until 72 weeks after OpenELIS adoption. The weekly improvement in the postimplementation trend of completeness was significant (OR 1.03, 95% CI 1.02-1.05; P<.001). The improvement in validity was not statistically significant (OR 1.34, 95% CI 0.69-2.60; P=.38), but validity did not fall below pre-OpenELIS levels.

CONCLUSIONS

These results demonstrate the value of electronic laboratory information systems in improving laboratory data quality and supporting evidence-based decision-making in health care. These findings highlight the importance of OpenELIS in Côte d'Ivoire and the potential for adoption in other low- and middle-income countries with similar health systems.

Detection and Clearance of Type-Specific and Phylogenetically Related Genital Human Papillomavirus Infections in Young Women in New Heterosexual Relationships

BACKGROUND

Understanding the natural history of human papillomavirus (HPV) infections is essential to cervical cancer prevention planning. We estimated HPV type-specific infection detection and clearance in young women.

METHODS

The HPV Infection and Transmission among Couples through Heterosexual activity (HITCH) study is a prospective cohort of 502 college-age women who recently initiated a heterosexual relationship. We tested vaginal samples collected at 6 clinical visits over 24 months for 36 HPV types. Using rates and Kaplan-Meier analysis, we estimated time-to-event statistics with 95% confidence intervals (CIs) for detection of incident infections and clearance of incident and present-at-baseline infections (separately). We conducted analyses at the woman- and HPV-levels, with HPV types grouped by phylogenetic relatedness.

RESULTS

By 24 months, we detected incident infections in 40.4% (CI, 33.4%-48.4%) of women. Incident subgenus 1 (43.4; CI, 33.6-56.4), 2 (47.1; CI, 39.9-55.5), and 3 (46.6; CI, 37.7-57.7) infections cleared at similar rates per 1000 infection-months. We observed similar homogeny in HPV-level clearance rates among present-at-baseline infections.

CONCLUSIONS

Our analyses provide type-specific infection natural history estimates for cervical cancer prevention planning. HPV-level analyses did not clearly indicate that high oncogenic risk subgenus 2 infections persist longer than their low oncogenic risk subgenera 1 and 3 counterparts.

Using Social Listening for Digital Public Health Surveillance of Human Papillomavirus Vaccine Misinformation Online: Exploratory Study

Despite challenges related to the data quality, representativeness, and accuracy of artificial intelligence-driven tools, commercially available social listening platforms have many of the attributes needed to be used for digital public health surveillance of human papillomavirus vaccination misinformation in the online ecosystem.

Syphilis Prevalence Among People Living With and Without HIV in Sub-Saharan Africa: A Systematic Review and Meta-Analysis

BACKGROUND

Syphilis is a curable sexually transmitted infection that, untreated, is associated with significant morbidity and mortality. In people living with HIV (PLWH), syphilis carries greater risks of disease progression. We estimated syphilis prevalence among PLWH in the general population in sub-Saharan Africa and compared the prevalence among PLWH and without HIV.

METHODS

We searched for studies published January 1, 2011, to March 28, 2022, reporting syphilis prevalence among PLWH in sub-Saharan Africa (PROSPERO No. CRD42020167328). We excluded studies in high-risk subpopulations. We estimated pooled syphilis prevalence among PLWH using random-effects modeling and compared the prevalence with people without HIV when included in the same study. We examined influences of region, study setting, and test type in subgroup analyses.

RESULTS

We identified 926 studies; 53 were included in the meta-analysis. Pooled syphilis prevalence among PLWH was 7.3% (95% confidence interval [CI], 6.3%-8.5%). Prevalence differed by region: 3.1% (95% CI, 2.2%-4.0%) in Southern, 5.5% (95% CI, 2.3%-9.3%) in West/Central, and 10.5% (95% CI, 8.0%-13.1%) in Eastern Africa. Prevalence also differed by study setting: 13.8% (95% CI, 5.7%-23.0%) in sexual and reproductive health/sexually transmitted infection care, 8.7% (95% CI, 5.0%-12.8%) in HIV care, 7.1% (95% CI, 5.8%-8.5%) in antenatal care, and 3.8% (95% CI, 2.0%-5.8%) in household/community-based settings. Syphilis prevalence was higher among PLWH than without HIV (relative risk, 3.5; 95% CI, 2.8-4.5).

CONCLUSIONS

Syphilis is highly prevalent among PLWH in sub-Saharan Africa and is more common among PLWH than without HIV. Integration of syphilis screening and management into HIV care may reduce complications of HIV-syphilis coinfection among PLWH in sub-Saharan Africa.

Addressing Unmet PrEP Needs in Women: Impact of a Laboratory-Driven Protocol at an Urban, Essential Hospital

Background

HIV pre-exposure prophylaxis (PrEP) uptake in women remains low. We developed a laboratory result-driven protocol to link women with a positive bacterial sexually transmitted infection (STI) to HIV PrEP at an urban safety-net hospital.

Methods

Electronic health records of women with positive chlamydia, gonorrhea, and/or syphilis tests were reviewed, and those eligible for PrEP were referred for direct or primary care provider-driven outreach. We assessed the proportion of women with STIs who received PrEP offers, acceptance, and prescriptions before (July 1, 2018-December 31, 2018) and after (January 1, 2019-June 30, 2020) implementation to evaluate changes in the delivery of key elements of the PrEP care cascade (ie, PrEP offers, acceptance, and prescribing) for women with STIs after protocol implementation.

Results

The proportion of women who received PrEP offers increased from 7.6% to 17.6% (P < .001). After multivariable adjustment, only the postintervention period was associated with PrEP offers (odds ratio [OR], 2.49; 95% CI, 1.68-3.68). In subgroup analyses, PrEP offers increased significantly among non-Hispanic Black (OR, 2.75; 95% CI, 1.65-4.58) and Hispanic (OR, 5.34; 95% CI, 1.77-16.11) women but not among non-Hispanic White women (OR, 1.49; 95% CI, 0.54-4.05). Significant changes in PrEP acceptance and prescriptions were not observed in the sample overall.

Conclusions

A laboratory result-driven protocol was associated with a significant increase in PrEP offers to Black and Hispanic women with STI. These results provide concrete suggestions for health systems seeking to increase PrEP access and equity among women.

Detection of resistance to macrolides and fluoroquinolones in Mycoplasma genitalium by targeted next-generation sequencing

Mycoplasma genitalium is fastidious to culture, and its detection in human clinical specimens relies mainly on molecular methods. Phenotypic determination of antibiotic susceptibility for this bacterium is not a timely or feasible option for most clinical laboratories. This study sought to determine whether next-generation sequencing technologies can effectively be employed in determining genetic mutations associated with drug resistance in M. genitalium samples collected in Aptima Hologic tubes and possibly integrating them into viable workflows in public health laboratories. Following analysis by a custom-designed bioinformatics pipeline, at least one mutation/sample has been identified in 94/98 specimens in at least one of seven loci (macrolides: rrl, rplD, rplV; fluoroquinolones: parC, parE, gyrA, gyrB) described previously to be connected to antibiotic resistance. This method identified a total of 469 single nucleotide polymorphisms (SNPs) (452 mutations): 134 of 23S rRNA SNPs and 318 amino acid mutations: 114 substitutions and 204 synonymous; the turnaround time (sample to analyzed sequence) was typically 3 days. The assays and workflows described in this work demonstrated that the determination of a drug resistance profile for macrolides and fluoroquinolones of M. genitalium samples by using next-generation sequencing in clinical samples is a feasible approach that can be implemented in clinical laboratories, following thorough and extensive validation studies.IMPORTANCEThe mechanisms of drug resistance in Mycoplasma genitalium are complex and involve several genetic loci. The molecular methods for accurately characterizing resistance to fluoroquinolones and macrolides in this organism are often not available or approved for patient use and do not cover all genetic determinants. To this end, we propose a next-generation sequencing-based method with a turnaround time of 3 days that includes the investigation of all drug resistance loci of M. genitalium. Following adaptation, validation, and verification for routine clinical use, assays based on this method may yield molecular results that can be used to guide proper treatment regimens and for surveillance of drug resistance in the general population.

High prevalence of syphilis among recyclable waste collectors in Central Brazil

BACKGROUND

Syphilis is associated with social and behavioral factors.

METHODS

This cross-sectional study determined the prevalence of syphilis and its associated risk factors among recyclable waste collectors in Central Brazil.

RESULTS

A lifetime syphilis prevalence rate of 7.91% (95% confidence interval: 5.25-11.75) was found among 278 participants. Low educational level, history of sexually transmitted infection, and age ≥ 36 years were associated with a high prevalence of lifetime syphilis.

CONCLUSIONS

These findings emphasize the need for syphilis prevention, screening, and treatment among recyclable waste collectors, highlighting the potential for the spread of infection in vulnerable populations.

Diagnostic and Therapeutic Approaches for a Diabetic Patient Presenting with Secondary Syphilis and Severe Odynophagia

Syphilis, an infectious disease caused by the spirochete Treponema pallidum, represents a pervasive global epidemic. Secondary syphilis is typically marked by the emergence of highly contagious mucocutaneous manifestations, including non-pruritic rashes on the palms and soles of the feet, alopecia, mucous patches, and condyloma lata. Here, we report a rare case of a 30-year-old male with newly discovered type 2 diabetes mellitus who presented with severe odynophagia due to secondary syphilis, confirmed by both nontreponemal VDRL/RPR and treponemal TPHA tests. Following the administration of a single-dose intramuscular injection of benzathine penicillin G 2.4 million units, the symptoms gradually decreased, allowing the patient to regain his health.

A pharmacist-driven deprescribing protocol for negative urine and sexually transmitted infection cultures in the emergency department increases antibiotic-free days

PURPOSE

Emergency department (ED) pharmacists commonly perform positive culture follow-ups that result in optimized antibiotic prescribing. The purpose of this study was to evaluate the potential positive impact on the outcome of antibiotic-free days through an ED pharmacist-driven protocol to contact patients with negative urine cultures and sexually transmitted infection (STI) test results who were discharged with antibiotics.

METHODS

This was a single-center, prospective, observational, pre-post intervention study to determine antibiotic use in patients with negative urine cultures who were discharged from the Loyola Medical University Center ED with antibiotics prescribed. Patients were identified through daily positive culture reports. The primary outcome was days free of antibiotics, defined as the number of calendar days within 28 days after urine culture or STI test collection on which the patient did not receive any antibiotic treatments.

RESULTS

One hundred ninety-two patients were screened. Sixty-three and twenty-six patients met the inclusion criteria in the pre- and postintervention groups, respectively. The study identified 163/465 (35.1%) antibiotic free days for the preintervention group, compared to 150.5/187 (80.5%) antibiotic-free days for the postintervention group. A majority of the patients did not have urinary tract infection as the chief complaint. The most common urinary and STI symptoms upon ED admission in the pre- and postintervention groups were dysuria (19.2% vs 28.1%) and unusual discharge (30.8% vs 28.6%), respectively.

CONCLUSION

This study showed that a pharmacist-driven protocol increased the number of antibiotic-free days for patients prescribed empiric antibiotic therapy and discharged from the ED with subsequent negative urine cultures and STI results. We propose taking a novel approach in discontinuation of antibiotics by implementing an expansion of ED culture programs to include negative cultures that promote antimicrobial stewardship.

Health services provided at the time of abortion in the US: a scoping review of the qualitative and quantitative evidence

Objectives

While it is well documented that abortion access is associated with improved health, pregnancy-related, and socioeconomic outcomes, the association between abortion access and other reproductive health outcomes is less well described. Abortion-providing clinics also offer preventative reproductive health services. We conducted a scoping review to ascertain the extent to which preventive reproductive healthcare services (contraception, sexually transmitted infection testing and treatment, cervical cancer screening) are affected by abortion access in the United States.

Methods

Researchers screened articles and extracted data from PubMed, Embase, Scopus and CINAHL. We excluded articles that did not link abortion to contraception, sexually transmitted infection testing and treatment and cervical cancer screening; or took place outside the US.

Results

5,359 papers were screened, 74 were included for full text review. Sixty-five were about contraception, seven on STIs, one on cervical cancer screening, and one on other services. The association between policies that restrict or protect abortion access and preventative health services has not been studied on a national scale. Drivers of variation were: insurance and billing policies; regulatory requirements of abortion-providing facilities, lack of staff training in clinics that did not specialize in abortion care; and limited follow up after abortion.

Conclusions

Abortion--providing clinics are a highly utilized access point for reproductive health services. More research is needed to determine the public health impact of constrained abortion access on contraceptive use, STI rates and cervical cancer in regions where many abortion-providing clinics have closed.

Implications

Attention should be paid to changing trends in contraceptive use, STI rates and cervical cancer as abortion-providing clinics close, this may reduce access to reproductive health services broadly.

Digital Triage Tools for Sexually Transmitted Infection Testing Compared With General Practitioners' Advice: Vignette-Based Qualitative Study With Interviews Among General Practitioners

BACKGROUND

Digital triage tools for sexually transmitted infection (STI) testing can potentially be used as a substitute for the triage that general practitioners (GPs) perform to lower their work pressure. The studied tool is based on medical guidelines. The same guidelines support GPs' decision-making process. However, research has shown that GPs make decisions from a holistic perspective and, therefore, do not always adhere to those guidelines. To have a high-quality digital triage tool that results in an efficient care process, it is important to learn more about GPs' decision-making process.

OBJECTIVE

The first objective was to identify whether the advice of the studied digital triage tool aligned with GPs' daily medical practice. The second objective was to learn which factors influence GPs' decisions regarding referral for diagnostic testing. In addition, this study provides insights into GPs' decision-making process.

METHODS

A qualitative vignette-based study using semistructured interviews was conducted. In total, 6 vignettes representing patient cases were discussed with the participants (GPs). The participants needed to think aloud whether they would advise an STI test for the patient and why. A thematic analysis was conducted on the transcripts of the interviews. The vignette patient cases were also passed through the digital triage tool, resulting in advice to test or not for an STI. A comparison was made between the advice of the tool and that of the participants.

RESULTS

In total, 10 interviews were conducted. Participants (GPs) had a mean age of 48.30 (SD 11.88) years. For 3 vignettes, the advice of the digital triage tool and of all participants was the same. In those vignettes, the patients' risk factors were sufficiently clear for the participants to advise the same as the digital tool. For 3 vignettes, the advice of the digital tool differed from that of the participants. Patient-related factors that influenced the participants' decision-making process were the patient's anxiety, young age, and willingness to be tested. Participants would test at a lower threshold than the triage tool because of those factors. Sometimes, participants wanted more information than was provided in the vignette or would like to conduct a physical examination. These elements were not part of the digital triage tool.

CONCLUSIONS

The advice to conduct a diagnostic STI test differed between a digital triage tool and GPs. The digital triage tool considered only medical guidelines, whereas GPs were open to discussion reasoning from a holistic perspective. The GPs' decision-making process was influenced by patients' anxiety, willingness to be tested, and age. On the basis of these results, we believe that the digital triage tool for STI testing could support GPs and even replace consultations in the future. Further research must substantiate how this can be done safely.

Cases of Monkeypox show highly-overlapping co-infection with HIV and syphilis

Purpose

Ongoing Monkeypox (MPX) outbreaks in countries outside Africa have unique characteristics. However, data on cohorts of confirmed cases in China is limited. The study provides important epidemiological, diagnostic, and clinical information about this disease in China.

Methods

We report a series of Chinese individuals with confirmed MPX infections identified at Beijing Youan Hospital (China) from June 10 to July 15, 2023. Samples were taken from the skin, anus, throat, and blood. An epidemiological questionnaire was used to collect demographic and clinical data. Further, we compared the MPX viral (MPXV) loads across different anatomical sites.

Results

66 samples were collected from 20 patients, all of whom were cisgender men. Median patient age was 29 years. Notably, 19 (95%) patients reported unprotected sexual encounters with men in the preceding month, and 13 (65%) were human immunodeficiency virus (HIV)-positive. Among those with HIV, 12 (92%) were receiving antiretroviral therapy, and 11 (85%) had well-controlled infections (HIV viral load <40/mL). The median CD4+ T cell count was 667 cells/mm3. In the HIV-negative group, three (43%) patients were taking preexposure prophylaxis. Fifteen patients (75%) had concurrent sexually transmitted infections (50% had syphilis and 65% had HIV) and eight (40%) had HIV and syphilis co-infection. MPXV loads were significantly higher in samples from the skin (cycle threshold value [Ct value]: 19·0) and anus (Ct value: 23.0) compared to samples from the throat (Ct value: 31.0) or blood (Ct value: 34.5). All patients had skin lesions (85% of whom presented with anogenital lesions). Common systemic symptoms included fever (85%) and lymphadenopathy (55%). The median incubation period was 8 d [interquartile range (IQR): 6-16 d]. The median time from the onset of skin lesions to scab removal was 14 d (IQR: 10-16 d). No deaths or severe cases were reported.

Conclusion

MPXV primarily affects young homosexual men. The high MPXV viral loads in skin and anal lesions indicate that transmission most likely occurs through direct and close body contact. This study also reports high rates of HIV and syphilis co-infection. Therefore, preventive efforts should focus on homosexual men.

A multicenter retrospective electronic health record database evaluation of subjects with Mycoplasma genitalium

BACKGROUND

Mycoplasma genitalium is a sexually transmitted infection (STI) increasing in prevalence. The recent availability of nucleic acid amplification tests (NAATs) has led to updated diagnostic and treatment guidelines. As medication therapy experts, pharmacists can facilitate appropriate antimicrobial selection and stewardship and optimize best patient-care practices in the setting of M. genitalium infection.

OBJECTIVE

This study aimed to evaluate patient demographics, therapeutic approaches, and complications of patients with laboratory evidence of M. genitalium hypothesizing that younger adolescent females are affected by this organism, receive suboptimal treatment, and have more complications than adults.

METHODS

This was a retrospective cohort study using TriNetX multicenter electronic health record data of subjects aged 12 years and older with evidence of M. genitalium DNA detected via NAATs. The cohort was divided into 2 age groups: adolescents (12-21 years) and adults (older than 21 years). We evaluated age, sex, race, ethnicity, diagnostic codes, and medication codes.

RESULTS

Our study included 1126 subjects (192 adolescents [17.1%] and 934 adults [82.9%]) who tested positive for M. genitalium. Subjects in the adolescent group had higher odds of being women (2.52 [1.80, 3.54], P < 0.001), having inflammatory diseases of female pelvic organs diagnostic codes (1.51 [1.06, 2.16], P = 0.025), increased odds of azithromycin prescription (1.70 [1.17, 2.48], P = 0.005), and decreased odds of moxifloxacin prescription (0.41 [0.26, 0.64], P < 0.001).

CONCLUSIONS

Our study revealed a higher prevalence of M. genitalium infection in adults and adolescents with increased odds of receiving azithromycin and decreased odds of receiving moxifloxacin. Both age groups had decreased odds of receiving doxycycline compared with azithromycin despite guidelines recommending initial empirical antibiotic treatment with doxycycline and growing macrolide resistance. Suboptimal treatment of this infection may lead to lifelong complications. Pharmacists may provide crucial guidance and education to both patients and health care providers regarding appropriate treatment for M. genitalium.

[Monkeypox: characteristics in female population, Buenos Aires, Argentina]

Monkeypox is a zoonotic viral disease caused by a virus of the genus Orthopoxvirus. As of January 1, 2022, it has been reported in 110 WHO Member States. It presents with fever, fatigue, painful lymphadenopathy, and rash. It lasts between 2 and 4 weeks. It is usually self-limited, but severe cases have been described in immunocompromised people. This study describes cases of monkeypox in women, diagnosed between June 2022 and February 2023, and it reports epidemiology, clinical aspects, and complications after infection. A retrospective observational study was carried out in the Febrile Emergency Unit (UFU), reviewing positive cases (RT-PCR) for monkeypox and the population with female biological sex was selected. They were questioned about gynecological complications, menstrual pattern, dyspareunia and pelvic pain. 340 consultations for monkeypox were made, 214 (63%) were positive, 211 cases (99%) male and 3 cases (1%) female. Among these cases is a trans woman, who was not included. The average age is 31 years, immunocompetent, with a negative serology report for HIV, syphilis, hepatitis B and C. Both cases had sexual intercourse without a barrier method. The most frequent symptoms are asthenia and skin lesions, especially in the upper and lower limbs, perianal and genital region. As a risk factor they presented unprotected sexual contact. Within the differential diagnoses, other sexually transmitted infections (STIs) should be considered. There were no gynecological complications reported during follow-up.

A structural foundation for studying chlamydial polymorphic membrane proteins

IMPORTANCE

Infections by bacteria in the genus Chlamydia cause a range of widespread and potentially debilitating conditions in humans and other animals. We analyzed predicted structures of a family of proteins that are potential vaccine targets found in all Chlamydia spp. Our findings deepen the understanding of protein structure, provide a descriptive framework for discussion of the protein structure, and outline regions of the proteins that may be key targets in host-microbe interactions and anti-chlamydial immunity.

Doxycycline postexposure prophylaxis for prevention of sexually transmitted infections

Doxycycline postexposure prophylaxis (doxy-PEP) is a novel strategy now demonstrated in several clinical trials to dramatically reduce incidence rates of gonorrhea, chlamydia, and syphilis in some key populations at high risk of sexually transmitted infections. Even so, much remains unknown about the long-term consequences of doxy-PEP, and several concerns, including the potential for the development of antibiotic resistance and disturbances to the microbiome, balance the benefits. This review highlights the history of antibiotic prophylaxis for sexually transmitted infections, and the rationale, current evidence, and future directions for doxy-PEP.

Heterogeneity in practitioner-reported barriers to use, cost considerations and priorities for point of care sexually transmitted infection tests on surveys across seven years

BACKGROUND

Point of care diagnostic tests (POCTs) for sexually transmitted infections (STIs) have the potential to improve STI care worldwide. However, barriers to adoption, cost considerations and practitioner priorities may not be uniform globally and over time. We conducted two surveys, 7 years apart, among members of the International Union Against Sexually Transmitted Infections (IUSTI), and compare results here.

METHODS

Surveys were given to members attending two IUSTI conferences in 2012 (Australia) and 2019 (Estonia). Descriptive analyses were performed and chi-square or Fisher's exact tests conducted.

RESULTS

Amongst N = 190 participants in 2012 and N = 166 in 2019, 61% in 2012 and 77% in 2019 were from high-income countries (HICs). In 2012, 84% of respondents from low- and middle-income countries (LMICs) and 70% from HICs thought cost of test was more important than amount of reimbursement. Trends were similar in 2019. In 2012, unreliability was considered the most important barrier to POCT use by all groups, followed by being laboratory-driven and complexity. In 2019, time frame was considered most important, followed by unreliability and being laboratory-driven. In 2012, the top priority for POCT development among LMIC respondents was early HIV seroconversion (31%), versus chlamydia (57%) for HICs. In 2019, chlamydia remained top priority for HICs (40%), followed by early HIV seroconversion (19%) and gonorrhea (17%); top priorities for LMICs were chlamydia (26%), HPV (24%), and early HIV seroconversion (21%).

CONCLUSIONS

Practitioner priorities for STI POCTs may be shifting. Cost may be critical to adoption in all settings. Larger studies are needed to verify findings.

Trends in Recommended Screening and Monitoring Tests for Users of HIV Pre-Exposure Prophylaxis Before and During the COVID-19 Pandemic

Introduction

To ensure the health and safety of persons taking pre-exposure prophylaxis to prevent HIV infection, the 2017 Centers for Disease Control and Prevention guidelines recommended initial and follow-up laboratory testing. We assessed the trends in adherence rates to recommended laboratory testing among pre-exposure prophylaxis users and identified factors associated with HIV testing among pre-exposure prophylaxis users from 2016 to 2020 and also examined rate changes during the COVID-19 pandemic in 2020.

Methods

We conducted a retrospective cohort study assessing the rates and trends of recommended laboratory testing among commercially insured pre-exposure prophylaxis users from 2016 to 2020, using the MarketScan database. We examined the proportion of pre-exposure prophylaxis users adhering to the following initial and follow-up laboratory testing: (1) HIV, creatinine clearance, hepatitis B virus, hepatitis C virus, and sexually transmitted infections (chlamydia/gonorrhea and syphilis) within 7 days before pre-exposure prophylaxis initiation; (2) HIV 90 days after initiation; and (3) HIV, creatinine clearance, and sexually transmitted infections 180 days after pre-exposure prophylaxis initiation. We used general linear models to examine trends and multivariable logistic regression to identify predictors of ≥1 HIV test within 180 days after index pre-exposure prophylaxis.

Results

We identified 19,581 new pre-exposure prophylaxis users. Most were male (96%) and aged 18-34 years (55%). Adherence rates to recommended testing increased from 2016 through 2019 (e.g., 9.0%-13.6% for all initial screening tests 7 days before initiation, 42.1%-44.6% for HIV testing 90 days after initiation, 33.8%-40.6% for all follow-up tests within 180 days after initiation), but all rates decreased during the COVID-19 pandemic (12.4%, 33.6%, and 31.6%, respectively). Younger age (aged 13-17 years: AOR=0.44, 95% CI=0.28, 0.71) and ages 18-34 years (AOR=0.80, 95% CI=0.74, 0.86) were associated with a significantly lower likelihood of getting an HIV test within 180 days after initiation than ages 35-44 years, and female sex (AOR=0.64, 95% CI=0.55, 0.74) were associated with a significantly lower likelihood than male sex. Pre-exposure prophylaxis users with a history of sexually transmitted infections had a higher likelihood (AOR=1.27, 95% CI=1.16, 1.40) of getting tested than those without.

Conclusions

Initial screening and follow-up testing rates were lower than those recommended by the Centers for Disease Control and Prevention. Public health efforts are needed to ensure that patients have access to needed laboratory testing during pandemics or natural disasters and to educate patients and clinicians about the importance of screening and monitoring tests to ensure the safety and health of pre-exposure prophylaxis users.

Exploring Whether the Electronic Optimization of Routine Health Assessments Can Increase Testing for Sexually Transmitted Infections and Provider Acceptability at an Aboriginal Community Controlled Health Service: Mixed Methods Evaluation

BACKGROUND

In the context of a syphilis outbreak in neighboring states, a multifaceted systems change to increase testing for sexually transmitted infections (STIs) among young Aboriginal people aged 15 to 29 years was implemented at an Aboriginal Community Controlled Health Service (ACCHS) in New South Wales, Australia. The components included electronic medical record prompts and automated pathology test sets to increase STI testing in annual routine health assessments, the credentialing of nurses and Aboriginal health practitioners to conduct STI tests independently, pathology request forms presigned by a physician, and improved data reporting.

OBJECTIVE

We aimed to determine whether the systems change increased the integration of STI testing into routine health assessments by clinicians between April 2019 and March 2020, the inclusion of syphilis tests in STI testing, and STI testing uptake overall. We also explored the understandings of factors contributing to the acceptability and normalization of the systems change among staff.

METHODS

We used a mixed methods design to evaluate the effectiveness and acceptability of the systems change implemented in 2019. We calculated the annual proportion of health assessments that included tests for chlamydia, gonorrhea, and syphilis, as well as an internal control (blood glucose level). We conducted an interrupted time series analysis of quarterly proportions 24 months before and 12 months after the systems change and in-depth semistructured interviews with ACCHS staff using normalization process theory.

RESULTS

Among 2461 patients, the annual proportion of health assessments that included any STI test increased from 16% (38/237) in the first year of the study period to 42.9% (94/219) after the implementation of the systems change. There was an immediate and large increase when the systems change occurred (coefficient=0.22; P=.003) with no decline for 12 months thereafter. The increase was greater for male individuals, with no change for the internal control. Qualitative data indicated that nurse- and Aboriginal health practitioner-led testing and presigned pathology forms proved more difficult to normalize than electronic prompts and shortcuts. The interviews identified that staff understood the modifications to have encouraged cultural change around the role of sexual health care in routine practice.

CONCLUSIONS

This study provides evidence for the first time that optimizing health assessments electronically is an effective and acceptable strategy to increase and sustain clinician integration and the completeness of STI testing among young Aboriginal people attending an ACCHS. Future strategies should focus on increasing the uptake of health assessments and promote whole-of-service engagement and accountability.

Sitafloxacin- Versus Moxifloxacin-Based Sequential Treatment for Mycoplasma Genitalium Infections: Protocol for a Multicenter, Open-Label Randomized Controlled Trial

BACKGROUND

Mycoplasma genitalium is an emerging sexually transmitted pathogen associated with increasing antibiotic resistance. The current treatment guidelines recommend moxifloxacin-sequential therapy for macrolide-resistant Mgenitalium or strains with unknown resistance profiles. However, it is unclear whether sitafloxacin, a 4th-generation fluoroquinolone antibiotic, is effective against resistant strains.

OBJECTIVE

This study aims to assess and compare the efficacy and safety of sitafloxacin- and moxifloxacin-based treatment regimens for managing Mgenitalium infections.

METHODS

We will conduct this randomized controlled trial at multiple centers in Japan. Eligible participants include adults aged 18 years or older with a confirmed Mgenitalium infection, as determined through the nucleic acid amplification test. Patients will be randomly assigned using a stratified approach based on the treatment facility and infection site. The interventions comprise oral sitafloxacin (200 mg) daily for 7 days (with optional pretreatment of oral doxycycline, 200 mg, daily for up to 7 days), with a control group receiving oral doxycycline (200 mg) daily for 7 days followed by moxifloxacin (400 mg) daily for another 7 days. The primary outcome is the treatment success rate with a superiority margin of 10%, as confirmed through the nucleic acid amplification test. Secondary outcomes encompass changes in the bacterial load at the urogenital or rectal sites and the emergence of posttreatment-resistant mutant strains.

RESULTS

Enrollment commenced in June 2023 and will conclude in December 2024, with findings anticipated by 2025. The expected success rates fall within the range of 80% for sitafloxacin and 42% for moxifloxacin against Mgenitalium carrying the G248T (S83I) mutation, based on previous studies. Accordingly, with a 5% significance level (2-sided) and 80% statistical power, we aim to recruit 50 participants per group, factoring in a 10% expected dropout rate.

CONCLUSIONS

This study will provide valuable insights into the efficacy and safety of sitafloxacin- versus moxifloxacin-based sequential therapy in treating Mgenitalium infections. These findings have the potential to influence clinical guidelines, favoring more effective therapeutic choices. The multicenter approach enhances the robustness of this study. However, a limitation is the potential insufficiency of statistical power to detect posttreatment-resistant mutant strains in each group, rendering posttreatment-resistance mutations a notable concern. In the future, we may need to increase the sample size to enhance power.

TRIAL REGISTRATION

Japan Registry of Clinical Trials (jRCTs031230111); https://jrct.niph.go.jp/en-latest-detail/jRCTs031230111.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/52565.

Nausea, Vomiting, and Nonbloody Diarrhea in the Emergency Department

Nausea, vomiting and diarrhea are frequent co-occurring symptoms that can mask or mimic commonly occurring conditions, or rarely, more serious concerns. The Ending the HIV Epidemic's focus on increased widespread use of PrEP, a biomedical HIV prevention strategy, highlights the importance of discussing common clinical management scenarios. The use of oral PrEP formulations has demonstrated a "startup syndrome" which involves GI upset. This case challenge of a 32year old client admitted to the ED with GI symptoms highlights key PrEP considerations including a sexual health history. Clinicians should understand common complaints associated with oral PrEP start to improve differential diagnosis and appropriate intervention.

Human Papillomavirus (HPV) Infections Among Participants Undergoing Chlamydia trachomatis Testing in Reunion Island (RUN-SurV-HPV Study): Protocol for a Prevalence Study

BACKGROUND

Infection by human papillomavirus (HPV) induces various cancers, mainly cervical cancer but also anal and pharyngeal cancers. Reunion Island is a French department in the Indian Ocean. Due to the history of its settlement, the island's population has a wide variety of origins, and the population's sociodemographic characteristics differ from those of the French mainland. These characteristics make the island's population an original French population in its own right, particularly in terms of health. Cervical cancer incidence and mortality in Reunion Island are 10.4 per 100,000 and 4.4 per 100,000, respectively, both of which are much higher than those in mainland France. There is also a disparity in the prevalence of different HPV types, with types 33 and 52 being overrepresented and type 18 being underrepresented. However, vaccination and screening coverage in Reunion Island is low. It is important to understand the burden of infection and its risk factors in members of the young Reunionese population at risk of HPV infection to promote and evaluate the implementation of future vaccination and screening programs on a larger scale.

OBJECTIVE

The RUN-SurV-HPV study will have the following four objectives: (1) to describe the prevalence of HPV genotypes in a population at risk of sexually transmitted infections in Reunion Island; (2) to describe the prevalence of HPV genotypes by anatomical site, gender, and sexuality; (3) to describe the correlates and risk factors for HPV detection; and (4) to examine HPV genotypes between different anatomical sites.

METHODS

Cross-sectional analyses of 1200 routine vaginal, anal, pharyngeal, and urinary samples collected between October 2020 to December 2022 from female and male patients aged 16 to 30 years undergoing Chlamydia trachomatis testing at a sexually transmitted infection (STI) testing center at Reunion Island will be performed. The population included 333 women who all had vaginal and pharyngeal swabs, with 80 of them also having had an anal swab. There are 167 men who have sex with men who have had anal and pharyngeal swabs, and 120 men who have sex with women who have had a urine swab only. Results will be correlated with sociodemographic and clinical data collected routinely during the consultations. HPV detection and genotyping will be performed using the Anyplex II HPV28 detection assay (Seegene).

RESULTS

The first polymerase chain reactions should begin in November 2023. The first results should be submitted for publication in 2024.

CONCLUSIONS

The study will determine HPV prevalence by age, sex, male sexual preference, human immunodeficiency virus status, and STI co-infection. Collecting data from young patients not usually routinely screened for HPV infection will be a simple and reproducible way of better understanding local specificities, encouraging vaccination campaigns in the short-term, and evaluating their effectiveness in the future.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/47379.

Relationship between Bacterial Vaginosis and Sexually Transmitted Infections: Coincidence, Consequence or Co-Transmission?

Sexually transmitted infections (STIs) are a serious global problem, causing disease, suffering, and death. Although bacterial vaginosis (BV) is not considered to be an STI, it may be associated with an increased risk of contracting a wide range of STIs. We sought to assess the link between the different microorganisms involved in STIs and BV. A total of 290 vaginal swabs from 290 women sent for diagnostic purposes to the clinical microbiology laboratory of the Marseille University Public Hospitals were tested by specific qPCR targeting STI-causing microorganisms and BV. Of these 290 swabs, 15.2% (44/290) were diagnosed with at least one STI-causing microorganism and 17.2% (50/290) with BV. The prevalence of STIs was significantly higher in women with BV (28%, 14/50) than in those without (20.4%, 51/240). The prevalence of co-infections involving two STI-causing microorganisms was significantly more frequent in women with BV than in those without (18% [8/50] vs. 2% [5/250]; p < 0.001). The prevalence of monoinfections and polyinfections with STI-causing microorganisms was lower in women without BV than in those with (8.8% [21/240] vs. 28% [14/50]), p < 0.001 and 2% (5/240) vs. 8% (4/50), p = 0.05, respectively). Our data suggest that a correlation between BV and STI may exist, with a higher prevalence of both monoinfections and polyinfections involving STI-causing microorganisms in women with BV. Further research is needed to better understand BV and its links to STIs.

Sexually Transmitted Infection Point-of-Care Testing in Resource-Limited Settings: A Narrative Review Guided by an Implementation Framework

ABSTRACT

Most sexually transmitted infections (STIs) are acquired in resource-limited settings (RLSs) where laboratory diagnostic access is limited. Advancements in point-of-care testing (POC) technology have the potential to bring STI testing to many RLSs. We define POC as performed near the patient and with results readily available to inform clinical practice. The World Health Organization Special Programme for Research and Training in Tropical Diseases further outlines desirable POC characteristics with the REASSURED criteria.Despite advantages related to immediate test-and-treat care, integrating POC into RLS health care systems can present challenges that preclude reliance on these tests. In 2018, we incorporated molecular near-POC for chlamydia, gonorrhea, and trichomoniasis and SDBioline treponemal immunochromatographic testing confirmed by rapid plasma reagin for syphilis diagnosis at the Mbarara University of Science and Technology Research Laboratory in rural southwestern Uganda. We describe our experiences with STI POC as a case example to guide a narrative review of the field using the Consolidated Framework for Implementation Research as a conceptual framework.Although POC and near-POC are described as easy to use, the challenges of limited person-power, health care processes, limited infrastructure/resources, high costs, and quality control obstacles can impede the impact of these tests. Increased investment in operators, training, and infrastructure, restructuring health care systems to accommodate increased POC access, and optimizing costs are all crucial to the successful implementation of STI POC in RLS. Expanded STI POC in RLS will increase access to accurate diagnoses, appropriate treatment, and engagement in partner notification, treatment, and prevention efforts.

Perplexing Tubo-Ovarian Abscess Presentation from an Inflammatory Process in a Patient with an Inconclusive Computed Tomography Scan

A tubo-ovarian abscess (TOA) is an infectious mass of the adnexa. This article presents a well-documented case of a 27-year-old female presenting to the emergency department with a TOA. Physical exam findings and an initial computed tomography scan (CT) with contrast revealed a right iliopsoas abscess, an inflammatory process in the right lower quadrant, later diagnosed as a TOA with the use of ultrasound (US) without a history of sexually transmitted infection (STI). The clinical decision tree utilized in this patient's case highlights the importance of keeping a TOA high on the list of differential diagnoses while investigating appendicitis and other inflammatory pathologies in the lower abdomen.

Antibacterial Activity of Selected Fruit Juices against Multidrug-Resistant Bacterial Pathogens Involved in Urinary Tract and Sexually Transmitted Infections among Tribal Women in Madhya Pradesh, India

Objectives

The aim of this study was to evaluate the effect of fruit juices on Multi-Drug Resistant (MDR) bacterial pathogens involved in Urinary Tract Infections (UTIs) and Sexually Transmitted Infections (STIs) among tribal women in the district Anuppur, Madhya Pradesh, India.

Methods

Fresh juices of lemon (Citrus limon), amla/Indian gooseberry (Phyllanthus emblica), pineapple (Ananas comosus), mosambi/sweet lime (Citrus limetta), orange (Citrus sinensis), kiwi (Actinidia deliciosa), and pomegranate (Punica granatum) fruits were evaluated for in vitro antibacterial activity against bacterial pathogens involved in UITs and STIs among tribal women. Physico-chemical analysis of fresh fruits was also carried out by measuring the pH, moisture, protein, fat, crude fibre, carbohydrate, and ascorbic acid content.

Results

Lemon and amla juice showed better antibacterial activity against the pathogens as compared to other juices. MIC results fruit juices against UTIs and STIs pathogens vary depending on the specific pathogen and juice chemical constituents. The physico-chemical analysis showed that the moisture content was highest in mosambi (90%), followed by orange (87%). Ascorbic acid content was found highest in amla (540 mg/100 g), followed by kiwi (90.3 mg/100 g). Pomegranate showed highest concentration of carbohydrate (15.28 g/100 g), fat (1.28 g/100 g), and protein (1.65 g/100 g). Lemon juice had lowest pH of 2.20, followed by amla 2.67.

Conclusion

The lemon juice showed highest antibacterial activity against MDR bacterial pathogens involved in UTIs and STIs among tribal women in district Anuppur, Madhya Pradesh, India. The low pH of lemon may be responsible for its high antibacterial activity as compared to other juices.

Understanding Women's Knowledge, Awareness, and Perceptions of STIs/STDs in Asia: A Scoping Review

OBJECTIVE

This study aimed to conduct a scoping review to collect current literature on the knowledge, awareness, and perception (KAP) of sexually transmitted infections/diseases (STIs/STDs) among women in Asia.

METHODOLOGY

The PRISMA-Scoping methodology was used in this study to extract papers from four databases published between 2018 and 2022. Sixty-eight articles were included after screening and elimination.

RESULTS

The studies on KAP of STIs/STDs among women were largely undertaken in Southeast Asia (Indonesia, Malaysia, and Vietnam) and South Asia (India, Pakistan, and Bangladesh). Regardless of the specific cohort of women studied, research indicates consistently low levels of knowledge and awareness across Asia. This trend seems to be more prevalent among female commercial sex workers, women with lower educational levels, and those in poorer socioeconomic positions. In South Asia, cultural, sociological, economic, and gender inequalities, particularly male domination, all have a significant impact on KAP levels.

CONCLUSION

As education is a major factor that influences health behaviour, this review underscores the need to allocate more resources to educational initiatives, particularly targeting vulnerable groups such as sex workers, transgender women, pregnant women, and rural housewives. This strategic focus may contribute significantly to preventing STIs/STDs, particularly in less developed regions/countries.

Prevalence and distribution of high-risk Human Papillomavirus in Western Türkiye between 2019 and 2022

Human Papillomavirus (HPV) is a primarily sexually transmitted human pathogen linked with the formation of anogenital warts and several types of cancer including cervical cancer, oropharyngeal cancer, penile cancer, and anal cancer. HPV genotypes are divided into high-risk and low-risk in accordance with their potential for carcinogenesis. The most notable high-risk genotypes are HPV-16 and HPV-18. In this study we report on the PCR analysis results of the cervical smear results of 328 females, and 50 males who have presented to a tertiary care university hospital in the port city of İzmir, Türkiye between August 2019 and August 2022. HPV-DNA positivity percentage was determined as 25.3% (96/378). 5 of 378 patients were HPV-18 positive (age range 31-80) whereas 27 patients were HPV-16 positive (age range 29-66). 64 patients were positive for other high-risk HPV types (age range 27-56). The positivity for HPV-16, HPV-18 and other high-risk HPV types were determined as 7.14%, 1.3% and 16.9% respectively. Our results demonstrate a 25.3% (96/378) positivity among tested patients moreover, out of 96 positive cases at least 32 are vaccine preventable. This study indicates the need for higher coverage of HPV vaccination in Western Türkiye.

When Bacteria and Viruses Collide: A Tale of Chlamydia trachomatis and Sexually Transmitted Viruses

The global incidence of sexually transmitted infections (STIs) remains high, with the World Health Organization (WHO) estimating that over 1 million people acquire STIs daily. STIs can lead to infertility, pregnancy complications, and cancers. Co-infections with multiple pathogens are prevalent among individuals with an STI and can lead to heightened infectivity and more severe clinical manifestations. Chlamydia trachomatis (CT) is the most reported bacterial STI worldwide in both men and women, and several studies have demonstrated co-infection of CT with viral and other bacterial STIs. CT is a gram-negative bacterium with a unique biphasic developmental cycle including infectious extracellular elementary bodies (EBs) and metabolically active intracellular reticulate bodies (RBs). The intracellular form of this organism, RBs, has evolved mechanisms to persist for long periods within host epithelial cells in a viable but non-cultivable state. The co-infections of CT with the most frequently reported sexually transmitted viruses: human immunodeficiency virus (HIV), human papillomavirus (HPV), and herpes simplex virus (HSV) have been investigated through in vitro and in vivo studies. These research studies have made significant strides in unraveling the intricate interactions between CT, these viral STIs, and their eukaryotic host. In this review, we present an overview of the epidemiology of these co-infections, while specifically delineating the underlying mechanisms by which CT influences the transmission and infection dynamics of HIV and HSV. Furthermore, we explore the intricate relationship between CT and HPV infection, with a particular emphasis on the heightened risk of cervical cancer. By consolidating the current body of knowledge, we provide valuable insights into the complex dynamics and implications of co-infection involving CT and sexually transmitted viruses.

Prevalence of trichomoniasis infection among adults in Nigerian community settings

BACKGROUND

Trichomonas vaginalis (TV) is a sexually transmitted pathogen. The study was conducted to determine its prevalence among 300 adult patients in 4 public health facilities in the Nsukka District of Enugu State, Nigeria.

METHOD

The researchers collected high vagina swabs and urine samples were collected from 150 men and 150 women, respectively. The specimens were scrutinized for color, odor of discharge and urine, and motile trichomoniasis.

RESULTS

The prevalence of the TV was 45.0% (135/300) with women showing the highest prevalence (63.7%). Among the patients attending the University of Nigeria, Nsukka Medical Center, the prevalence was the highest at 31.9%. TV infection was more common among older adults aged 38 to 47 years (39.3%), married adults (76.3%), and those with secondary education (68.9%). Urogenital analysis reported that males with pains during urination were 51.0% and males with penile tingling were 12.2%. The highest vaginal Hydrogen ion concentration level of 6.8 was observed in women aged 38 to 47 years. Additionally, the results reported that Vaginal candidiasis, Bacterial vaginosis, and Herpes simplex virus type 2 antibodies were not independently associated with TV infection. In the unadjusted analysis, the odds of TV infection were higher in men (8.1), while Chlamydia trachomatis infection was higher in women (8.8). Among the adults diagnosed with herpes simplex virus type 2 antibodies, the odds of TV infection were 3.9 for both men and women. Men with penile human papillomavirus infection had lower odds of TV infection (1.9), while women with vaginal human papillomavirus infection had higher odds of TV infection (2.2).

CONCLUSION

The prevalence of TV infection is high among sexually active adults in the Nigerian community. It is therefore crucial to implement the increased public health actions such as regular and early diagnosis to reduce its prevalence.

A Web-Based, Mail-Order Sexually Transmitted Infection Testing Program: Qualitative Analysis of User Feedback

BACKGROUND

The incidence of sexually transmitted infections (STIs) is increasing in the United States. The COVID-19 pandemic resulted in significant reductions in access to health care services, including STI testing and treatment, leading to underreporting of STI cases and a need for alternatives to clinic-based testing. Moreover, concerns around confidentiality, accessibility, and stigma continue to limit access to clinic-based STI testing, particularly for high-priority populations. IWantTheKit (IWTK) is a web-based platform that mails free, confidential, self-administered sample collection kits for testing for gonorrhea, chlamydia (both genital and extragenital sites), and vaginal trichomonas. Individuals visiting the IWTK website may select genital, pharyngeal, and rectal samples for chlamydia and gonorrhea testing. Vaginal samples are tested for trichomoniasis. Self-collected samples are processed in a College of American Pathologists-accredited laboratory, and results are posted to an individual's secure digital account.

OBJECTIVE

This study aimed to (1) describe users' experience with the IWTK service through analysis of routine data and (2) optimize retention among current users and expand reach among high-priority populations by responding to user needs through programmatic and functional changes to the IWTK service.

METHODS

Free-text entries were submitted by IWTK users via a confidential "Contact Us" page on the IWTK website from May 17, 2021, to January 31, 2022. All entries were deidentified prior to analysis. Two independent analysts coded these entries using a predefined codebook developed inductively for thematic analysis.

RESULTS

A total of 254 free-text entries were analyzed after removing duplicates and nonsensical entries. Themes emerged regarding the functionality of the website and personal experiences using IWTK's services. Users' submissions included requests related to order status, address changes, replacement of old kits, clinical information (eg, treatment options and symptom reports), and reported risk behaviors.

CONCLUSIONS

This analysis demonstrates how routine data can be used to propose potential programmatic improvements. IWTK implemented innovations on the website based on the study results to improve users' experience, including a tracking system for orders, address verification for each order, a physical drop box, additional textual information, direct linkage to care navigation, and printable results. Web-based, mail-order STI testing programs can leverage user feedback to optimize implementation and retention among current users and potentially expand reach among high-priority populations. This analysis is supported by other data that demonstrate how comprehensive support and follow-up care for individuals testing positive are critical components of any self-testing service. Additional formal assessments of the IWTK user experience and efforts to optimize posttesting linkage to care may be needed.

Assessing Public Interest in Mpox via Google Trends, YouTube, and TikTok

Public response to the recent Mpox outbreak was analyzed using internet search trends and social media posts.

Human Papillomavirus Vaccinations: Provider Education to Enhance Vaccine Uptake

Human papillomavirus (HPV) is the number one sexually transmitted infection (STI) worldwide. The Centers for Disease Control and Prevention (CDC) approximated that 92% of HPV-related cancers might be prevented by receiving the HPV 9-valent vaccine (Gardasil 9). The 2-dose HPV vaccine for children ages 11 to 12 years provides almost 100% protection against strains affiliated with cervical, vaginal, and vulvar cancers. Provider education is essential to decrease clinical knowledge deficits and increase vaccination uptake. Evidence-based provider recommendations expressed to eligible individuals improves vaccination rates. Evidence-based approaches for vaccine-hesitant parents involve using the presumptive announcement approach, asking for and addressing main concerns, and trying again if the parent initially declines. Seventy percent of parents who initially decide not to get their child vaccinated later agree to the vaccine or schedule a follow-up appointment. The CDC guidelines for HPV vaccinations, including the catch-up and adult guidelines, are reviewed. A clinical vignette with case scenarios and a Q&A quiz are included.

Disseminated Gonococcal Infection With Dermatitis-Arthritis Syndrome

Gonorrhea is a sexually transmitted infection caused by gram-negative diplococci, Neisseria gonorrhoeae. Disseminated gonorrhea is diagnosed infrequently, partly due to low suspicion at the time of presentation, and at times, due to overlapping symptoms associated with non-infectious conditions like systemic lupus erythematosus (SLE). In this article, we present a 42-year-old sexually active female with knee pain and swelling, fever, and rash. Knee aspirate showed the presence of monosodium urate crystals, and the synovial culture grew gram-negative diplococci, requiring multiple joint washouts. The urine nucleic acid amplification test (NAAT) was indeterminate. She was treated with high-dose intravenous ceftriaxone for one week post-joint washout with rapid improvement in her condition and resolution of the rash.

Update on Mpox: a brief narrative review

Mpox (formerly Monkeypox), a neglected tropical disease once confined to Central and West Africa, emerged as a global epidemic outbreak in May, 2022 with 87,529 cases reported as of May, 23, 2023. It predominantly affected men (96.2%) who have sex with men (84-100%), although other transmission routes have been reported, including occupational exposure and vertical transmission. Concomitant HIV infection has been recorded in 21-46.9% and pre-exposure prophylaxis against HIV infection has been reported in 11-57% of published cases. The current outbreak clinical presentation differs from endemic cases with prodromal symptoms that could be absent: the number of lesions is generally low, with skin lesions predominantly localised in the ano-genital areas and frequent lesions present in different stages of progression (i.e., asynchronous). Asymptomatic Mpox infection can occur in 1.8-6.5% of at-risk subjects. People living with HIV with severe immunodeficiency (less than 100 CD4+ lymphocytes per microliter) are at risk of more severe clinical manifestations and death. According to a systematic review and meta-analysis, the hospitalisation rate is around 6% and the observed case-fatality rate is less than 0.1%. Tecovirimat is the drug of choice for treating severe cases although there is no evidence of efficacy from randomised controlled trials. Immunization with a live non-replicating vaccine (JYNNEOS) effectively reduces the disease's incidence.

Diagnosed Gonorrhea Among Privately Insured Women: Analysis of United States Claims Data

Background: Gonorrhea incidence in the United States has risen by nearly 50% in the last decade, while screening rates have increased. Gonorrhea sequelae rates could indicate whether increased gonorrhea incidence is due to better screening. We estimated the association of gonorrhea diagnosis with pelvic inflammatory disease (PID), ectopic pregnancy (EP), and tubal factor infertility (TFI) in women and detected changes in associations over time. Materials and Methods: This retrospective cohort study included 5,553,506 women aged 18-49 tested for gonorrhea in the IBM MarketScan claims administrative database from 2013-2018 in the United States. We estimated incidence rates and hazard ratios (HRs) of gonorrhea diagnosis for each outcome, adjusting for potential confounders using Cox proportional hazards models. We tested the interaction between gonorrhea diagnosis and the initial gonorrhea test year to identify changes in associations over time. Results: We identified 32,729 women with a gonorrhea diagnosis (mean follow-up time in years: PID = 1.73, EP = 1.75, TFI = 1.76). A total of 131,500 women were diagnosed with PID, 64,225 had EP, and 41,507 had TFI. Women with gonorrhea diagnoses had greater incidence per 1000 person-years for all outcomes (PID = 33.5, EP = 9.4, TFI = 5.3) compared to women without gonorrhea diagnoses (PID = 13.9, EP = 6.7, TFI = 4.3). After adjustment, HRs were higher in women with a gonorrhea diagnosis vs. those without [PID = 2.29 (95% confidence interval, CI: 2.15-2.44), EP = 1.57, (95% CI: 1.41-1.76), TFI = 1.70 (95% CI: 1.47-1.97)]. The interaction of gonorrhea diagnosis and test year was not significant, indicating no change in relationship by initial test year. Conclusion: The relationship between gonorrhea and reproductive outcomes has persisted, suggesting a higher disease burden.

Higher serologic responses of early syphilis to single-dose benzathine penicillin G plus doxycycline versus single-dose benzathine penicillin G alone among people with HIV

BACKGROUND

Single-dose benzathine penicillin G (BPG) is the preferred therapy for early syphilis, but poorer serologic responses have been observed among people with HIV (PWH). No enhanced regimen has previously been shown to improve serologic outcomes of early syphilis.

METHODS

We conducted a retrospective study to compare the treatment responses to single-dose BPG combined with 7-day doxycycline versus BPG alone in PWH who presented with early syphilis. Rapid plasma reagin (RPR) titers were determined every 3-6 months for all included PWH. Serologic response was defined as at least a fourfold decline in RPR titers at month 12.

RESULTS

During January 2018 to March 2022, 223 PWH with 307 episodes of early syphilis received single-dose BPG plus doxycycline and 347 PWH with 391 episodes received BPG alone. The median age was 36 years and baseline CD4 count was 600 cells/mm3. In the intention-to-treat with last-observation-carried-forward analysis, PWH receiving BPG plus doxycycline had a significantly higher serologic response rate at 12 months of treatment than those receiving BPG alone (79.5% vs 70.3%, respectively; P= .006). The factors associated with 12-month serologic response were RPR titer (per 1-log2 increase, adjusted odds ratio [AOR], 1.25; 95% CI, 1.15-1.35) and receipt of BPG plus doxycycline (AOR, 1.71; 95% CI, 1.20-2.46). In the subgroup analyses, BPG plus doxycycline was consistently associated with a better serologic response than BPG alone at month 12.

CONCLUSIONS

Among PWH with early syphilis, single-dose BPG plus doxycycline achieved higher serologic responses than BPG alone during a 12-month follow-up period.

A Web-Based Sexual Health Intervention to Prevent Sexually Transmitted Infections in Hong Kong: Model-Based Cost-Effectiveness Analysis

BACKGROUND

Sexually transmitted infections (STIs) remain a significant public health concern, particularly among young adults, and Chlamydia trachomatis (CT) infections are the most common STIs in young women. One of the most effective ways to prevent STIs is the consistent use of condoms during sexual intercourse. There has been no economic evaluation of the interactive web-based sexual health program, Smart Girlfriend, within the Chinese population.

OBJECTIVE

This study aimed to evaluate the long-term cost-effectiveness of Smart Girlfriend in preventing STIs in the Chinese population. The evaluation compared the program with a control intervention that used a 1-page information sheet on condom use.

METHODS

A decision-analytic model that included a decision tree followed by a Markov structure of CT infections was developed since CT is the most prevalent STI among young women. The model represents the long-term experience of individuals who received either the intervention or the control. One-way and probabilistic sensitivity analyses were conducted. The main outcomes were the number of CT infections and the incremental cost as per quality-adjusted life year (QALY).

RESULTS

A cohort of 10,000 sexually active nonpregnant young women initially entered the model in a noninfectious state (ie, "well"). In the base-case analysis, the implementation of the Smart Girlfriend program resulted in the prevention of 0.45% of CT infections, 0.3% of pelvic inflammatory disease, and 0.04% of chronic pelvic pain, leading to a gain of 70 discounted QALYs and cost savings over a 4-year time horizon, compared to the control group. With more than 4548 users, the intervention would be cost-effective, and with more than 8315 users, the intervention would be cost saving. A 99% probability of being cost-effective was detected with a willingness to pay US $17,409 per QALY.

CONCLUSIONS

Smart Girlfriend is a cost-effective and possibly cost-saving program over a 4-year time horizon. This result was particularly sensitive to the number of website users; launching the website would be cost-effective if more than 4548 people used it. Further work is warranted to explore if the findings could be expanded to apply to women who have sex with women and in the context of other STIs.

TRIAL REGISTRATION

ClinicalTrial.gov NCT03695679; https://clinicaltrials.gov/study/NCT03695679.

Sexual Health and Drug Use Prevention for Black Girls (The Dreamer Girls Project): Protocol for an Intervention Development

BACKGROUND

Substance use among adolescent girls is associated with numerous risk characteristics, including engaging in sexual risk behaviors, which can lead to HIV and sexually transmitted infection (STI) diagnoses. This is an important phenomenon to target as there is a significant race-gendered paradox that occurs when Black girls use and misuse drugs. When misuse occurs among this group, they are more likely to face harsher consequences and worse health outcomes than boys and other ethnic-minority girls. Therefore, there is a need to understand the risk and protective factors of drug use and sexual risk behaviors among Black girls and develop a robust intervention that can cater for this group.

OBJECTIVE

We propose the development of a strengths-based prevention education intervention for Black girls between the ages of 13 and 18 years to promote protective factors.

METHODS

A sequential, mixed methods study will be conducted, and we will use the first 3 steps of the ADAPT-ITT (assessment, decision, adaptation, production, topical experts, integration, training, testing) framework to begin the development of the intervention. Three aims will be described in this protocol. First, aim 1 is to explore sociocultural risk and protective factors among Black girls between the ages 13 and 18 years in drug use and HIV/STI prevention using focus group methodology and surveys. We will conduct at least 10 focus groups to include up to 75 Black girls or until we reach saturation. Our target sample size for the quantitative portion of the study will be 200 participants. Aim 2 will focus on deciding upon an intervention based on findings from aim 1 and forming a youth advisory board to guide intervention development. Aim 3 will be to conduct a pretest of the intervention with the youth advisory board to determine if the intervention is feasible and will be accepted by Black girls.

RESULTS

The study is part of a 2-year research pilot study award from the National Institutes of Mental Health. Data collection for this study began in October 2021. For aim 1, data collection is 95% complete. We expect to complete all data collection for aim 1 on or before May 30, 2023. Study activities for aim 2 are occurring simultaneously as data are being collected and analyzed and will be completed in the summer of 2023. Study activities for aim 3 will begin in the fall of 2023.

CONCLUSIONS

This study will be one of the few interventions that address both sexual health and drug use together and cater to Black girls. We anticipate that the intervention will be beneficial for Black girls across the nation to work on building culturally appropriate prevention education and building peer social supports, resulting in reduction or delayed substance use and improved sexual health.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05014074; https://clinicaltrials.gov/ct2/show/NCT05014074.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/45007.

Studies on HIV/AIDS Among Students: Bibliometric Analysis

BACKGROUND

In recent years, HIV infection in students has been an ongoing concern worldwide. A large number of articles have been published; however, statistical analysis of the data presented in these publications is lacking.

OBJECTIVE

This study aimed to detect and analyze emerging trends and collaborative networks in research on HIV/AIDS among students.

METHODS

Research publications on HIV/AIDS among students from 1985 to 2022 were collected from the Web of Science Core Collection. A topic search was used for this study, and articles in English were included. CiteSpace was used to generate visual networks of countries/regions, institutions, references, and keywords. Citation analysis was used to discover milestones in the field and trace the roots of the knowledge base. Keyword analysis was used to detect research hotspots and predict future trends.

RESULTS

A total of 2726 publications met the inclusion criteria. Over the past 38 years, the number of publications annually has been on the rise overall. The United States had the highest number of publications (n=1303) and the highest centrality (0.91). The University of California system was the core institution. The main target population of studies on HIV/AIDS among students were medical and university students. These studies focused on students' knowledge, attitudes, risk behaviors, and education about HIV/AIDS. The recent bursting keywords (gay, sexual health, adherence, barriers, mental health, HIV testing, stigma, and antiretroviral therapy) revealed research trends and public interest on this topic.

CONCLUSIONS

This study identified countries/regions and institutions contributing to the research area of HIV/AIDS among students and revealed research hotspots and emerging trends. The field of research on HIV/AIDS among students was growing rapidly. The United States was at the center, and the University of California system was the core institution. However, academic collaboration should be strengthened. Future research may focus on exploring gay students, sexual health, adherence, barriers, mental health, HIV testing, stigma, and antiretroviral therapy.

Use of viability PCR for detection of live Chlamydia trachomatis in clinical specimens

Background

The current testing approach to diagnose Chlamydia trachomatis (CT) infection relies on nucleic acid amplification tests (NAATs). These tests are highly sensitive, but do not distinguish between active infection and residual bacterial nucleic acid which may remain after resolution of infection, or via cross-contamination. Better methods to assess the viability of CT detected in clinical samples would be useful in determining the relevance of CT detection in a variety of clinical settings. The goal of this study was to test viability PCR (vPCR) as a method to distinguish viable bacteria from non-viable CT.

Methods

The vPCR relies on a propidium monoazide dye (PMAxx), which intercalates into accessible DNA from dead organisms and prevents their detection in a PCR assay for the CT ompA gene. We used digital PCR to quantify absolute genome copy numbers from samples. We validated the vPCR approach using laboratory stocks of CT with known viability. Then, we tested total DNA, viable CT DNA, and culture results from 18 clinical vaginal specimens and 25 rectal clinical specimens, all of which had tested positive by NAAT.

Results

In laboratory stocks of CT, vPCR using defined ratios of heat-killed to live bacteria tracked closely with expected results. In vaginal clinical specimens, vPCR and total DNA results were correlated, though total DNA genomes outnumbered viable genomes by 2.2-52.6-fold more copies. As expected, vPCR detected more total genomes than culture results. Both vPCR and total DNA correlated with culture results (Spearman correlation R = 0.8425 for total DNA and 0.8056 for vPCR). Ten rectal NAAT positive specimens were negative by total DNA PCR, vPCR, and were negative or inconclusive by culture. Of the 6 rectal specimens that were culture positive, all were total DNA and vPCR positive. vPCR additionally detected viable bacterial DNA in 8 specimens which were NAAT + and culture negative, though levels were very low (mean 1,357 copies/ml).

Conclusions

vPCR is a fast and easy method to assess viability in clinical specimens and is more correlated with culture results than total DNA PCR. Inconsistent ratios between total DNA and vPCR results suggest that the amount of dead bacteria varies considerably in clinical specimens. Results from rectal specimens suggest that many NAAT positive specimens do not in fact represent live replicating bacteria, and likely result in significant overuse of unnecessary antibiotics.

Heterogeneity in network structure switches the dominant transmission mode of infectious diseases

Several recent emerging diseases have exhibited both sexual and nonsexual transmission modes (Ebola, Zika, and mpox). In the recent mpox outbreaks, transmission through sexual contacts appears to be the dominant mode of transmission. Motivated by this, we use an SIR-like model to argue that an initially dominant sexual transmission mode can be overtaken by casual transmission at later stages, even if the basic casual reproduction number is less than one. Our results highlight the risk of intervention designs which are informed only by the early dynamics of the disease.

A Description of Telehealth Use Among Sexually Transmitted Infection Providers in the United States, 2021

BACKGROUND

Telehealth offers one approach to improving access to sexually transmitted infection (STI) prevention and care services. Therefore, we described recent telehealth use among those providing STI-related care and identified opportunities for improving STI service delivery.

MATERIALS AND METHODS

Using the DocStyles Web-based, panel survey conducted by Porter Novelli from September 14 to November 10, 2021, 1500 healthcare providers were asked about their current telehealth usage, demographics, and practice characteristics, and compared STI providers (≥10% of time spent on STI care and prevention) to non-STI providers.

RESULTS

Among those whose practice consisted of at least 10% STI visits (n = 597), 81.7% used telehealth compared with 75.7% for those whose practice consisted of less than 10% STI visits (n = 903). Among the providers with at least 10% STI visits in their practice, telehealth use was highest among obstetrics and gynecology specialists, those practicing in suburban areas, and those practicing in the South. Among providers whose practice consisted of at least 10% STI visits and who used telehealth (n = 488), the majority were female and obstetrics and gynecology specialists practicing in suburban areas of the South. After controlling for age, gender, provider specialty, and geographic location of their practice, providers whose practice consisted of at least 10% STI visits had increased odds (odds ratio, 1.51; 95% confidence interval, 1.16-1.97) of using telehealth compared with providers whose visits consisted of less than 10% STI visits.

CONCLUSIONS

Given the widespread use of telehealth, efforts to optimize delivery of STI care and prevention via telehealth are important to improve access to services and address STIs in the United States.

Sexual behavioral factors of the subjects visiting the clinic of sexually transmitted infections in Northern Finland: A cross-sectional study among 775 subjects

Background and Aims

Sexually transmitted infections (STI) are among the most common infections globally. However, the sexual behavioral factors and sexual history of people visiting STI clinics have only been surveyed in a few studies. We aimed to evaluate the characteristics of the patients visiting the open STI clinic.

Methods

This is a prospective observational study performed in the STI clinic in the premises of Department of Dermatology, Oulu University Hospital. All individuals (n = 775) attending the STI clinic between February and August 2022 were included to the study and the profile of the patients was evaluated.

Results

We found that the majority of the STI clinic attendees (58.5%) were female. Mean age of the study population was 28.9 years, with females being significantly younger than males (p < 0.001). Only one-third (30.6%) of the patients reported having symptoms at the time of attending. Most commonly, patients had had one sex partner in the last 6 months. However, one-fifth (21.7%) reported several sex partners (over four). Almost half of the patients (47.6%) reported using a condom only randomly. Those with heterosexual orientation had fewer multiple-sex partners (p < 0.001) than those with homo- or bisexual orientation (p < 0.05).

Conclusion

It is important to increase knowledge about the profile of STI clinic visitors to effectively target STI prevention on the groups at the highest risk of STIs.

Evaluation of Monkeypox as an Unrecognized Sexually Transmitted Disease: A Rare Case of Monkeypox Infection with HIV and Syphilis Coinfection

Monkeypox (MPX) virus is endemic in Africa. However, since May 2022, many cases have been reported worldwide in many non-endemic regions as well. The virus usually spreads from animals to humans or from humans to humans through respiratory droplets or after contact with infected lesions. In the recent outbreak of MPX, many cases did not have any travel history to endemic areas and were reported in men who have sex with men (MSM) along with the diagnosis of other sexually transmitted diseases (STDs). However, MPX is not yet considered a sexually transmitted infection (STI), even though a relationship between MPX and other STIs may exist with a possible facilitating action on their spreading. We present a similar case of MPX infection in an MSM patient with concomitant HIV and syphilis infections and no travel history to an endemic area.

The profile of sexually transmitted infections of men who have sex with men: A tertiary care center-based comparative cross-sectional study

Context

Very few studies have compared the prevalence of sexually transmitted infections (STIs) and risk factors particularly among men who have sex with men (MSM) with the non-MSM group.

Aims

(1) To compare the profile of STIs among MSM and non-MSM attending our STI clinic, (2) To identify the risk factors for STIs among MSM.

Subjects and Methods

In this comparative cross-sectional study, we analyzed the records of all male attendees of our STI clinic from March 2015 to March 2020 for demographic details, sexual history, clinical examination and laboratory findings.

Statistical Analysis Used

Chi-square test and logistic regression were utilized in analysis.

Results

The number of both MSM and non-MSM attending the clinic increased over 5 years with a more sharp increase in the number of MSM, after 2017. 68.9% of MSM had their first sexual contact before attaining 20 years of age. The most common STIs were syphilis (53.75%), genital warts (30%) and herpes genitalis (20.62%). Syphilis was the most frequent STI among MSM (48/74, 64.90%) as well as non-MSM (38/86, 44.20%); though its frequency was significantly more among MSM (P < 0.01). Being unmarried (odds ratio [OR] = 3.58, 95% confidence interval [CI] = 1.85-6.93, P < 0.01), having more than two sexual partners (OR = 4.49, 95% CI = 2.12-9.50, P < 0.01), practising peno-oral sex (OR = 4.74, 95% CI = 2.33-9.62, P < 0.01) and peno-anal sex (OR = 19, CI = 8.55-42.38, P < 0.01) were significantly associated with MSM behavior.

Conclusions

There was an increasing trend of MSM attending the STI clinic from the year 2017. MSM persons are likely to be younger, unmarried, and have more than two sex partners. The commonest STI among MSM was syphilis.