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We examined changes in sexual behavior and sexually transmitted infection (STI) prevalence among 183 men who have sex with men (MSM) initiating pre-exposure prophylaxis (PrEP) at an STD Clinic in Seattle, WA. We used generalized estimating equations to measure changes in sexual behavior during PrEP use, and linked PrEP patient data with STI surveillance data to compare the prevalence of chlamydia, gonorrhea, and early syphilis in the periods prior to and during PrEP use. Reporting never using condoms in the prior 30 days increased (adjusted relative risk = 1.46; 95% confidence interval 1.13, 1.88) at 12 months after PrEP initiation compared to the initial PrEP visit. Reporting unknown status partners in the prior 30 days decreased at 12 months compared to the initial PrEP visit, but there was no change in number of sexual partners or reporting HIV-positive or HIV-negative partners. The percentage of patients diagnosed with any STI while using PrEP (49.2%) was higher than the percentage diagnosed in the 12 months prior to PrEP use (35.0%), likely driven in part by increased STI screening during PrEP use. Among MSM on PrEP, we observed decreases in condom use, and a higher prevalence of STIs during PrEP use compared to prior to PrEP initiation.

When paired with CHWs, who are of Haitian descent and well respected in Little Haiti, self-sampling is a highly acceptable method of cervical screening for Haitian women in this ethnic enclave. This approach addresses critical access barriers, including poverty, language difficulties, and sociocultural concerns about modesty, that may similarly affect Pap smear utilization among other immigrant or medically underserved population sub-groups. Coupled with generally positive reviews of the device, the low rate of insufficient specimens for testing suggests that this device is promising for use in non-clinical settings.

Background Approximately 15% of HIV-infected MSM engaged in HIV primary care have been diagnosed with an STI in the past year, yet STI testing frequency remains low. Methods We sought to quantify STI testing frequencies at a large, urban HIV care clinic, and to identify patient- and provider-related barriers to increased STI testing. We extracted laboratory data in aggregate from the electronic medical record to calculate STI testing frequencies (defined as the number of HIV-infected MSM engaged in care who were tested at least once over an 18-month period divided by the number of MSM engaged in care). We created anonymous surveys of patients and providers to elicit barriers. Results Extra-genital gonorrhea and chlamydia testing were low (29%–32%), but the frequency of syphilis testing was higher (72%). Patients frequently reported high-risk behaviors, including drug use (16.4%) and recent bacterial STI (25.5%), as well as substantial rates of recent testing (>60% in prior 6 months). Most (72%) reported testing for STI in HIV primary care, but one-third went elsewhere for “easier” (42%), anonymous (21%) or more frequent (16%) testing. HIV primary care providers lacked testing and treatment knowledge (25–32%), and cited lack of time (68%), discomfort with sexual history taking and genital exam (21%), and patient reluctance (39%) as barriers to increased STI testing. Conclusion STI testing in HIV care remains unacceptably low. Enhanced education of providers, along with strategies to decrease provider time and increase patient ease and frequency of STI testing, are needed.

Background: Antimicrobial-resistant Neisseria gonorrhoeae is a major public health threat. Current CDC treatment guidelines for uncomplicated gonorrhoea recommend only ceftriaxone plus either azithromycin or doxycycline. Additional treatment options are needed.Methods: We used antibiotic gradient synergy testing (the Etest) to evaluate antimicrobial combinations that included a third-generation cephalosporin (cefixime or ceftriaxone) plus azithromycin, doxycycline, gentamicin, rifampicin or fosfomycin. We tested each combination against 28 clinical N. gonorrhoeae isolates and four control strains of varying susceptibility profiles, and compared the results with those obtained using combination antimicrobial testing using agar dilution. We calculated the fractional inhibitory concentration index (FICI) for each combination to determine synergy, the results being interpreted as follows: FICI ≤ 0.5 ¼ synergy; FICI .4.0¼ antagonism; and FICI .0.5 -4¼ indifference.Results: The combinations of a third-generation cephalosporin plus azithromycin, doxycycline, rifampicin, gentamicin or fosfomycin produced FICIs of indifference. The Etest and agar dilution methods produced comparable results.Conclusions: Combinations of ceftriaxone plus rifampicin, gentamicin or fosfomycin may warrant further clinical investigation as treatments for gonorrhoea. Using the Etest for synergy testing is a viable method that has practical advantages over agar dilution.

During the COVID-19 pandemic in King County, WA, declines were observed in both county sexually transmitted infection cases and sexual health clinic visits following stay-at-home orders in Washington.

Summary Rectal gonorrhea and chlamydia increase the risk of a new diagnosis of HIV independent of rectal sexual behavior among men who have sex with men. Background Rectal sexually transmitted infections (STI) have been associated with HIV diagnosis, but inferring a causal association requires disentangling them from receptive anal intercourse (RAI). Methods We conducted a stratified case-control study by frequency matching 4 controls to each case within year using clinical data from men who have sex with men (MSM) attending the Seattle STD Clinic 2001–2014. Cases were MSM with a new HIV diagnosis and negative HIV test ≤12 months. Controls were HIV-negative MSM. All included men had rectal STI testing, tested negative for syphilis, and had complete sexual behavior data. We categorized men by RAI: (1) none; (2) condoms for all RAI; (3) condomless RAI (CRAI) only with HIV-negative partners; and (4) CRAI with HIV-positive or unknown-status partners. We created three logistic regression models: (1) three univariate models of concurrent rectal gonorrhea, rectal chlamydia, and rectal STI in ≤12 months with new HIV diagnosis; (2) those three infections, plus age, race, year, number of sexual partners ≤2 months, and methamphetamine use; and (3) model 2 with RAI categories. We calculated the population attributable risk of rectal STI on HIV diagnoses. Results Among 176 cases and 704 controls, rectal gonorrhea, chlamydia and rectal STI ≤12 months were associated with HIV diagnosis. The magnitude of these associations attenuated in the second model, but persisted in model 3 (gonorrhea aOR 2.3 95%CI 1.3 – 3.8; chlamydia aOR 2.5 95%CI 1.5 – 4.3; prior STI aOR 3.0 95%CI 1.5 – 6.2). One in 7 HIV diagnoses can be attributed to rectal STI. Conclusion Rectal STI are independently associated with HIV acquisition. These findings support the hypothesis that rectal STI play a biologically-mediated causal role in HIV acquisition and support screening/treatment of STI for HIV prevention.

Extragenital testing with NAAT substantially increases the number of infected MSM identified with GC or CT infection and should continue to be promoted.