Sexually Transmitted Infections

Houlihan, C F; Sanjosé, S de; Baisley, K; Changalucha, J; Ross, D; Kapiga, S; Godinez, J M; Bozicevic, I; Hayes, R; Watson-Jones, D

doi: 10.1136/sextrans-2013-051184.0516pmid: N/A

Objectives The HPV vaccine is recommended for girls prior to sexual debut since it is most effective if administered prior to HPV acquisition. Little research has been conducted in high HPV-prevalence countries regarding HPV infection in girls who report not having passed sexual debut. We present the HPV prevalence in girls enrolled in a cohort study in Mwanza, Tanzania, who report not having passed sexual debut. Methods Girls aged 15–16 years who had previously attended 82 randomly selected primary schools were enrolled and underwent a face-to-face interview on socio-demographic variables, sexual behaviour and intra-vaginal practises. A nurse-assisted self-administered vaginal swab was collected. Swabs were tested for 13 high-risk (HR) and 24 low-risk (LR) HPV genotypes using the Roche LINEAR ARRAY® HPV genotype test. Results Of 1555 female primary school attenders, 1177 (76%) were located, of whom 801 were aged 15 or 16 years. Of these, 628 (78%) consented to eligibility screening and 480 girls who reported not having passed sexual debut were enrolled. B-globin negative results (to ensure sample quality) were excluded (N = 6). HPV was detected in 40/474 (8.4%; 95% C-I: 5.9–11.0) girls. The most common genotype was HPV42, detected in 9/474 (1.9%; 95% CI: 0.9–3.7). HR genotypes were detected in 5.3% (95% CI: 3.5–7.8). Overall, 50% of girls with HPV had infection with > 1 genotype. In multivariate analysis, only intra-vaginal cleansing (practised by 21.0%) was associated with HPV detection (aOR = 3.16.95% CI: 1.46–6.85) Conclusion In this cohort of adolescent Tanzanian girls, we found a high HPV prevalence prior to self-reported sexual debut, which was associated with intra-vaginal cleansing. This is likely to reflect under-reporting of sexual activity. However, vaginal HPV could be acquired during vaginal cleansing. Potential HPV transmission through genital hygiene practises or other practises (e.g.female genital mutilation or masturbation) should be explored to determine the possibility of HPV acquisition prior to first sex, which may have implications for vaccination programmes.

Rijn, V M van; Mollers, M; Mooij, S H; Speksnijder, A C G L; King, A J; Vries, H J C de; Klis, F R M van der; Melker, H E de; Sande, M A B van der; Loeff, M F Schim van der

doi: 10.1136/sextrans-2013-051184.0177

Taylor, S N; Smith, B; Schwebke, J; Lebed, J; Fuller, D; Lillis, R; Gaydos, C A; Pol, B Van Der; Nye, M; Body, B

doi: 10.1136/sextrans-2013-051184.0340pmid: N/A

Background Trichomonas vaginalis (TV) is a sexually transmitted organism associated with vaginitis, cervicitis, urethritis, low birth weight, preterm delivery, pelvic inflammatory disease and HIV transmission and acquisition. Nucleic acid amplification testing improves the sensitivity for detection of pathogens. The performance of the BD ProbeTec™ TV Qx (TVQ) Amplified DNA Assay and the Gen-Probe Aptima TV assay were compared to patient infected status (PIS) established by the InPouch TV culture and wet mount for the detection of trichomonas in women. Methods Participants with symptoms of trichomonas or presenting for routine visit were enrolled from seven geographically diverse centres. First void urine, a patient collected vaginal swab, and three clinician-collected vaginal swabs were obtained from each participant. Urine was aliquoted into BD neat and UPT tubes as well as an Aptima UTT tube. The first two clinician-collected vaginal swabs were randomised for wet mount and InPouch TV culture. The third was used for the Aptima TV assay. Results There were a total of 1034 compliant participants with evaluable PIS. Specimen and instrument level exclusions resulted in 830 compliant vaginal result sets and 733 neat, UPT and UTT urine result sets for evaluation. For vaginal specimens, the sensitivity (specificity) of the TVQ Assay and the Aptima TV Assay compared to PIS were 98.3% (99%) and 100% (98.3%), respectively. For BD neat and UPT urine specimens, the sensitivity (specificity) of the TVQ Assay compared to PIS were 95.5% (98.7%) and 94.6% (98.6%). For the Aptima UTT urine specimen, the sensitivity and specificity of the Aptima TV Assay compared to PIS were 97.3% and 98.7%. Conclusion The BD ProbeTec™ Trichomonas vaginalis Qx Amplified DNA Assay on the BD Viper™ System in extracted mode demonstrated excellent performance characteristics that were comparable to the only commercially available nucleic acid amplification assay for the detection of Trichomonas vaginalis.

Harding-Esch, E M; Hegazi, A; Okolo, O; Pond, M J; Nori, A V; Nardone, A; Baraitser, P; Campbell, L; Hay, P; Sadiq, S T

doi: 10.1136/sextrans-2013-051184.0427pmid: N/A

Background Excluding HIV testing, point-of-care tests (POCTs) for STIs are not routinely available in UK sexual health clinics, apart from microscopy which has limited sensitivity, is observer dependent and often only allows for imprecise syndromic treatment. From sample-to-result for routine Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) molecular tests usually takes several days. Molecular and non-molecular STI-POCTs, including automated urine flow cytometry, may improve patient pathways, obviate the need for microscopy and personalise treatment effectively. Methods This was a clinic evaluation using a rapid molecular test for CT/NG (Cepheid GeneXpert; 90 minute turnaround) combined with non-molecular POCTs for Trichomonas vaginalis (OSOM), Bacterial vaginosis (Alere VS-Sense) and automated urinary white cell count (WCC) for urethritis (Alere UF-100). Contacts of CT/NG, males with symptoms of urethritis, and symptomatic females provided samples immediately on arrival, prior to clinical consultation. Patients also concurrently had routine culture and microscopy. Results Abstract P2.163 Table 1 Males Females Total Number of patients recruited 19 39 58 Cepheid CT positive: N (% of total) 5 (26.3) 0 (0) 5 (8.6) Cepheid NG positive: N (% of total) 1 (5.3) 0 (0) 1 (1.7) Non-gonococcal urethritis by smear: N (% of male total) 9a (47.4) N/A 9a (47.4) Non-gonococcal urethritis by automated urine white cell count N (% of male total) 8a (42.1) N/A 8a (42.1) OSOM TV positive: N (% of female total) N/A 4b (10.3) 4b (10.3) Microscopy TV positive: N (% of female total) N/A 2b (5.1) 2b (5.1) Alere BV positive: N (% of female total) N/A 24 (61.5) 24 (61.5) Microscopy BV positive: N (% of female total) N/A 7b,c (17.9) 7b,c (17.9) Waited for CT/NG test result: N (% of total) 3 (15.8) 12 (30.8) 15 (25.9) aUrethral smear and WCC not done for 2 patients; Urethral smear alone was not done for 1 patient and the result was unavailable for 4 patients bMicroscopy was not done for 4 patients; 1 of these was positive for both the TV and BV POCTs cAn additional 9 were borderline Of eighteen patients providing feedback, all but one found providing samples on arrival acceptable; waiting < 2 hours was acceptable to all, but waiting > 2 hours was seen as too long. All patients waited for the results of their non-molecular POCT but only three of nineteen men waited for the rapid GeneXpert results, despite six being positive. All positive patients were given appropriate empirical treatment. A third of women waited despite all being GeneXpert negative. The TV and BV POCTs detected more cases than microscopy, and urethral smear detected more urethritis than automated WCC. Conclusion Despite the provision of genital samples on arrival being acceptable and patients liking the idea of receiving results in the same clinical visit, only a quarter of all patients waited for their GeneXpert results. Larger studies to evaluate the clinical impact of rapid molecular testing in clinic are required before any large scale implementation is considered.

Hart, G J

doi: 10.1136/sextrans-2013-051184.0061pmid: N/A

Epidemics of HIV in men who have sex with men (MSM) were first recognised in the early 1980s. Since the introduction of antiretroviral treatment (ART) in the mid-1990s incidence of HIV has not, despite expectations, reduced significantly in many countries. Indeed, the numbers of new diagnoses has increased in some European countries, the USA and Australia. In the UK, for example, over 3000 MSM were diagnosed with HIV in 2010, the highest number since the beginning of the epidemic. As a consequence, the prevalence of HIV is increasing and, for gay communities, a growing number of men are now living with HIV. Although incidence of sexually transmitted infections (STIs) in MSM fell dramatically in the early years of AIDS, post-ART we have seen a return in some jurisdictions to pre-AIDS incident STIs, and the emergence of new sexually transmitted pathogens. This paper will focus on behavioural and epidemiological research in the era of ART, with particular reference to the continuing transmission of HIV. It will review current risk factors for HIV infection in negative MSM, sexual risk behaviour and risk reduction interventions among HIV positive MSM, and the emergence and re-emergence of new and established STIs. It will conclude with current challenges to the prevention of HIV and STIs in MSM, and prospects for the future.

Mehta, S D; Moses, S; Agot, K; Maclean, I; Odoyo-June, E; Li, H; Bailey, R C

doi: 10.1136/sextrans-2013-051184.0685pmid: N/A

Background We estimated the 72-month efficacy of medical male circumcision (MMC) against HSV-2 seroincidence among men in the randomised trial of MMC in Kisumu, Kenya. Methods From 2002–2005, 2,784 men aged 18–24 were randomised 1:1 to immediate circumcision or control. At trial end in December 2006, control men were offered free circumcision. Follow-up continued through September 2010. Cox proportional hazards regression incorporating stabilised inverse probability of treatment and censoring weights generated through marginal structural modelling was used to account for potential time-varying confounding and censoring to estimate the efficacy of MMC on HSV-2 risk. Conventional Cox regression identified multivariable risks for HSV-2 acquisition. Results Among 2,044 men who were HSV-2 seronegative at baseline, the cumulative 72-month HSV-2 seroincidence was 33.1%: 32.7% among circumcised men, 33.5% among uncircumcised men. In weight-adjusted Cox regression, the HR was 0.88 [95% CI: 0.77 – 1.10]. In conventional multivariable analyses, risks (p < 0.05) for HSV-2 included: HIV infection [aHR = 3.75], GUD [aHR = 4.75], penile epithelial trauma [aHR = 1.47], ≥ 2 recent sex partners [aHR = 1.54], and being married/cohabiting [aHR = 1.66]. Of men with seroincident HSV-2, 21% experienced GUD and 80% reported penile epithelial trauma. Conversely, 45% of men with GUD and 80% of men reporting penile epithelial trauma did not acquire HSV-2. GUD preceded HSV-2 in 59% of men with both conditions, with median time to HSV-2 of 12 months. Penile epithelial trauma preceded HSV-2 in 92% of men with both conditions, with median time to HSV-2 of 24 months. Conclusion MMC had no effect on HSV-2 acquisition at 72 months. The temporal sequence and limited correlation between HSV-2, GUD, and penile epithelial trauma indicate these are distinct phenomena, rather than misclassification of HSV-2 symptoms. Determining the aetiology of non-STI GUD and penile epithelial trauma is necessary as both are risks for HIV acquisition, and are common in populations in sub-Saharan Africa.

Chesson, H; Owusu-Edusei, K; Kirkcaldy, R D; Gift, T L; Weinstock, H S

doi: 10.1136/sextrans-2013-051184.1140pmid: N/A

Background Antimicrobial resistance to treatment can hinder gonorrhoea prevention and control efforts, thereby leading to increases in gonorrhoea incidence. We estimated the economic burden of potential increases in gonorrhoea incidence in the US as a result of emerging cephalosporin resistance. Methods The potential increase in gonorrhoea due to resistance was based on an analysis of historical gonorrhoea incidence and ciprofloxacin resistance data. We used clinic-level resistance data from the Gonococcal Isolates Surveillance Project (GISP) and city-level gonorrhoea incidence rates from surveillance data for 17 GISP cities from 1991 to 2006. We performed a regression analysis in which the gonorrhoea rate (log) was the dependent variable and the independent variable of interest was the percentage of GISP isolates (from the clinic in the respective city) resistant to ciprofloxacin. To estimate the cost of potential increases in gonorrhoea, we used STIC-Figure, a spreadsheet programme that applies published equations of the economic impact of STDs. Results The regression analysis found a significant, positive association (p < 0.01) between ciprofloxacin resistance and gonorrhoea incidence at the city level. The results suggested that an increase in resistance from 0% to 10% of isolates could result in a net increase in gonorrhoea of about 7% (range: 3% - 12%) in the first year and 17% (range: 6% - 28%) after ten years. Over ten years, the estimated impact would be substantial: 48,000 additional cases of PID, 5,000 additional cases of epididymitis, and 560 additional HIV infections, with direct medical costs totaling $405 million (range: $152 million - $689 million). Conclusions Ciprofloxacin resistance was associated with increased gonorrhoea rates, despite availability of alternative treatments at the time. Correspondingly, emerging cephalosporin resistance could have substantial health and economic consequences. Efforts to control the spread and reduce the consequences of resistant strains can mitigate this potential burden.

Zou, H; Morrow, A; Tabrizi, S; Grulich, A; Garland, S; Hocking, J; Bradshaw, C; Prestage, G; Fairley, C; Chen, M

doi: 10.1136/sextrans-2013-051184.0176pmid: N/A

Background Homosexually active men are at increased risk for human papillomavirus (HPV) infection and HPV associated anal cancer. Prophylactic HPV vaccines have maximum efficacy in people who have not already been infected with HPV. This study aims to determine the prevalence of HPV among teenage MSM. Methods Same sex attracted males aged 16 to 20 were recruited in Melbourne via clinics, universities, community events, media, social networking and peer recruitment. At baseline, 3, 6, and 12 months anal and penile swabs and an oral rinse were obtained to test for 37 HPV genotypes. Results 200 men were recruited. At baseline 39% had at least one type of HPV DNA detected from at least one site. High risk (HR), low risk (LR) and quadrivalent vaccine (QV) preventable types were detected in 31% (95% CI: 25–37%), 30% (95% CI: 24–37%) and 23% (95% CI: 17–29%) of men respectively. Multiple types of any, HR, LR and QV preventable HPV were detected in 27%, 13%, 11% and 8% of men respectively. The site specific prevalence of any HPV detected from the oral cavity, penis and anus were 2%, 9% and 31% respectively: the prevalence of QV preventable types at these 3 sites was 0.5%, 4% and 20% respectively. Anal HPV was absent in 27 of 30 men who reported never receiving anal sex. Additional results of serology for HPV 6/11/16 and 18 will also be presented. Conclusion In this study, the first to focus on early HPV acquisition among teenage MSM, HPV was common but in the minority. HPV vaccination prior to the onset of sexual activity is ideal; however, short of universal vaccination of school aged males, selected vaccination of teenage same sex attracted young men could still prevent many infections.

Hovhannisyan, G; Lee, C; Hogg-Johnson, S; Bondy, S; Millson, M

doi: 10.1136/sextrans-2013-051184.0530pmid: N/A

Background Chlamydia and gonorrhoea are the most common bacterial sexually transmitted infections (STIs) in Canada. However, the prevalence of these STIs, as well as the risk profile of clients attending public health sexual health (SH) clinics, have not been well characterised in Canada. Methods Female clients of Hamilton Public Health SH clinics between Jan 2009 and Dec 2011 were enrolled in the study. Retrospective chart review was conducted. Logistic regression was conducted to identify important risk factors for STIs in predicting gonococcal and chlamydial infections. Results 2694 charts were abstracted from Hamilton Public Health SH clinics. The mean age of the clients was 24 years; 50% of the clients were under 21 years of age. The majority of the clients were sexually active (98%), of whom 147(6%) had both male and female partners, 27(1%) had only female partners, and 2405 (92%) had only male partners. Most clients practised vaginal (96.6%) and oral sex (74%). Anal sex, oral-anal sex and shared sex toys were less common with 12%, 2.2% and 2% of clients reporting these practises, respectively. Over half of the clients reported having more than 1 partner in the past year, 36% of clients reported two or three partners and 15% reported having four or more partners in the past year. The proportion of clients who had at least one test for gonorrhoea and chlamydia during the study period was 58%. The overall prevalence of chlamydia and gonorrhoea were 8% and 1%, respectively. The strongest predictor of these STIs was young age: ORs were 3.4 and 4.2 for age groups < 20 and 20–24 compared to > 30 years old. Conclusion The prevalence of chlamydia and gonorrhoea was considerably higher in clients attending SH clinics in Hamilton compared to population and family practise based estimates. Age remains the strongest predictor of these infections.

Tsai, A Y; Dueger, E; Macalino, G E; Montano, S M; Mbuchi, M; Puplampu, N; McClelland, R S; Sanchez, J L

doi: 10.1136/sextrans-2013-051184.0732pmid: N/A

Background GC constitutes the second most commonly reportable disease in the United States with over 320,000 cases annually. With the emergence of drug-resistant GC in the past 40 years, treatment options have become very limited. Hence, the U.S. Department of Defense has launched a GC resistance surveillance network in 8 countries; preliminary results are reported from the United States, Djibouti, Ghana, Kenya, and Peru. Methods Patients with urethritis, cervicitis or vaginitis symptoms were recruited at participating clinics serving military personnel and beneficiaries, civilians, and at-risk groups of men who have sex with men and female commercial sex workers. Urethral swabs were collected from men; urethral or vaginal swabs from women; diagnosis was done using culture identification, nucleic acid amplification testing, and real-time PCR. Antimicrobial susceptibility testing (AST) was conducted on GC positive isolates using real-time PCR, disc diffusion, and E-test strip methods. Results Overall, 108 (6%) of 1,694 enrolled subjects tested positive for GC. Prevalence was found to be highest in Kenya where 33 (38%) of 86 patients were positive and was lowest in Peru where only 30 (2%) of 1,296 patients were positive. AST results were available on 66 GC positives; resistance to at least three antibiotics was observed across all overseas sites. Greatest variability in resistance was noted in Djibouti as follows: penicillin (100%), tetracycline (88%), ciprofloxacin (38%), levofloxacin (17%), cefepime (13%), and ceftriaxone (13%). High-level resistance (100%) was also noted in Ghana to ciprofloxacin, penicillin, and tetracycline. Conclusion These findings provide evidence of emerging drug-resistant GC in several regions of the world; the resistance found against third-generation cephalosporin in Djibouti is especially noteworthy. With continuing global vigilance, GC drug resistance information will provide an important basis for the development of effective control measures, particularly among deployable forces and at-risk populations in geographical regions of military relevance.