Sexually Transmitted Infections Among HIV-Infected Individuals in the District of Columbia and Estimated HIV Transmission Risk: Data From the DC Cohort

Sexually Transmitted Infections Among HIV-Infected Individuals in the District of Columbia and... Open Forum Infectious Diseases MAJOR ARTICLE Sexually Transmitted Infections Among HIV-Infected Individuals in the District of Columbia and Estimated HIV Transmission Risk: Data From the DC Cohort 1,2,6 3 3 4 1,2 1 1 2,5 2,7 Jose Lucar, , Rachel Hart, Nabil Rayeed, Arpi Terzian, Amy Weintrob, Marc Siegel, David M. Parenti, Leah E. Squires, Rush Williams, 4 1,2 Amanda D. Castel, and Debra A. Benator ; for the DC Cohort Executive Committee 1 2 3 Division of Infectious Diseases, The George Washington University Medical Center, Washington, DC; Infectious Diseases Section, Veterans Affairs Medical Center, Washington, DC; Cerner 4 5 6 Corporation, Kansas City, Missouri; Milken School of Public Health and Department of Psychology, The George Washington University, Washington, DC; Division of Infectious Diseases, University of Mississippi Medical Center, Jackson, Mississippi; Columbia Health, Columbia University in the City of New York, New York, New York Background. Washington, DC, has one of the highest rates of HIV infection in the United States. Sexual intercourse is the lead- ing mode of HIV transmission, and sexually transmitted infections (STIs) are a risk factor for HIV acquisition and transmission. Methods. We evaluated the incidence and demographic factors associated with chlamydia, gonorrhea, and syphilis among HIV- infected persons enrolled at 13 DC Cohort sites from 2011 to 2015. Using Poisson regression, we assessed covariates of risk for inci- dent STIs. We also examined HIV viral loads (VLs) at the time of STI diagnosis as a proxy for HIV transmission risk. Results. Six point seven percent (451/6672) developed an incident STI during a median follow-up of 32.5  months (4% chla- mydia, 3% gonorrhea, 2% syphilis); 30% of participants had 2 or more STI episodes. The incidence rate of any STIs was 3.8 cases per 100 person-years (95% confidence interval [CI], 3.5–4.1); age 18–34  years, 10.8 (95% CI, 9.7–12.0); transgender women, 9.9 (95% CI, 6.9–14.0); Hispanics, 9.2 (95% CI, 7.2–11.8); and men who have sex with men (MSM), 7.7 (95% CI, 7.1–8.4). Multivariate Poisson regression showed younger age, Hispanic ethnicity, MSM risk, and higher nadir CD4 counts to be strongly associated with STIs. Among those with an STI, 41.8% had a detectable VL within 1 month of STI diagnosis, and 14.6% had a VL ≥1500 copies/mL. Conclusions. STIs are highly prevalent among HIV-infected persons receiving care in DC. HIV transmission risk is considerable at the time of STI diagnosis. Interventions toward risk reduction, antiretroviral therapy adherence, and HIV virologic suppression are critical at the time of STI evaluation. Keywords. District of Columbia; HIV; human immunodeficiency virus; sexually transmitted infections; STI. According to data from the Centers for Disease Control and through mucosal disruption and inflammation, and by increas- Prevention, the District of Columbia had one of the highest incidence ing HIV RNA in genital secretions. There is a direct correlation rates of HIV infection in adults and adolescents living in the United between plasma and genital HIV RNA concentrations, which States in 2015, at 66.1 cases per 100 000 population [1]. As of 2015, underscores the importance of antiretroviral therapy (ART) to the prevalence of HIV infection in DC was 2.0%, which exceeded prevent HIV transmission [9]. In the presence of an STI, genital the World Health Organization definition of 1% as a generalized epi- HIV shedding can occur despite being on ART with plasma HIV demic [2]. The leading mode of HIV transmission for new diagnoses RNA suppression [10]. On the other hand, a multicenter rand- from 2011 to 2015 was sexual contact (76%). Men who have sex with omized controlled trial comparing early vs delayed ART initi- men (MSM) accounted for 58% of those new cases, whereas hetero- ation in HIV-serodiscordant heterosexual couples showed that sexually identified men and women accounted for 16%. early ART was associated with a 93% lower risk of linked-part- Sexually transmitted infections (STIs) are a well known risk ner infection [11]. Also, a European prospective observational factor for HIV acquisition and transmission [3–8]. Both ulcer- study in HIV-serodiscordant heterosexual and MSM couples ative and nonulcerative STIs provide a portal of entry for HIV having condomless sex showed no linked HIV transmission when the viral load was undetectable on ART [12]. This study aimed to describe the incidence and demographic Received 28 November 2017; editorial decision 1 January 2018; accepted 16 January 2018. factors associated with the development of chlamydia, gonor- Correspondence: J. Lucar, MD, University of Mississippi Medical Center, 2500 N State St, rhea, and syphilis in people living with HIV in care in DC. We Suite N502, Jackson, MS 39216 (jlucarlloveras@umc.edu). also examined plasma HIV viral loads (VLs) at the time of STI Open Forum Infectious Diseases diagnosis as an approximation of HIV transmission risk. © The Author(s) 2018. Published by Oxford University Press on behalf of Infectious Diseases Society of America. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs licence (http://creativecommons.org/licenses/ METHODS by-nc-nd/4.0/), which permits non-commercial reproduction and distribution of the work, in any medium, provided the original work is not altered or transformed in any way, and that the work The DC Cohort is a clinic-based, city-wide, longitudinal obser- is properly cited. For commercial re-use, please contact journals.permissions@oup.com DOI: 10.1093/ofid/ofy017 vational cohort launched in 2011 to better understand HIV STIs in the DC Cohort • OFID • 1 Downloaded from https://academic.oup.com/ofid/article-abstract/5/2/ofy017/4823096 by Ed 'DeepDyve' Gillespie user on 16 March 2018 epidemiology in DC, describe clinical outcomes among those in previous data that HIV-infected persons with VLs higher than care, and improve the quality of care for people living with HIV 1500 copies/mL had an increased risk of transmitting HIV to in the DC metropolitan area [13]. At the time of this analysis, others [8, 16]. Because the risk of HIV transmission increases as there were 13 participating outpatient sites: 8 hospital-based clin- the plasma viral load increases [8, 17], we performed a second ics and 5 community-based clinics. Following the provision of analysis using the following cutoffs: less than the lower limit written informed consent, participants’ clinical data was man- of quantification (<LLOQ), LLOQ–<1500, 1500–<10 000, and ually entered or electronically exported from patient medical ≥10 000 copies/mL. Of note, more than 99% of the VLs included records and entered into a web-based data entry system called in this analysis had an LLOQ of either 20 or 40 copies/mL. Discovere (Cerner Corporation, Kansas City, MO). Details of the Statistical Analysis DC Cohort study design have been described previously [14, 15]. Frequencies on demographic and clinical characteristics at study enrollment were measured. Differences by factor across a Study Population and Design specific STI (chlamydia, gonorrhea, syphilis) were determined Eligible participants included those enrolled from January 1, using chi-square test statistics and Fisher exact tests for cat- 2011, to March 31, 2015. Participant follow-up time included egorical variables and Wilcoxon rank-sum tests for continuous time from enrollment to June 30, 2015, or until the first of these variables, excluding other and unknown values. Incidence occurred: death, withdrawal from the DC Cohort, or loss to rates were calculated per 100 person-years (P-Y) of observa- follow-up. Demographic and clinical characteristics were col- tion, using Rothman/Greenland estimation for 95% confidence lected at study enrollment. A  descriptive, retrospective cohort intervals (CIs). Univariate and multivariate Poisson regres- design was used to examine the incidence of confirmed cases of sion analyses were conducted for factors associated with STIs chlamydia, gonorrhea, and syphilis, as well as the VLs in indi- using a Bonferroni correction (to account for multiple testing), viduals with any STIs, 1 STI, and 2 or more STIs. As STI screen- resulting in a significance level of .05/3 = .0167, and subsequent ing may be unevenly applied between study sites, true incidence confidence intervals were set at 98.33%. Characteristics with is not known. However, incidence here will refer to those cases unknown values were multiply imputed in the Poisson model. detected by testing in association with either symptoms or po- All analyses were conducted in SAS 9.4 (Cary, NC). tential exposure, and by clinician- or program-directed screen- ing in asymptomatic participants. Ethics Participants newly diagnosed with chlamydia, gonorrhea, The George Washington University Institutional Review Board and syphilis more than 30  days aer s ft tudy enrollment were (IRB), the DC-DOH IRB, and the IRBs of the individual study defined as incident STI cases. An incident case of chlamydia or sites approved the study protocol, consent forms, and research gonorrhea was defined as a positive nucleic acid amplification instruments. test (NAAT) or culture on urogenital or extragenital specimens; RESULTS a subsequent new case was accepted as such if there was a pos- itive test ≥3 weeks aer t ft he previous positive test. An incident Around the time this data set was closed, the estimated popula- case of syphilis was defined as having (i) positive nontrepone- tion of persons with HIV infection receiving care at the 13 DC mal test (NTr) titer of ≥1:8 with a previous nonreactive NTr, (ii) Cohort sites was 11 235, of which 8732 persons (77.7%) were 4-fold increase in the NTr titer from the previous test, or (iii) approached for enrollment. Of those persons approached, 7004 positive treponemal test (Tr) if a NTr titer was ≥1:8 and the pre- (80.2%) were consented, 948 (10.9%) declined enrollment, 14 vious Tr test was negative. A possible incident syphilis case was (0.2%) withdrew consent, and 766 (8.8%) remained undecided. defined as a single, high-titer NTr test of ≥1:32 that otherwise There were significant differences between those consenting did not fit the criteria for a true incident case. An STI episode and declining, which included female gender (27.8% of those may include any combination of chlamydia, gonorrhea, and consenting vs 36.1% of those declining, P < .0001), white race/ syphilis diagnosed at the same date. The occurrence and num- ethnicity (13.1% of those consenting vs 6.6% of those declining, ber of incident STI episodes among participants was assessed. P  <  .0001), and private insurance status (27.6% of those con- To evaluate the HIV transmission potential in individuals senting vs 33.2% of those declining, P < .0001). with incident STIs, we also examined their plasma HIV VLs. We Among the 6762 participants enrolled in the study between determined the VLs at the time of STI diagnosis, defined as the January 1, 2011, and March 31, 2015, the median age at con- VL within ±1 month, 3 months, and 6 months of the STI diag- sent was 47  years (interquartile range, 36.5–54.5  years); 71% nosis date. If a participant had 2 or more STI episodes within were male, 76% were non-Hispanic black, 39% were MSM, each ±1-, 3-, or 6-month period, the highest VL was selected. and 29% were heterosexual participants. er Th e were 113 (2%) Subsequently, we categorized the individuals with STIs as either transgender women and 5 (0.1%) transgender males enrolled in having any number, 1, or 2 or more STIs, as well as their VLs as the study (Table 1). At the time of consent, 7.8% of participants either <1500 or ≥1500 copies/mL. This cutoff was used given were known to be homeless or have unstable housing, 63.8% 2 • OFID • Lucar et al Downloaded from https://academic.oup.com/ofid/article-abstract/5/2/ofy017/4823096 by Ed 'DeepDyve' Gillespie user on 16 March 2018 a Table 1. Baseline Characteristics of the DC Cohort Participants by Incident STIs (n = 6762) Total Chlamydia Gonorrhea Syphilis Any STI No. Column % No. Row % Column % No. Row % Column % No. Row % Column % No. Row % Column % 6762 250 3.7 212 3.1 123 1.8 451 6.7 Age at enrollment, y 0–17 149 2.2 10 6.7 4.0 7 4.7 3.3 1 0.7 0.8 11 7.4 2.4 18–34 1377 20.4 137 9.9 54.8 114 8.3 53.8 45 3.3 36.6 220 16.0 48.8 35–54 3637 53.8 95 2.6 38.0 80 2.2 37.7 69 1.9 56.1 196 5.4 43.5 55+ 1599 23.6 8 0.5 3.2 11 0.7 5.2 8 0.5 6.5 24 1.5 5.3 Age at consent, median (IQR) 47.0 (36.5–54.5) 32.8 (25.6–42.3) 32.1 (26.0–42.9) 38.9 (31.6–47.4) 34.8 (26.9–44.3) Gender at consent Male 4823 71.3 210 4.4 84.0 187 3.9 88.2 116 2.4 94.3 392 8.1 86.9 Female 1821 26.9 29 1.6 11.6 15 0.8 7.1 3 0.2 2.4 39 2.1 8.6 Transgender female 113 1.7 11 9.7 4.4 10 8.8 4.7 4 3.5 3.3 20 17.7 4.4 Transgender male 5 0.1 0 0.0 0.0 0 0.0 0.0 0 0.0 0.0 0 0.0 0.0 Race/ethnicity Non-Hispanic black 5161 76.3 169 3.3 67.6 132 2.6 62.3 75 1.5 61.0 290 5.6 64.3 Non-Hispanic white 940 13.9 54 5.7 21.6 52 5.5 24.5 28 3.0 22.8 101 10.7 22.4 Hispanic 314 4.6 21 6.7 8.4 23 7.3 10.8 11 3.5 8.9 43 13.7 9.5 Other 137 2.0 3 2.2 1.2 4 2.9 1.9 1 0.7 0.8 6 4.4 1.3 Unknown 210 3.1 3 1.4 1.2 1 0.5 0.5 8 3.8 6.5 11 5.2 2.4 HIV risk behavior MSM 2652 39.2 196 7.4 78.4 181 6.8 85.4 109 4.1 88.6 365 13.8 80.9 HRH 1989 29.4 23 1.2 9.2 11 0.6 5.2 4 0.2 3.3 35 1.8 7.8 IDU 452 6.7 1 0.2 0.4 1 0.2 0.5 0 0.0 0.0 2 0.4 0.4 Other 354 5.2 11 3.1 4.4 8 2.3 3.8 0 0.0 0.0 14 4.0 3.1 Unknown 1315 19.4 19 1.4 7.6 11 0.8 5.2 10 0.8 8.1 35 2.7 7.8 3d Nadir CD4 cell count, cells/mm <50 1056 15.6 17 1.6 6.8 17 1.6 8.0 9 0.9 7.3 37 3.5 8.2 50–199 1452 21.5 38 2.6 15.2 35 2.4 16.5 30 2.1 24.4 81 5.6 18.0 200–349 1703 25.2 74 4.3 29.6 72 4.2 34.0 34 2.0 27.6 137 8.0 30.4 350–499 1265 18.7 63 5.0 25.2 46 3.6 21.7 32 2.5 26.0 107 8.5 23.7 500+ 1279 18.9 58 4.5 23.2 42 3.3 19.8 17 1.3 13.8 88 6.9 19.5 Housing at index date Permanent/stable 4486 66.3 152 3.4 60.8 124 2.8 58.5 86 1.9 69.9 281 6.3 62.3 Temporary/unstable/homeless 530 7.8 29 5.5 11.6 31 5.8 14.6 17 3.2 13.8 59 11.1 13.1 Other 15 0.2 0 0.0 0.0 0 0.0 0.0 0 0.0 0.0 0 0.0 0.0 Unknown 1731 25.6 69 4.0 27.6 57 3.3 26.9 20 1.2 16.3 111 6.4 24.6 Primary insurance at consent Public 4313 63.8 137 3.2 54.8 119 2.8 56.1 56 1.3 45.5 239 5.5 53.0 Private 1819 26.9 72 4.0 28.8 60 3.3 28.3 54 3.0 43.9 143 7.9 31.7 Other 427 6.3 19 4.4 7.6 11 2.6 5.2 9 2.1 7.3 34 8.0 7.5 Unknown 203 3.0 22 10.8 8.8 22 10.8 10.4 4 2.0 3.3 35 17.2 7.8 Alcohol use at consent Yes 906 13.4 49 5.4 19.6 42 4.6 19.8 23 2.5 18.7 89 9.8 19.7 No 4149 61.4 104 2.5 41.6 83 2.0 39.2 45 1.1 36.6 193 4.7 42.8 Unknown 1707 25.2 97 5.7 38.8 87 5.1 41.0 55 3.2 44.7 169 9.9 37.5 Substance abuse at consent Yes 822 12.2 54 6.6 21.6 49 6.0 23.1 24 2.9 19.5 87 10.6 19.3 No 3787 56.0 97 2.6 38.8 73 1.9 34.4 52 1.4 42.3 178 4.7 39.5 Unknown 2153 31.8 99 4.6 39.6 90 4.2 42.5 47 2.2 38.2 186 8.6 41.2 Diagnoses of mental health conditions at consent 341 5.0 3 0.9 1.2 2 0.6 0.9 0 0.0 0.0 4 1.2 0.9 Ever HBV infection prior to consent 379 5.6 13 3.4 5.2 8 2.1 3.8 10 2.6 8.1 27 7.1 6.0 Ever HCV infection prior to consent 780 11.5 14 1.8 5.6 12 1.5 5.7 7 0.9 5.7 28 3.6 6.2 Abbreviations: HBV, hepatitis B virus; HCV, hepatitis C virus; HRH, heterosexual; IDU, injection drug user; IQR, interquartile range; MSM, men who have sex with men; STI, sexually trans- mitted infection. All characteristics are at the time of consent into the DC Cohort. Other race/ethnicity includes persons of Asian/Pacific Island descent and those with more than 1 reported race. HIV risk behaviors: HRH, IDU, MSM. MSM who are also IDUs are grouped with MSM. Other HIV transmission risk behavior includes persons who were perinatally infected or infected through blood transfusions, coagulation disorders, or occupational exposures. Nadir CD4 is the lowest CD4 record available dated prior to enrollment into the DC Cohort. Seven participants had an unknown nadir CD4 cell count. Temporary/unstable housing was defined as a housing unit in which persons who are without housing or a fixed address receive temporary housing or shelter. Public insurance includes Medicare, Medicaid, and other public insurance coverage plans; “Other” insurance includes self-pay, recently terminated plans, clinical trial. Mental health conditions diagnosed previously or at the time of consent include major depressive disorder, anxiety disorder, bipolar disorder, psychoses, other. STIs in the DC Cohort • OFID • 3 Downloaded from https://academic.oup.com/ofid/article-abstract/5/2/ofy017/4823096 by Ed 'DeepDyve' Gillespie user on 16 March 2018 a b Table 2A. Incidence Rates per 100 Person-Years of Chlamydia, Gonorrhea, and Syphilis by Baseline Demographic Characteristics Among DC Cohort Participants (n = 6762) Chlamydia Gonorrhea Syphilis Any STI Rate (95% CI) Rate (95% CI) Rate (95% CI) Rate (95% CI) Overall 1.8 (1.7–2.1) 1.7 (1.5–1.9) 0.8 (0.7–0.9) 3.8 (3.5–4.1) Age at enrollment, y 0–17 3.0 (1.7–5.3) 2.3 (1.2–4.4) 0.3 (0–1.8) 5.0 (3.3–7.8) 18–34 5.7 (5.0–6.6) 5.1 (4.4–5.9) 1.6 (1.2–2.1) 10.8 (9.7–12.0) 35–54 1.2 (1.0–1.5) 1.1 (0.9–1.3) 0.8 (0.7–1.0) 2.8 (2.5–3.2) 55+ 0.2 (0.1–0.4) 0.3 (0.2–0.5) 0.2 (0.1–0.4) 0.6 (0.4–0.9) Gender at consent Male 2.1 (1.9–2.4) 2.0 (1.8–2.3) 1.0 (0.9–1.2) 4.6 (4.2–5.0) Female 0.7 (0.5–1.0) 0.4 (0.2–0.6) 0.1 (0–0.2) 1.1 (0.9–1.5) Transgender female 5.1 (3.1–8.3) 3.8 (2.2–6.7) 1.6 (0.7–3.8) 9.9 (6.9–14.0) Race/ethnicity Non-Hispanic black 1.7 (1.5–1.9) 1.4 (1.2–1.6) 0.6 (0.5–0.8) 3.3 (3.0–3.7) Non-Hispanic white 2.5 (2.0–3.2) 2.6 (2.1–3.3) 1.2 (0.8–1.7) 5.3 (4.6–6.3) Hispanic 4.2 (2.9–6.0) 4.4 (3.1–6.4) 1.9 (1.1–3.3) 9.2 (7.2–11.8) Other 0.9 (0.3–2.8) 1.5 (0.6–3.7) 0.3 (0–2.2) 2.4 (1.2–4.9) Unknown 0.5 (0.2–1.5) 0.2 (0–1.1) 1.5 (0.8–2.8) 2.1 (1.2–3.6) HIV risk behavior MSM 3.6 (3.2–4.0) 3.6 (3.2–4.1) 1.7 (1.4–2.1) 7.7 (7.1–8.4) HRH 0.5 (0.3–0.7) 0.2 (0.1–0.4) 0.1 (0–0.2) 0.8 (0.6–1.1) IDU 0.1 (0–0.5) 0.1 (0–0.5) NA 0.1 (0–0.6) Other 1.6 (0.9–2.6) 1.0 (0.5–1.9) NA 2.4 (1.6–3.7) Unknown 0.8 (0.6–1.2) 0.4 (0.2–0.7) 0.3 (0.2–0.6) 1.5 (1.1–2.0) Abbreviations: CI, confidence interval; HRH, heterosexual; IDU, injection drug user; MSM, men who have sex with men; NA, insufficient data for calculation; STI, sexually transmitted infection. Rate per 100 person-years of observation using Rothman/Greenland estimation for 95% confidence intervals. All characteristics are at the time of consent into the DC Cohort. had public insurance and 26.9% had private insurance, 13.4 and P-Y; 95% CI, 7.1–8.4) (Table 2A). The STI incidence rates were 12.2% had a history of alcohol and substance abuse, respect- stratified for race/ethnicity by age, gender, and risk behavior, as ively, and 11.5% had a hepatitis C diagnosis. well as for age by risk behavior and gender. Taking into account During a median follow-up period of 32.5  months, 6.7% of the number of participants, the highest incidence rates were all participants developed an incident STI (n = 451); 3.7% of all noted in transgender females age 18–34  years (21.0 cases per participants had incident chlamydia infection (n  =  250), 3.1% 100 P-Y; 95% CI, 14.0–31.0) and MSM age 18–34  years (15.0 gonorrhea (n  =  212), and 1.8% syphilis (n  =  123). There was cases per 100 P-Y; 95% CI, 14.0–17.0). Please refer to Table 2B an additional 2.6% with possible incident syphilis that did not for additional details. meet the definition of an incident case. Among participants with In the univariate Poisson regression model, younger age, male an incident STI, 30.4% had 2 or more STI episodes (n = 137); gender, transgender women, non-Hispanic white and Hispanic 19.3% had 2 STI episodes (n = 87), 7.3% had 3 (n = 33), 1.8% race/ethnicity, MSM risk behavior, temporary/unstable hous- had 4 (n  =  8), and 2.0% had 5–8 STI episodes (n  =  9). Of all ing, alcohol use, substance abuse, and higher nadir CD4 counts the STI episodes, 64.3% were among non-Hispanic blacks and were all associated with a higher risk of developing an STI, 22.4% were among non-Hispanic whites. However, 5.6% of all while the presence of a mental health diagnosis and history of enrolled non-Hispanic blacks developed an STI, whereas 10.7% hepatitis C infection were associated with a lower risk (data not of non-Hispanic whites and 13.7% of Hispanics developed an shown). In the multivariate Poisson regression model, younger STI. Furthermore, 80.9% of individuals who developed an STI age, especially 0–17 and 18–34 years, Hispanic ethnicity, MSM were MSM (Table 1). risk behavior, and higher nadir CD4 counts remained associ- e in Th cidence rate of any STIs in the DC Cohort was 3.8 cases ated with a higher risk of developing an STI, while the presence per 100 P-Y (95% CI, 3.5–4.1). The highest incidence rates of of a mental health diagnosis was still associated with a lower any STIs were noted in the following groups: age 18–34  years risk (Table 3). (10.8 cases per 100 P-Y; 95% CI, 9.7–12.0), transgender females In the assessment of potential HIV transmission risk at the (9.9 cases per 100 P-Y; 95% CI, 6.9–14.0), Hispanics (9.2 cases time of STI diagnosis, the VLs were assessed at ±1  month, per 100 P-Y; 95% CI, 7.2–11.8), and MSM (7.7 cases per 100 3 months, and 6 months (Table 4). VL measurements were not 4 • OFID • Lucar et al Downloaded from https://academic.oup.com/ofid/article-abstract/5/2/ofy017/4823096 by Ed 'DeepDyve' Gillespie user on 16 March 2018 a b Table 2B. Incidence Rates per 100 Person-Years of Chlamydia, Gonorrhea, and Syphilis by Baseline Demographic Characteristics Among DC Cohort Participants (n = 6762), Stratified for Race/Ethnicity by Age, Gender, and Risk Behavior Chlamydia Gonorrhea Syphilis Any STI No. Rate (95% CI) Rate (95% CI) Rate (95% CI) Rate (95% CI) Stratify race/ethnicity by age, y Non-Hispanic black 0–17 131 3.5 (2.0–6.1) 2.6 (1.3–5.0) 0.3 (0.0–2.0) 5.8 (3.7–8.9) 18–34 1057 5.7 (4.8–6.7) 4.9 (4.1–5.9) 1.5 (1.1–2.1) 10.8 (9.6–12.2) 35–54 2732 0.9 (0.7–1.2) 0.7 (0.5–0.9) 0.6 (0.4–0.8) 2.0 (1.7–2.4) 55+ 1238 0.1 (0.0–0.3) 0.2 (0.1–0.4) 0.1 (0.0–0.2) 0.3 (0.2–0.6) Non-Hispanic white 0–17 8 NA NA NA NA 18–34 141 7.8 (5.5–11.2) 7.3 (5.1–10.6) 1.6 (0.7–3.5) 13.1 (9.9–17.2) 35–54 537 2.2 (1.6–3.0) 2.4 (1.7–3.3) 1.4 (1.0–2.2) 5.3 (4.3–6.6) 55+ 254 0.6 (0.3–1.5) 0.9 (0.4–1.8) 0.5 (0.2–1.3) 1.9 (1.1–3.1) Hispanic 0–17 5 NA NA NA NA 18–34 89 6.7 (3.8–11.8) 7.2 (4.2–12.5) 1.1 (0.3–4.5) 13.4 (9.0–20.0) 35–54 170 4.0 (2.5–6.6) 4.3 (2.7–6.9) 2.5 (1.4–4.7) 9.4 (6.8–13.0) 55+ 48 NA NA 1.1 (0.2–8.1) 1.1 (0.2–8.1) Stratify race/ethnicity by gender Non-Hispanic black Male 3414 1.9 (1.7–2.2) 1.8 (1.5–2.1) 0.9 (0.7–1.1) 4.1 (3.7–4.5) Female 1648 0.8 (0.6–1.1) 0.4 (0.2–0.6) 0.1 (0.0–0.2) 1.2 (0.9–1.6) Transgender Female 96 6.1 (3.7–10.0) 3.4 (1.8–6.6) 1.9 (0.8–4.6) 10.7 (7.4–15.5) Non-Hispanic white Male 882 2.6 (2.1–3.3) 2.8 (2.2–3.5) 1.2 (0.9–1.8) 5.7 (4.8–6.7) Female 55 NA NA NA NA Transgender Female 3 NA NA NA NA Hispanic Male 270 4.7 (3.2–6.8) 4.7 (3.2–6.8) 2.2 (1.3–3.8) 10.1 (7.8–13.0) Female 31 NA NA NA 0.0 (0.0–) Transgender Female 11 NA 6.6 (1.6–26.2) NA 6.6 (1.6–26.2) Stratify race/ethnicity by risk behavior Non-Hispanic black MSM 1620 3.8 (3.3–4.5) 3.6 (3.1–4.2) 1.7 (1.3–2.1) 8.1 (7.3–8.9) HRH 1792 0.5 (0.3–0.8) 0.2 (0.1–0.4) 0.1 (0.0–0.2) 0.8 (0.6–1.1) IDU 425 0.1 (0.0–0.6) NA NA 0.1 (0.0–0.6) Other 292 1.9 (1.1–3.3) 1.2 (0.6–2.4) NA 3.0 (2.0–4.6) Unknown 1029 0.7 (0.4–1.1) 0.4 (0.2–0.8) 0.4 (0.2–0.7) 1.4 (1.0–2.0) Non-Hispanic white MSM 667 3.3 (2.6–4.2) 3.6 (2.9–4.6) 1.6 (1.1–2.3) 7.3 (6.2–8.6) HRH 58 NA NA NA NA IDU 19 NA NA NA NA Other 37 NA NA NA NA Unknown 159 0.9 (0.3–2.3) 0.2 (0.0–1.5) 0.2 (0.0–1.5) 1.3 (0.6–2.9) Hispanic MSM 194 4.7 (3.1–7.2) 6.0 (4.2–8.7) 2.4 (1.3–4.3) 11.2 (8.5–14.7) HRH 57 1.0 (0.1–6.8) NA 1.0 (0.1–6.8) 1.9 (0.5–7.7) IDU 4 NA 18.8 (2.7–133.6) NA 18.8 (2.7–133.6) Other 9 NA NA NA NA Unknown 48 6.7 (2.8–16.0) 1.3 (0.2–9.5) 1.3 (0.2–9.5) 9.3 (4.4–19–5) Stratify age by risk behavior MSM 5 24.0 (6.0–95.0) 24.0 (6.0–95.0) 12.0 (1.7–85.0) 48.0 (18 127 .0) HRH 8 16.0 (5.1–49.0) 5.2 (0.7–37.0) NA 21.0 (7.9–56.0) IDU 0 NA NA NA NA Other 132 1.9 (0.9–4.1) 1.7 (0.7–3.7) NA 3.3 (1.9–5.9) 0–17 y Unknown 4 NA NA NA NA MSM 796 7.7 (6.5–9.0) 7.8 (6.7–9.2) 2.4 (1.8–3.1) 15.0 (14.0–17.0) HRH 300 2.1 (1.3–3.4) 1.0 (0.5–2.0) 0.3 (0.1–1.1) 3.0 (2.0–4.6) IDU 5 NA 9.5 (1.3–67.0) NA 9.5 (1.3–67.0) Other 120 2.2 (1.0–4.8) 1.1 (0.3–3.3) NA 3.2 (1.7–6.2) 18–34 y Unknown 155 5.5 (3.5–8.8) 1.5 (0.6–3.7) 1.2 (0.5–3.3) 8.0 (5.4–12.0) MSM 1433 2.5 (2.1–3.0) 2.4 (1.9–2.9) 1.8 (1.4–2.2) 5.9 (5.2–6.7) HRH 1200 0.3 (0.1–0.5) 0.1 (0.0–0.3) 0.1 (0.0–0.3) 0.5 (0.3–0.8) IDU 156 NA NA NA NA Other 72 0.5 (0.1–3.8) NA NA 0.5 (0.1–3.8) STIs in the DC Cohort • OFID • 5 Downloaded from https://academic.oup.com/ofid/article-abstract/5/2/ofy017/4823096 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Table 2B. Continued Chlamydia Gonorrhea Syphilis Any STI No. Rate (95% CI) Rate (95% CI) Rate (95% CI) Rate (95% CI) 35–54 y Unknown 772 0.3 (0.1–0.7) 0.3 (0.1–0.7) 0.3 (0.1–0.7) 0.8 (0.5–1.4) MSM 417 0.5 (0.2–1.1) 0.9 (0.5–1.7) 0.5 (0.2–1.1) 1.8 (1.1–2.7) HRH 481 NA NA 0.1 (0.0–0.6) 0.1 (0.0–0.6) IDU 291 0.1 (0.0–0.8) NA NA 0.1 (0.0–0.8) Other 29 NA NA NA NA 55+ y Unknown 381 0.2 (0.1–0.9) 0.1 (0.0–0.8) 0.1 (0.0–0.8) 0.5 (0.2–1.2) Stratify age by gender Male 61 3.1 (1.3–7.5) 1.9 (0.6–5.8) 0.6 (0.1–4.4) 5.0 (2.5–10) Female 88 3.0 (1.4–6.2) 2.5 (1.1–5.6) NA 5.1 (2.9–8.9) 0–17 y Transgender female 0 NA NA NA NA Male 993 6.6 (5.6–7.7) 6.2 (5.3–7.3) 2.0 (1.5–2.6) 13.0 (11–14) Female 338 2.3 (1.5–3.7) 1.2 (0.6–2.2) NA 3.3 (2.2–4.8) 18–34 y Transgender female 45 10 (5.7–18.0) 9.1 (5.1–16.0) 3.3 (1.2–8.8) 21.0 (14.0–31.0) Male 2552 1.5 (1.3–1.9) 1.5 (1.2–1.8) 1.1 (0.9–1.4) 3.7 (3.3–4.2) Female 1024 0.3 (0.1–0.6) 0.1 (0.0–0.3) 0.1 (0.0–0.3) 0.4 (0.2–0.8) 35–54 y Transgender female 57 1.8 (0.6–5.6) 0.6 (0.1–4.3) 0.6 (0.1–4.3) 3.0 (1.2–7.2) Male 1217 0.2 (0.1–0.5) 0.4 (0.2–0.6) 0.2 (0.1–0.4) 0.7 (0.5–1.1) Female 371 NA NA 0.1 (0.0–0.8) 0.1 (0.0–0.8) 55+ y Transgender female 11 3.8 (0.5–27.0) 0.0 (0.0–0.0) NA 3.8 (0.5–27) Abbreviations: CI, confidence interval; HRH, heterosexual; IDU, injection drug user; MSM, men who have sex with men; NA, insufficient data for calculation; STI, sexually transmitted infection. Rate per 100 person-years of observation using Rothman/Greenland estimation for 95% confidence intervals. All characteristics are at the time of consent into the DC Cohort. available for 116 (25.7%) participants at ±1  month, 44 (9.8%) the populations at particularly high risk included 18–34-year- at ±3 months, and 29 (6.4%) at ±6 months aer S ft TI diagnosis. olds of all races/ethnicities, MSM of all races/ethnicities, Although VL measurements were missing for 25.7% of partic- Hispanic men, and non-Hispanic black transgender women. ipants at the assessment closest to the STI episode, VL results All groups were at substantial risk of STIs, with incidence were similar to those at 3 and 6 months and therefore assumed rates ranging from 7.3 to 13.4 cases per 100 P-Y. Although to be representative. Among individuals with any number the overall number of transgender women enrolled in the DC of STI episodes, 41.8% had a detectable viral load (above the Cohort was relatively low, at 113, this sample size afforded LLOQ) within 1  month of the STI diagnosis; 14.6% had a VL an opportunity for comparison of risk across the larger HIV- ≥1500 copies/mL. For those with 1 STI episode, 13.5% had a VL infected population overall and other high-risk populations. ≥1500 copies/mL and 7.4% had a VL ≥10 000 copies/mL. These The very high risk of STIs identified among transgender percentages were higher in participants with 2 or more STI epi- women highlights the importance of strategies to reduce STI sodes; 17.1% had a VL ≥1500 copies/mL, and 13.3% had a VL and HIV transmission that are culturally and gender sensitive ≥10 000 copies/mL. However, these differences did not achieve across all at-risk groups. statistical significance. In the multivariate analysis of factors associated with STI risk, younger age (especially <18 and 18–34  years), Hispanic DISCUSSION ethnicity, MSM risk behavior, and higher nadir CD4 counts In this large-scale, single city–focused analysis, we reported the were strongly associated with a higher risk of developing an incidence and factors associated with the development of chla- STI. It has been hypothesized that with higher CD4 counts (as mydia, gonorrhea, and syphilis in a cohort of people living with a consequence of virologic suppression on ART), patients may HIV (PLWH) in care in DC. Consistent with incidence rates perceive a lower “threat” of HIV transmission and therefore among the DC general population [2], chlamydia had the high- have higher-risk sexual behaviors [18–20]. To date, this associ- est incidence, followed by gonorrhea and then syphilis, each ation has not been proven [21–23], but our data on CD4 counts with particularly high rates among 18–34-year-olds, MSM, may suggest a potential association between improved general transgender women, and Hispanic participants. well-being and high-risk sexual behaviors. Certainly, it has been Among age, gender, race/ethnicity, and risk categories, proposed that the greatest prevalence of STIs in PLWH is at the 18–34-year-olds, transgender women, Hispanics, and MSM time of HIV diagnosis [24]. However, it is also widely recognized had the highest STI incidence rates. In our stratified analysis, that high-risk sexual behaviors can continue at any point aer ft 6 • OFID • Lucar et al Downloaded from https://academic.oup.com/ofid/article-abstract/5/2/ofy017/4823096 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Table 3. Multivariate Poisson Regression Analysis for Factors Associated With the Development of STIs Among Participants in the DC Cohort Chlamydia Gonorrhea Syphilis Any STI Participant Characteristic RR (95% CI) P RR (95% CI) P RR (95% CI) P RR (95% CI) P Age at consent, y 0–17 24.2 (7.3–80.4) <.0001 23.5 (7.2–76.6) <.0001 2.5 (0.3–20.1) .40 17.6 (7.2–42.9) <.0001 18–34 15.7 (7.9–31.4) <.0001 9.9 (5.4–18.2) <.0001 6.1 (2.8–13.2) <.0001 9.4 (6.2–14.1) <.0001 35–54 4.4 (2.2–8.8) <.0001 2.9 (1.6–5.2) .001 3.9 (1.8–8.1) .000 3.3 (2.2–4.9) <.0001 55+ Ref Ref Ref Ref Gender at consent Male Ref Ref Ref Ref Female 0.8 (0.5–1.3) .385 0.6 (0.4–1.2) .143 0.1 (0–0.3) <.0001 0.7 (0.5–1) .0316 Transgender female 1.3 (0.8–2.2) .335 1 (0.5–1.8) .945 1.3 (0.5–3.3) .53 1.2 (0.8–1.8) .3053 Race/ethnicity Non-Hispanic black Ref Ref Ref Ref Non-Hispanic white 1.3 (0.9–1.7) .12 1.5 (1.1–2) .009 1.3 (0.8–2) .23 1.2 (1–1.5) .05 Hispanic 1.4 (0.9–2.1) .130 1.7 (1.1–2.5) .009 1.7 (0.9–3) .095 1.5 (1.1–1.9) .008 Other 0.5 (0.2–1.5) .21 1 (0.4–2.4) .95 0.4 (0.1–2.7) .33 0.6 (0.3–1.2) .18 HIV risk behavior MSM Ref Ref Ref Ref HRH 0.3 (0.2–0.4) <.0001 0.1 (0.1–0.3) <.0001 1.3 (0.7–2.4) .325 0.2 (0.1–0.3) <.0001 IDU 0.1 (0–1.4) .088 0.1 (0–1) .045 0.2 (0–0.8) .022 0.1 (0–0.7) .03 Other 0.3 (0.1–0.8) .02 0.2 (0–0.5) .001 0.6 (0.4–0.9) .01 0.2 (0.1–0.5) <.001 Housing at consent Permanent/stable Ref Ref Ref Ref Temporary/unstable 1 (0.7–1.5) .84 1.2 (0.8–1.9) .29 1.8 (0.9–3.5) .12 1.2 (1–1.6) .089 Homeless 0.9 (0.4–2.3) .88 1.5 (0.4–6.3) .54 1.6 (0.9–2.6) .08 0.8 (0.4–1.6) .52 Primary insurance Public 1.3 (1–1.8) .039 1.5 (1.1–2) .020 1.3 (0.7–2.3) .444 1.2 (1–1.5) .062 Private Ref Ref Ref Ref Other 1.2 (0.6–2.4) .576 0.7 (0.2–2) .480 1.3 (0.7–2.5) .374 1.2 (0.8–2) .3727 Alcohol use 1.2 (0.8–1.9) .320 1.2 (0.8–1.7) .442 0.7 (0.4–1.4) .355 1.2 (0.9–1.6) .1598 Substance abuse 1.3 (0.8–2.1) .194 1.4 (1–2) .056 2.2 (1.1–4.4) .034 1.3 (1–1.7) .0345 Mental health diagnosis at consent 0.3 (0.1–1) .044 0.4 (0.1–1.1) .072 2 (1–4) .063 0.3 (0.1–0.6) .0028 Ever HBV infection prior to consent 0.9 (0.5–1.5) .631 0.7 (0.4–1.3) .316 2.6 (1.3–5.2) .009 0.9 (0.7–1.3) .7119 Ever HCV infection prior to consent 1 (0.6–1.5) .880 0.7 (0.4–1.2) .215 1.8 (0.9–3.8) .124 0.9 (0.7–1.3) .5952 Nadir CD4 cell count <50 Ref Ref Ref Ref 50–199 1.5 (0.9–2.6) .108 1.3 (0.8–2.2) .29 1.3 (0.8–2.2) .290 1.5 (1.1–2.1) .017 200–349 2.6 (1.6–4.2) <.0001 2.2 (1.4–3.5) .001 2.2 (1.4–3.5) .001 2.2 (1.6–3) <.0001 350–499 2.2 (1.4–3.6) .0015 1.8 (1.1–3) .014 1.8 (1.1–3) .014 1.9 (1.4–2.7) <.0001 500+ 2.4 (1.4–3.9) .0007 1.7 (1.1–2.9) .028 1.7 (1.1–2.9) .03 1.9 (1.4–2.7) .00 Abbreviations: HBV, hepatitis B virus; HCV, hepatitis C virus; HRH, heterosexual; IDU, injection drug user; MSM, men who have sex with men; Ref, reference group; RR, relative risk; STI, sexually transmitted infection. Transgender men were not included in this analysis due to the small number (n = 5). Other HIV transmission risk behavior includes persons who were perinatally infected or infected through blood transfusions, coagulation disorders, or occupational exposures. Temporary/unstable housing was defined as a housing unit in which persons who are without housing or a fixed address receive temporary housing or shelter. Public insurance includes Medicare, Medicaid, and other public insurance coverage plans; “Other” insurance includes self-pay, recently terminated plans, clinical trial. Mental health conditions diagnosed previously or at the time of consent include major depressive disorder, anxiety disorder, bipolar disorder, psychoses, other. Nadir CD4 is the lowest CD4 record available dated prior to enrollment into the DC Cohort. Seven participants had an unknown nadir CD4 cell count. A Bonferroni correction was applied to account for multiple testing, resulting in a significance level of .05/3 = .0167, and subsequent confidence intervals set at 98.33%. HIV diagnosis [25, 26]. Thus, though risk may be reduced com- incidence (3.8 cases per 100 P-Y) with other cohorts should be pared with before HIV diagnosis, this study demonstrates that interpreted with caution. There are several studies that examine ongoing STI and HIV transmission risk remains considerable. the incidence of bacterial STIs, but many of them focus on spe- er Th e is significant heterogeneity between previous studies cific groups (eg, men, MSM, women) or settings (eg, STI clin- of STIs among PLWH in other large metropolitan areas of the ics, military personnel). For example, a study on self-reported United States [24]. Hence, the comparison between our STI STIs via structured computer interviews in PLWH in Atlanta, prevalence (6.7% over a median follow-up of 32.5 months) and Georgia, showed that 14% of respondents had an STI diagnosed STIs in the DC Cohort • OFID • 7 Downloaded from https://academic.oup.com/ofid/article-abstract/5/2/ofy017/4823096 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Table 4. HIV Viral Load in Participants With at Least 1 STI Episode (<LLOQ, LLOQ–<1500, 1500–<10 000, and ≥10 000 copies/mL) Within ±1 Month, ±3 Months, and ±6 Months of STI Diagnosis (n = 451) Within 1 mo Within 3 mo Within 6 mo Participants with at least 1 LLOQ– LLOQ– LLOQ– STI episode <LLOQ <1500 1500–9999 ≥10 000 <LLOQ <1500 1500–9999 ≥10 000 <LLOQ <1500 1500–9999 ≥10 000       451 195 (58.2%) 91 (27.2%) 18 (5.4%) 31 (9.3%) 241 (59.4%) 108 (26.6%) 19 (4.7%) 38 (9.4%) 253 (60.0%) 112 (26.5%) 19 (4.5%) 38 (9.0%) One hundred sixteen participants (25.7%) did not have a VL recorded within ±1 month, 44 participants (9.8%) did not have a VL recorded within ±3 months, and 29 (4.4%) participants did not have a VL recorded within ±6 months of STI diagnosis.  Abbreviations: LLOQ, lower limit of quantification; STI, sexually transmitted infection; VL, viral load. linkage to care and virologic suppression opportunities may also in the previous 6  months, with a high frequency of STIs ever require cross-site communication. We propose specifically that at since HIV diagnosis (20% had chlamydia, 13% had gonorrhea, each encounter for STI evaluation and/or treatment, even outside of and 36% had syphilis) [25]. In contrast, in a cohort of HIV- the usual site of HIV care, a focused discussion and intensive efforts infected Department of Defense beneficiaries, the prevalence of syphilis at the time of HIV diagnosis was 6%; the incidence rate toward engagement in care and virologic suppression should be was 1.3 cases per 100 P-Y [21]. As expected, published studies provided. This high-impact intervention among those potentially in which HIV-infected individuals were tested following STI transmitting HIV not only provides profound individual benefit, screening protocols reported higher STI rates [27, 28] and are but may also prevent new HIV cases in the community. more likely to approach a true STI incidence. This study has several limitations. First, the observational Virologic suppression with antiretroviral therapy has been nature of the DC Cohort precluded standardized STI screening widely recognized as the key intervention to prevent HIV for all participants. STIs are frequently asymptomatic, and dif- transmission, as recently confirmed in 2 large studies [11, 12]. ferences in screening practices can impact the observed STI fre- er Th e have been multiple attempts in the past to determine the quency [32, 33]. Subsequently, our reported STI incidence rates extent to which STI control could impact HIV transmission, are likely underestimating the true STI incidence in PLWH in with mixed results [29–31]. Nevertheless, even when we fail care in DC. Furthermore, STI screening may provide diagnosis to impact high-risk sexual behaviors, it is possible to interrupt dates distant from the actual time of STI acquisition with impli- HIV transmission if the VL is suppressed. Arguably the most cations in our estimation of HIV transmission risk. Similarly, important (and disappointing) finding of our analysis was the the study design also limited the availability of HIV VLs during fact that 41.8% of participants with at least 1 STI episode had a the same encounter of STI diagnosis. Second, we were unable to detectable VL within 1  month of STI diagnosis. Furthermore, distinguish genital or extragenital sites of chlamydia and gonor- when using ≥1500 copies/mL as a proxy for transmission risk rhea infection. Third, the population enrolled in the DC Cohort (albeit based on data in heterosexual transmission), 14.5% had may not be fully representative of the larger HIV-infected pop- ≥1500 copies/mL. Sustained virologic suppression among indi- ulation in DC, as enrollment requires some degree of engage- viduals with ongoing risk behaviors, signaled by the occurrence ment in care, and the demographics of those declining consent of an STI, may prevent HIV transmission from an infected differed slightly from those who provided consent. sexual partner, and thus new HIV cases. Additionally, a nota- Nonetheless, the strengths of this study include its city-wide, ble finding from our data is the absence of VL measurement prospective enrollment of participants, its longitudinal study on 25.7% of those with STIs within ±1 month of STI diagnosis, design, and the large sample size that is inclusive of male, female, 9.8% within ±3 months, and 6.4% at ±6 months. Yet our finding and transgender participants. Also, our study is unique in link- that 41.8% of participants within 1 month of STI diagnosis had ing data from multiple clinical sites with data reported to the a detectable VL should be an important reminder that presenta- local health department. Merging of the DC Cohort and the tion for STI evaluation is also a critical opportunity to address DC-DOH databases improved the accuracy of STI diagnosis fre- ART adherence and virologic suppression. quency and provided insight into care received for STIs outside e D Th C Cohort database is linked semi-annually with the DC of the primary HIV care site. Finally, to our knowledge, this is the Department of Health (DC-DOH) HIV/AIDS surveillance data- largest cohort to examine the occurrence of STIs and estimated base to enhance data accuracy, as individuals may receive care at HIV transmission risk in the DC metropolitan area, which has multiple clinical sites. Aer co ft mpleting our planned STI analyses, one of the highest incidence rates of HIV in the United States. we examined linked data and found a 9.2% increase in the number In conclusion, STIs are frequent among HIV-positive indi- of chlamydia cases (from 250 to 273 cases) and a 20.8% increase in viduals receiving care in DC; thus risk reduction interventions the number of cases of gonorrhea (from 212 to 256 cases) during the are needed for people living with HIV to help control the spread period of study (unpublished data). These findings highlight that of STIs, achieve durable HIV virologic suppression, and reduce 8 • OFID • Lucar et al Downloaded from https://academic.oup.com/ofid/article-abstract/5/2/ofy017/4823096 by Ed 'DeepDyve' Gillespie user on 16 March 2018 10. Politch JA, Mayer KH, Welles SL, et al. Highly active antiretroviral therapy does HIV transmission. These findings will help health care pro- not completely suppress HIV in semen of sexually active HIV-infected men who viders and policy makers provide high-impact interventions have sex with men. AIDS 2012; 26:1535–43. toward STI control and achievement of virologic suppression 11. Cohen MS, Chen YQ, McCauley M, et al; HPTN 052 Study Team. Antiretroviral therapy for the prevention of HIV-1 transmission. N Engl J Med 2016; 375:830–9. among PLWH with the goal of improving the health of the indi- 12. Rodger AJ, Cambiano V, Bruun T, et al; PARTNER Study Group. Sexual activity vidual and reducing the incidence of HIV in the community. without condoms and risk of HIV transmission in serodifferent couples when the HIV-Positive partner is using suppressive antiretroviral therapy. JAMA 2016; Acknowledgments 316:171–81. 13. DC Cohort Longitudinal HIV Study. Washington, DC: Milken Institute School Data in this manuscript were collected by the DC Cohort with inves- of Public Health, The George Washington University; 2017. http://go.gwu.edu/ tigators and research staff located at Cerner Corporation (Harlen dccohort. Accessed 27 February 2017. Hays, Jeffrey Binkley, Rachel Hart, Dana Franklin, Nabil Rayeed, 14. Greenberg AE, Hays H, Castel AD, et  al; DC Cohort Executive Committee. Rob Taylor, Qingjiang Hou, Thilakavathy Subramanian); Children’s Development of a large urban longitudinal HIV clinical cohort using a web-based National Medical Center Adolescent (Lawrence D’Angelo) and platform to merge electronically and manually abstracted data from disparate Pediatric (Natella Rahkmanina) clinics; The Senior Deputy Director medical record systems: technical challenges and innovative solutions. J Am Med of the DC Department of Health HAHSTA (Michael Kharfen); Inform Assoc 2016; 23:635–43. 15. Castel AD, Kalmin MM, Hart RL, et  al. 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STIs in the DC Cohort • OFID • 9 Downloaded from https://academic.oup.com/ofid/article-abstract/5/2/ofy017/4823096 by Ed 'DeepDyve' Gillespie user on 16 March 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Open Forum Infectious Diseases Oxford University Press

Sexually Transmitted Infections Among HIV-Infected Individuals in the District of Columbia and Estimated HIV Transmission Risk: Data From the DC Cohort

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Open Forum Infectious Diseases MAJOR ARTICLE Sexually Transmitted Infections Among HIV-Infected Individuals in the District of Columbia and Estimated HIV Transmission Risk: Data From the DC Cohort 1,2,6 3 3 4 1,2 1 1 2,5 2,7 Jose Lucar, , Rachel Hart, Nabil Rayeed, Arpi Terzian, Amy Weintrob, Marc Siegel, David M. Parenti, Leah E. Squires, Rush Williams, 4 1,2 Amanda D. Castel, and Debra A. Benator ; for the DC Cohort Executive Committee 1 2 3 Division of Infectious Diseases, The George Washington University Medical Center, Washington, DC; Infectious Diseases Section, Veterans Affairs Medical Center, Washington, DC; Cerner 4 5 6 Corporation, Kansas City, Missouri; Milken School of Public Health and Department of Psychology, The George Washington University, Washington, DC; Division of Infectious Diseases, University of Mississippi Medical Center, Jackson, Mississippi; Columbia Health, Columbia University in the City of New York, New York, New York Background. Washington, DC, has one of the highest rates of HIV infection in the United States. Sexual intercourse is the lead- ing mode of HIV transmission, and sexually transmitted infections (STIs) are a risk factor for HIV acquisition and transmission. Methods. We evaluated the incidence and demographic factors associated with chlamydia, gonorrhea, and syphilis among HIV- infected persons enrolled at 13 DC Cohort sites from 2011 to 2015. Using Poisson regression, we assessed covariates of risk for inci- dent STIs. We also examined HIV viral loads (VLs) at the time of STI diagnosis as a proxy for HIV transmission risk. Results. Six point seven percent (451/6672) developed an incident STI during a median follow-up of 32.5  months (4% chla- mydia, 3% gonorrhea, 2% syphilis); 30% of participants had 2 or more STI episodes. The incidence rate of any STIs was 3.8 cases per 100 person-years (95% confidence interval [CI], 3.5–4.1); age 18–34  years, 10.8 (95% CI, 9.7–12.0); transgender women, 9.9 (95% CI, 6.9–14.0); Hispanics, 9.2 (95% CI, 7.2–11.8); and men who have sex with men (MSM), 7.7 (95% CI, 7.1–8.4). Multivariate Poisson regression showed younger age, Hispanic ethnicity, MSM risk, and higher nadir CD4 counts to be strongly associated with STIs. Among those with an STI, 41.8% had a detectable VL within 1 month of STI diagnosis, and 14.6% had a VL ≥1500 copies/mL. Conclusions. STIs are highly prevalent among HIV-infected persons receiving care in DC. HIV transmission risk is considerable at the time of STI diagnosis. Interventions toward risk reduction, antiretroviral therapy adherence, and HIV virologic suppression are critical at the time of STI evaluation. Keywords. District of Columbia; HIV; human immunodeficiency virus; sexually transmitted infections; STI. According to data from the Centers for Disease Control and through mucosal disruption and inflammation, and by increas- Prevention, the District of Columbia had one of the highest incidence ing HIV RNA in genital secretions. There is a direct correlation rates of HIV infection in adults and adolescents living in the United between plasma and genital HIV RNA concentrations, which States in 2015, at 66.1 cases per 100 000 population [1]. As of 2015, underscores the importance of antiretroviral therapy (ART) to the prevalence of HIV infection in DC was 2.0%, which exceeded prevent HIV transmission [9]. In the presence of an STI, genital the World Health Organization definition of 1% as a generalized epi- HIV shedding can occur despite being on ART with plasma HIV demic [2]. The leading mode of HIV transmission for new diagnoses RNA suppression [10]. On the other hand, a multicenter rand- from 2011 to 2015 was sexual contact (76%). Men who have sex with omized controlled trial comparing early vs delayed ART initi- men (MSM) accounted for 58% of those new cases, whereas hetero- ation in HIV-serodiscordant heterosexual couples showed that sexually identified men and women accounted for 16%. early ART was associated with a 93% lower risk of linked-part- Sexually transmitted infections (STIs) are a well known risk ner infection [11]. Also, a European prospective observational factor for HIV acquisition and transmission [3–8]. Both ulcer- study in HIV-serodiscordant heterosexual and MSM couples ative and nonulcerative STIs provide a portal of entry for HIV having condomless sex showed no linked HIV transmission when the viral load was undetectable on ART [12]. This study aimed to describe the incidence and demographic Received 28 November 2017; editorial decision 1 January 2018; accepted 16 January 2018. factors associated with the development of chlamydia, gonor- Correspondence: J. Lucar, MD, University of Mississippi Medical Center, 2500 N State St, rhea, and syphilis in people living with HIV in care in DC. We Suite N502, Jackson, MS 39216 (jlucarlloveras@umc.edu). also examined plasma HIV viral loads (VLs) at the time of STI Open Forum Infectious Diseases diagnosis as an approximation of HIV transmission risk. © The Author(s) 2018. Published by Oxford University Press on behalf of Infectious Diseases Society of America. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs licence (http://creativecommons.org/licenses/ METHODS by-nc-nd/4.0/), which permits non-commercial reproduction and distribution of the work, in any medium, provided the original work is not altered or transformed in any way, and that the work The DC Cohort is a clinic-based, city-wide, longitudinal obser- is properly cited. For commercial re-use, please contact journals.permissions@oup.com DOI: 10.1093/ofid/ofy017 vational cohort launched in 2011 to better understand HIV STIs in the DC Cohort • OFID • 1 Downloaded from https://academic.oup.com/ofid/article-abstract/5/2/ofy017/4823096 by Ed 'DeepDyve' Gillespie user on 16 March 2018 epidemiology in DC, describe clinical outcomes among those in previous data that HIV-infected persons with VLs higher than care, and improve the quality of care for people living with HIV 1500 copies/mL had an increased risk of transmitting HIV to in the DC metropolitan area [13]. At the time of this analysis, others [8, 16]. Because the risk of HIV transmission increases as there were 13 participating outpatient sites: 8 hospital-based clin- the plasma viral load increases [8, 17], we performed a second ics and 5 community-based clinics. Following the provision of analysis using the following cutoffs: less than the lower limit written informed consent, participants’ clinical data was man- of quantification (<LLOQ), LLOQ–<1500, 1500–<10 000, and ually entered or electronically exported from patient medical ≥10 000 copies/mL. Of note, more than 99% of the VLs included records and entered into a web-based data entry system called in this analysis had an LLOQ of either 20 or 40 copies/mL. Discovere (Cerner Corporation, Kansas City, MO). Details of the Statistical Analysis DC Cohort study design have been described previously [14, 15]. Frequencies on demographic and clinical characteristics at study enrollment were measured. Differences by factor across a Study Population and Design specific STI (chlamydia, gonorrhea, syphilis) were determined Eligible participants included those enrolled from January 1, using chi-square test statistics and Fisher exact tests for cat- 2011, to March 31, 2015. Participant follow-up time included egorical variables and Wilcoxon rank-sum tests for continuous time from enrollment to June 30, 2015, or until the first of these variables, excluding other and unknown values. Incidence occurred: death, withdrawal from the DC Cohort, or loss to rates were calculated per 100 person-years (P-Y) of observa- follow-up. Demographic and clinical characteristics were col- tion, using Rothman/Greenland estimation for 95% confidence lected at study enrollment. A  descriptive, retrospective cohort intervals (CIs). Univariate and multivariate Poisson regres- design was used to examine the incidence of confirmed cases of sion analyses were conducted for factors associated with STIs chlamydia, gonorrhea, and syphilis, as well as the VLs in indi- using a Bonferroni correction (to account for multiple testing), viduals with any STIs, 1 STI, and 2 or more STIs. As STI screen- resulting in a significance level of .05/3 = .0167, and subsequent ing may be unevenly applied between study sites, true incidence confidence intervals were set at 98.33%. Characteristics with is not known. However, incidence here will refer to those cases unknown values were multiply imputed in the Poisson model. detected by testing in association with either symptoms or po- All analyses were conducted in SAS 9.4 (Cary, NC). tential exposure, and by clinician- or program-directed screen- ing in asymptomatic participants. Ethics Participants newly diagnosed with chlamydia, gonorrhea, The George Washington University Institutional Review Board and syphilis more than 30  days aer s ft tudy enrollment were (IRB), the DC-DOH IRB, and the IRBs of the individual study defined as incident STI cases. An incident case of chlamydia or sites approved the study protocol, consent forms, and research gonorrhea was defined as a positive nucleic acid amplification instruments. test (NAAT) or culture on urogenital or extragenital specimens; RESULTS a subsequent new case was accepted as such if there was a pos- itive test ≥3 weeks aer t ft he previous positive test. An incident Around the time this data set was closed, the estimated popula- case of syphilis was defined as having (i) positive nontrepone- tion of persons with HIV infection receiving care at the 13 DC mal test (NTr) titer of ≥1:8 with a previous nonreactive NTr, (ii) Cohort sites was 11 235, of which 8732 persons (77.7%) were 4-fold increase in the NTr titer from the previous test, or (iii) approached for enrollment. Of those persons approached, 7004 positive treponemal test (Tr) if a NTr titer was ≥1:8 and the pre- (80.2%) were consented, 948 (10.9%) declined enrollment, 14 vious Tr test was negative. A possible incident syphilis case was (0.2%) withdrew consent, and 766 (8.8%) remained undecided. defined as a single, high-titer NTr test of ≥1:32 that otherwise There were significant differences between those consenting did not fit the criteria for a true incident case. An STI episode and declining, which included female gender (27.8% of those may include any combination of chlamydia, gonorrhea, and consenting vs 36.1% of those declining, P < .0001), white race/ syphilis diagnosed at the same date. The occurrence and num- ethnicity (13.1% of those consenting vs 6.6% of those declining, ber of incident STI episodes among participants was assessed. P  <  .0001), and private insurance status (27.6% of those con- To evaluate the HIV transmission potential in individuals senting vs 33.2% of those declining, P < .0001). with incident STIs, we also examined their plasma HIV VLs. We Among the 6762 participants enrolled in the study between determined the VLs at the time of STI diagnosis, defined as the January 1, 2011, and March 31, 2015, the median age at con- VL within ±1 month, 3 months, and 6 months of the STI diag- sent was 47  years (interquartile range, 36.5–54.5  years); 71% nosis date. If a participant had 2 or more STI episodes within were male, 76% were non-Hispanic black, 39% were MSM, each ±1-, 3-, or 6-month period, the highest VL was selected. and 29% were heterosexual participants. er Th e were 113 (2%) Subsequently, we categorized the individuals with STIs as either transgender women and 5 (0.1%) transgender males enrolled in having any number, 1, or 2 or more STIs, as well as their VLs as the study (Table 1). At the time of consent, 7.8% of participants either <1500 or ≥1500 copies/mL. This cutoff was used given were known to be homeless or have unstable housing, 63.8% 2 • OFID • Lucar et al Downloaded from https://academic.oup.com/ofid/article-abstract/5/2/ofy017/4823096 by Ed 'DeepDyve' Gillespie user on 16 March 2018 a Table 1. Baseline Characteristics of the DC Cohort Participants by Incident STIs (n = 6762) Total Chlamydia Gonorrhea Syphilis Any STI No. Column % No. Row % Column % No. Row % Column % No. Row % Column % No. Row % Column % 6762 250 3.7 212 3.1 123 1.8 451 6.7 Age at enrollment, y 0–17 149 2.2 10 6.7 4.0 7 4.7 3.3 1 0.7 0.8 11 7.4 2.4 18–34 1377 20.4 137 9.9 54.8 114 8.3 53.8 45 3.3 36.6 220 16.0 48.8 35–54 3637 53.8 95 2.6 38.0 80 2.2 37.7 69 1.9 56.1 196 5.4 43.5 55+ 1599 23.6 8 0.5 3.2 11 0.7 5.2 8 0.5 6.5 24 1.5 5.3 Age at consent, median (IQR) 47.0 (36.5–54.5) 32.8 (25.6–42.3) 32.1 (26.0–42.9) 38.9 (31.6–47.4) 34.8 (26.9–44.3) Gender at consent Male 4823 71.3 210 4.4 84.0 187 3.9 88.2 116 2.4 94.3 392 8.1 86.9 Female 1821 26.9 29 1.6 11.6 15 0.8 7.1 3 0.2 2.4 39 2.1 8.6 Transgender female 113 1.7 11 9.7 4.4 10 8.8 4.7 4 3.5 3.3 20 17.7 4.4 Transgender male 5 0.1 0 0.0 0.0 0 0.0 0.0 0 0.0 0.0 0 0.0 0.0 Race/ethnicity Non-Hispanic black 5161 76.3 169 3.3 67.6 132 2.6 62.3 75 1.5 61.0 290 5.6 64.3 Non-Hispanic white 940 13.9 54 5.7 21.6 52 5.5 24.5 28 3.0 22.8 101 10.7 22.4 Hispanic 314 4.6 21 6.7 8.4 23 7.3 10.8 11 3.5 8.9 43 13.7 9.5 Other 137 2.0 3 2.2 1.2 4 2.9 1.9 1 0.7 0.8 6 4.4 1.3 Unknown 210 3.1 3 1.4 1.2 1 0.5 0.5 8 3.8 6.5 11 5.2 2.4 HIV risk behavior MSM 2652 39.2 196 7.4 78.4 181 6.8 85.4 109 4.1 88.6 365 13.8 80.9 HRH 1989 29.4 23 1.2 9.2 11 0.6 5.2 4 0.2 3.3 35 1.8 7.8 IDU 452 6.7 1 0.2 0.4 1 0.2 0.5 0 0.0 0.0 2 0.4 0.4 Other 354 5.2 11 3.1 4.4 8 2.3 3.8 0 0.0 0.0 14 4.0 3.1 Unknown 1315 19.4 19 1.4 7.6 11 0.8 5.2 10 0.8 8.1 35 2.7 7.8 3d Nadir CD4 cell count, cells/mm <50 1056 15.6 17 1.6 6.8 17 1.6 8.0 9 0.9 7.3 37 3.5 8.2 50–199 1452 21.5 38 2.6 15.2 35 2.4 16.5 30 2.1 24.4 81 5.6 18.0 200–349 1703 25.2 74 4.3 29.6 72 4.2 34.0 34 2.0 27.6 137 8.0 30.4 350–499 1265 18.7 63 5.0 25.2 46 3.6 21.7 32 2.5 26.0 107 8.5 23.7 500+ 1279 18.9 58 4.5 23.2 42 3.3 19.8 17 1.3 13.8 88 6.9 19.5 Housing at index date Permanent/stable 4486 66.3 152 3.4 60.8 124 2.8 58.5 86 1.9 69.9 281 6.3 62.3 Temporary/unstable/homeless 530 7.8 29 5.5 11.6 31 5.8 14.6 17 3.2 13.8 59 11.1 13.1 Other 15 0.2 0 0.0 0.0 0 0.0 0.0 0 0.0 0.0 0 0.0 0.0 Unknown 1731 25.6 69 4.0 27.6 57 3.3 26.9 20 1.2 16.3 111 6.4 24.6 Primary insurance at consent Public 4313 63.8 137 3.2 54.8 119 2.8 56.1 56 1.3 45.5 239 5.5 53.0 Private 1819 26.9 72 4.0 28.8 60 3.3 28.3 54 3.0 43.9 143 7.9 31.7 Other 427 6.3 19 4.4 7.6 11 2.6 5.2 9 2.1 7.3 34 8.0 7.5 Unknown 203 3.0 22 10.8 8.8 22 10.8 10.4 4 2.0 3.3 35 17.2 7.8 Alcohol use at consent Yes 906 13.4 49 5.4 19.6 42 4.6 19.8 23 2.5 18.7 89 9.8 19.7 No 4149 61.4 104 2.5 41.6 83 2.0 39.2 45 1.1 36.6 193 4.7 42.8 Unknown 1707 25.2 97 5.7 38.8 87 5.1 41.0 55 3.2 44.7 169 9.9 37.5 Substance abuse at consent Yes 822 12.2 54 6.6 21.6 49 6.0 23.1 24 2.9 19.5 87 10.6 19.3 No 3787 56.0 97 2.6 38.8 73 1.9 34.4 52 1.4 42.3 178 4.7 39.5 Unknown 2153 31.8 99 4.6 39.6 90 4.2 42.5 47 2.2 38.2 186 8.6 41.2 Diagnoses of mental health conditions at consent 341 5.0 3 0.9 1.2 2 0.6 0.9 0 0.0 0.0 4 1.2 0.9 Ever HBV infection prior to consent 379 5.6 13 3.4 5.2 8 2.1 3.8 10 2.6 8.1 27 7.1 6.0 Ever HCV infection prior to consent 780 11.5 14 1.8 5.6 12 1.5 5.7 7 0.9 5.7 28 3.6 6.2 Abbreviations: HBV, hepatitis B virus; HCV, hepatitis C virus; HRH, heterosexual; IDU, injection drug user; IQR, interquartile range; MSM, men who have sex with men; STI, sexually trans- mitted infection. All characteristics are at the time of consent into the DC Cohort. Other race/ethnicity includes persons of Asian/Pacific Island descent and those with more than 1 reported race. HIV risk behaviors: HRH, IDU, MSM. MSM who are also IDUs are grouped with MSM. Other HIV transmission risk behavior includes persons who were perinatally infected or infected through blood transfusions, coagulation disorders, or occupational exposures. Nadir CD4 is the lowest CD4 record available dated prior to enrollment into the DC Cohort. Seven participants had an unknown nadir CD4 cell count. Temporary/unstable housing was defined as a housing unit in which persons who are without housing or a fixed address receive temporary housing or shelter. Public insurance includes Medicare, Medicaid, and other public insurance coverage plans; “Other” insurance includes self-pay, recently terminated plans, clinical trial. Mental health conditions diagnosed previously or at the time of consent include major depressive disorder, anxiety disorder, bipolar disorder, psychoses, other. STIs in the DC Cohort • OFID • 3 Downloaded from https://academic.oup.com/ofid/article-abstract/5/2/ofy017/4823096 by Ed 'DeepDyve' Gillespie user on 16 March 2018 a b Table 2A. Incidence Rates per 100 Person-Years of Chlamydia, Gonorrhea, and Syphilis by Baseline Demographic Characteristics Among DC Cohort Participants (n = 6762) Chlamydia Gonorrhea Syphilis Any STI Rate (95% CI) Rate (95% CI) Rate (95% CI) Rate (95% CI) Overall 1.8 (1.7–2.1) 1.7 (1.5–1.9) 0.8 (0.7–0.9) 3.8 (3.5–4.1) Age at enrollment, y 0–17 3.0 (1.7–5.3) 2.3 (1.2–4.4) 0.3 (0–1.8) 5.0 (3.3–7.8) 18–34 5.7 (5.0–6.6) 5.1 (4.4–5.9) 1.6 (1.2–2.1) 10.8 (9.7–12.0) 35–54 1.2 (1.0–1.5) 1.1 (0.9–1.3) 0.8 (0.7–1.0) 2.8 (2.5–3.2) 55+ 0.2 (0.1–0.4) 0.3 (0.2–0.5) 0.2 (0.1–0.4) 0.6 (0.4–0.9) Gender at consent Male 2.1 (1.9–2.4) 2.0 (1.8–2.3) 1.0 (0.9–1.2) 4.6 (4.2–5.0) Female 0.7 (0.5–1.0) 0.4 (0.2–0.6) 0.1 (0–0.2) 1.1 (0.9–1.5) Transgender female 5.1 (3.1–8.3) 3.8 (2.2–6.7) 1.6 (0.7–3.8) 9.9 (6.9–14.0) Race/ethnicity Non-Hispanic black 1.7 (1.5–1.9) 1.4 (1.2–1.6) 0.6 (0.5–0.8) 3.3 (3.0–3.7) Non-Hispanic white 2.5 (2.0–3.2) 2.6 (2.1–3.3) 1.2 (0.8–1.7) 5.3 (4.6–6.3) Hispanic 4.2 (2.9–6.0) 4.4 (3.1–6.4) 1.9 (1.1–3.3) 9.2 (7.2–11.8) Other 0.9 (0.3–2.8) 1.5 (0.6–3.7) 0.3 (0–2.2) 2.4 (1.2–4.9) Unknown 0.5 (0.2–1.5) 0.2 (0–1.1) 1.5 (0.8–2.8) 2.1 (1.2–3.6) HIV risk behavior MSM 3.6 (3.2–4.0) 3.6 (3.2–4.1) 1.7 (1.4–2.1) 7.7 (7.1–8.4) HRH 0.5 (0.3–0.7) 0.2 (0.1–0.4) 0.1 (0–0.2) 0.8 (0.6–1.1) IDU 0.1 (0–0.5) 0.1 (0–0.5) NA 0.1 (0–0.6) Other 1.6 (0.9–2.6) 1.0 (0.5–1.9) NA 2.4 (1.6–3.7) Unknown 0.8 (0.6–1.2) 0.4 (0.2–0.7) 0.3 (0.2–0.6) 1.5 (1.1–2.0) Abbreviations: CI, confidence interval; HRH, heterosexual; IDU, injection drug user; MSM, men who have sex with men; NA, insufficient data for calculation; STI, sexually transmitted infection. Rate per 100 person-years of observation using Rothman/Greenland estimation for 95% confidence intervals. All characteristics are at the time of consent into the DC Cohort. had public insurance and 26.9% had private insurance, 13.4 and P-Y; 95% CI, 7.1–8.4) (Table 2A). The STI incidence rates were 12.2% had a history of alcohol and substance abuse, respect- stratified for race/ethnicity by age, gender, and risk behavior, as ively, and 11.5% had a hepatitis C diagnosis. well as for age by risk behavior and gender. Taking into account During a median follow-up period of 32.5  months, 6.7% of the number of participants, the highest incidence rates were all participants developed an incident STI (n = 451); 3.7% of all noted in transgender females age 18–34  years (21.0 cases per participants had incident chlamydia infection (n  =  250), 3.1% 100 P-Y; 95% CI, 14.0–31.0) and MSM age 18–34  years (15.0 gonorrhea (n  =  212), and 1.8% syphilis (n  =  123). There was cases per 100 P-Y; 95% CI, 14.0–17.0). Please refer to Table 2B an additional 2.6% with possible incident syphilis that did not for additional details. meet the definition of an incident case. Among participants with In the univariate Poisson regression model, younger age, male an incident STI, 30.4% had 2 or more STI episodes (n = 137); gender, transgender women, non-Hispanic white and Hispanic 19.3% had 2 STI episodes (n = 87), 7.3% had 3 (n = 33), 1.8% race/ethnicity, MSM risk behavior, temporary/unstable hous- had 4 (n  =  8), and 2.0% had 5–8 STI episodes (n  =  9). Of all ing, alcohol use, substance abuse, and higher nadir CD4 counts the STI episodes, 64.3% were among non-Hispanic blacks and were all associated with a higher risk of developing an STI, 22.4% were among non-Hispanic whites. However, 5.6% of all while the presence of a mental health diagnosis and history of enrolled non-Hispanic blacks developed an STI, whereas 10.7% hepatitis C infection were associated with a lower risk (data not of non-Hispanic whites and 13.7% of Hispanics developed an shown). In the multivariate Poisson regression model, younger STI. Furthermore, 80.9% of individuals who developed an STI age, especially 0–17 and 18–34 years, Hispanic ethnicity, MSM were MSM (Table 1). risk behavior, and higher nadir CD4 counts remained associ- e in Th cidence rate of any STIs in the DC Cohort was 3.8 cases ated with a higher risk of developing an STI, while the presence per 100 P-Y (95% CI, 3.5–4.1). The highest incidence rates of of a mental health diagnosis was still associated with a lower any STIs were noted in the following groups: age 18–34  years risk (Table 3). (10.8 cases per 100 P-Y; 95% CI, 9.7–12.0), transgender females In the assessment of potential HIV transmission risk at the (9.9 cases per 100 P-Y; 95% CI, 6.9–14.0), Hispanics (9.2 cases time of STI diagnosis, the VLs were assessed at ±1  month, per 100 P-Y; 95% CI, 7.2–11.8), and MSM (7.7 cases per 100 3 months, and 6 months (Table 4). VL measurements were not 4 • OFID • Lucar et al Downloaded from https://academic.oup.com/ofid/article-abstract/5/2/ofy017/4823096 by Ed 'DeepDyve' Gillespie user on 16 March 2018 a b Table 2B. Incidence Rates per 100 Person-Years of Chlamydia, Gonorrhea, and Syphilis by Baseline Demographic Characteristics Among DC Cohort Participants (n = 6762), Stratified for Race/Ethnicity by Age, Gender, and Risk Behavior Chlamydia Gonorrhea Syphilis Any STI No. Rate (95% CI) Rate (95% CI) Rate (95% CI) Rate (95% CI) Stratify race/ethnicity by age, y Non-Hispanic black 0–17 131 3.5 (2.0–6.1) 2.6 (1.3–5.0) 0.3 (0.0–2.0) 5.8 (3.7–8.9) 18–34 1057 5.7 (4.8–6.7) 4.9 (4.1–5.9) 1.5 (1.1–2.1) 10.8 (9.6–12.2) 35–54 2732 0.9 (0.7–1.2) 0.7 (0.5–0.9) 0.6 (0.4–0.8) 2.0 (1.7–2.4) 55+ 1238 0.1 (0.0–0.3) 0.2 (0.1–0.4) 0.1 (0.0–0.2) 0.3 (0.2–0.6) Non-Hispanic white 0–17 8 NA NA NA NA 18–34 141 7.8 (5.5–11.2) 7.3 (5.1–10.6) 1.6 (0.7–3.5) 13.1 (9.9–17.2) 35–54 537 2.2 (1.6–3.0) 2.4 (1.7–3.3) 1.4 (1.0–2.2) 5.3 (4.3–6.6) 55+ 254 0.6 (0.3–1.5) 0.9 (0.4–1.8) 0.5 (0.2–1.3) 1.9 (1.1–3.1) Hispanic 0–17 5 NA NA NA NA 18–34 89 6.7 (3.8–11.8) 7.2 (4.2–12.5) 1.1 (0.3–4.5) 13.4 (9.0–20.0) 35–54 170 4.0 (2.5–6.6) 4.3 (2.7–6.9) 2.5 (1.4–4.7) 9.4 (6.8–13.0) 55+ 48 NA NA 1.1 (0.2–8.1) 1.1 (0.2–8.1) Stratify race/ethnicity by gender Non-Hispanic black Male 3414 1.9 (1.7–2.2) 1.8 (1.5–2.1) 0.9 (0.7–1.1) 4.1 (3.7–4.5) Female 1648 0.8 (0.6–1.1) 0.4 (0.2–0.6) 0.1 (0.0–0.2) 1.2 (0.9–1.6) Transgender Female 96 6.1 (3.7–10.0) 3.4 (1.8–6.6) 1.9 (0.8–4.6) 10.7 (7.4–15.5) Non-Hispanic white Male 882 2.6 (2.1–3.3) 2.8 (2.2–3.5) 1.2 (0.9–1.8) 5.7 (4.8–6.7) Female 55 NA NA NA NA Transgender Female 3 NA NA NA NA Hispanic Male 270 4.7 (3.2–6.8) 4.7 (3.2–6.8) 2.2 (1.3–3.8) 10.1 (7.8–13.0) Female 31 NA NA NA 0.0 (0.0–) Transgender Female 11 NA 6.6 (1.6–26.2) NA 6.6 (1.6–26.2) Stratify race/ethnicity by risk behavior Non-Hispanic black MSM 1620 3.8 (3.3–4.5) 3.6 (3.1–4.2) 1.7 (1.3–2.1) 8.1 (7.3–8.9) HRH 1792 0.5 (0.3–0.8) 0.2 (0.1–0.4) 0.1 (0.0–0.2) 0.8 (0.6–1.1) IDU 425 0.1 (0.0–0.6) NA NA 0.1 (0.0–0.6) Other 292 1.9 (1.1–3.3) 1.2 (0.6–2.4) NA 3.0 (2.0–4.6) Unknown 1029 0.7 (0.4–1.1) 0.4 (0.2–0.8) 0.4 (0.2–0.7) 1.4 (1.0–2.0) Non-Hispanic white MSM 667 3.3 (2.6–4.2) 3.6 (2.9–4.6) 1.6 (1.1–2.3) 7.3 (6.2–8.6) HRH 58 NA NA NA NA IDU 19 NA NA NA NA Other 37 NA NA NA NA Unknown 159 0.9 (0.3–2.3) 0.2 (0.0–1.5) 0.2 (0.0–1.5) 1.3 (0.6–2.9) Hispanic MSM 194 4.7 (3.1–7.2) 6.0 (4.2–8.7) 2.4 (1.3–4.3) 11.2 (8.5–14.7) HRH 57 1.0 (0.1–6.8) NA 1.0 (0.1–6.8) 1.9 (0.5–7.7) IDU 4 NA 18.8 (2.7–133.6) NA 18.8 (2.7–133.6) Other 9 NA NA NA NA Unknown 48 6.7 (2.8–16.0) 1.3 (0.2–9.5) 1.3 (0.2–9.5) 9.3 (4.4–19–5) Stratify age by risk behavior MSM 5 24.0 (6.0–95.0) 24.0 (6.0–95.0) 12.0 (1.7–85.0) 48.0 (18 127 .0) HRH 8 16.0 (5.1–49.0) 5.2 (0.7–37.0) NA 21.0 (7.9–56.0) IDU 0 NA NA NA NA Other 132 1.9 (0.9–4.1) 1.7 (0.7–3.7) NA 3.3 (1.9–5.9) 0–17 y Unknown 4 NA NA NA NA MSM 796 7.7 (6.5–9.0) 7.8 (6.7–9.2) 2.4 (1.8–3.1) 15.0 (14.0–17.0) HRH 300 2.1 (1.3–3.4) 1.0 (0.5–2.0) 0.3 (0.1–1.1) 3.0 (2.0–4.6) IDU 5 NA 9.5 (1.3–67.0) NA 9.5 (1.3–67.0) Other 120 2.2 (1.0–4.8) 1.1 (0.3–3.3) NA 3.2 (1.7–6.2) 18–34 y Unknown 155 5.5 (3.5–8.8) 1.5 (0.6–3.7) 1.2 (0.5–3.3) 8.0 (5.4–12.0) MSM 1433 2.5 (2.1–3.0) 2.4 (1.9–2.9) 1.8 (1.4–2.2) 5.9 (5.2–6.7) HRH 1200 0.3 (0.1–0.5) 0.1 (0.0–0.3) 0.1 (0.0–0.3) 0.5 (0.3–0.8) IDU 156 NA NA NA NA Other 72 0.5 (0.1–3.8) NA NA 0.5 (0.1–3.8) STIs in the DC Cohort • OFID • 5 Downloaded from https://academic.oup.com/ofid/article-abstract/5/2/ofy017/4823096 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Table 2B. Continued Chlamydia Gonorrhea Syphilis Any STI No. Rate (95% CI) Rate (95% CI) Rate (95% CI) Rate (95% CI) 35–54 y Unknown 772 0.3 (0.1–0.7) 0.3 (0.1–0.7) 0.3 (0.1–0.7) 0.8 (0.5–1.4) MSM 417 0.5 (0.2–1.1) 0.9 (0.5–1.7) 0.5 (0.2–1.1) 1.8 (1.1–2.7) HRH 481 NA NA 0.1 (0.0–0.6) 0.1 (0.0–0.6) IDU 291 0.1 (0.0–0.8) NA NA 0.1 (0.0–0.8) Other 29 NA NA NA NA 55+ y Unknown 381 0.2 (0.1–0.9) 0.1 (0.0–0.8) 0.1 (0.0–0.8) 0.5 (0.2–1.2) Stratify age by gender Male 61 3.1 (1.3–7.5) 1.9 (0.6–5.8) 0.6 (0.1–4.4) 5.0 (2.5–10) Female 88 3.0 (1.4–6.2) 2.5 (1.1–5.6) NA 5.1 (2.9–8.9) 0–17 y Transgender female 0 NA NA NA NA Male 993 6.6 (5.6–7.7) 6.2 (5.3–7.3) 2.0 (1.5–2.6) 13.0 (11–14) Female 338 2.3 (1.5–3.7) 1.2 (0.6–2.2) NA 3.3 (2.2–4.8) 18–34 y Transgender female 45 10 (5.7–18.0) 9.1 (5.1–16.0) 3.3 (1.2–8.8) 21.0 (14.0–31.0) Male 2552 1.5 (1.3–1.9) 1.5 (1.2–1.8) 1.1 (0.9–1.4) 3.7 (3.3–4.2) Female 1024 0.3 (0.1–0.6) 0.1 (0.0–0.3) 0.1 (0.0–0.3) 0.4 (0.2–0.8) 35–54 y Transgender female 57 1.8 (0.6–5.6) 0.6 (0.1–4.3) 0.6 (0.1–4.3) 3.0 (1.2–7.2) Male 1217 0.2 (0.1–0.5) 0.4 (0.2–0.6) 0.2 (0.1–0.4) 0.7 (0.5–1.1) Female 371 NA NA 0.1 (0.0–0.8) 0.1 (0.0–0.8) 55+ y Transgender female 11 3.8 (0.5–27.0) 0.0 (0.0–0.0) NA 3.8 (0.5–27) Abbreviations: CI, confidence interval; HRH, heterosexual; IDU, injection drug user; MSM, men who have sex with men; NA, insufficient data for calculation; STI, sexually transmitted infection. Rate per 100 person-years of observation using Rothman/Greenland estimation for 95% confidence intervals. All characteristics are at the time of consent into the DC Cohort. available for 116 (25.7%) participants at ±1  month, 44 (9.8%) the populations at particularly high risk included 18–34-year- at ±3 months, and 29 (6.4%) at ±6 months aer S ft TI diagnosis. olds of all races/ethnicities, MSM of all races/ethnicities, Although VL measurements were missing for 25.7% of partic- Hispanic men, and non-Hispanic black transgender women. ipants at the assessment closest to the STI episode, VL results All groups were at substantial risk of STIs, with incidence were similar to those at 3 and 6 months and therefore assumed rates ranging from 7.3 to 13.4 cases per 100 P-Y. Although to be representative. Among individuals with any number the overall number of transgender women enrolled in the DC of STI episodes, 41.8% had a detectable viral load (above the Cohort was relatively low, at 113, this sample size afforded LLOQ) within 1  month of the STI diagnosis; 14.6% had a VL an opportunity for comparison of risk across the larger HIV- ≥1500 copies/mL. For those with 1 STI episode, 13.5% had a VL infected population overall and other high-risk populations. ≥1500 copies/mL and 7.4% had a VL ≥10 000 copies/mL. These The very high risk of STIs identified among transgender percentages were higher in participants with 2 or more STI epi- women highlights the importance of strategies to reduce STI sodes; 17.1% had a VL ≥1500 copies/mL, and 13.3% had a VL and HIV transmission that are culturally and gender sensitive ≥10 000 copies/mL. However, these differences did not achieve across all at-risk groups. statistical significance. In the multivariate analysis of factors associated with STI risk, younger age (especially <18 and 18–34  years), Hispanic DISCUSSION ethnicity, MSM risk behavior, and higher nadir CD4 counts In this large-scale, single city–focused analysis, we reported the were strongly associated with a higher risk of developing an incidence and factors associated with the development of chla- STI. It has been hypothesized that with higher CD4 counts (as mydia, gonorrhea, and syphilis in a cohort of people living with a consequence of virologic suppression on ART), patients may HIV (PLWH) in care in DC. Consistent with incidence rates perceive a lower “threat” of HIV transmission and therefore among the DC general population [2], chlamydia had the high- have higher-risk sexual behaviors [18–20]. To date, this associ- est incidence, followed by gonorrhea and then syphilis, each ation has not been proven [21–23], but our data on CD4 counts with particularly high rates among 18–34-year-olds, MSM, may suggest a potential association between improved general transgender women, and Hispanic participants. well-being and high-risk sexual behaviors. Certainly, it has been Among age, gender, race/ethnicity, and risk categories, proposed that the greatest prevalence of STIs in PLWH is at the 18–34-year-olds, transgender women, Hispanics, and MSM time of HIV diagnosis [24]. However, it is also widely recognized had the highest STI incidence rates. In our stratified analysis, that high-risk sexual behaviors can continue at any point aer ft 6 • OFID • Lucar et al Downloaded from https://academic.oup.com/ofid/article-abstract/5/2/ofy017/4823096 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Table 3. Multivariate Poisson Regression Analysis for Factors Associated With the Development of STIs Among Participants in the DC Cohort Chlamydia Gonorrhea Syphilis Any STI Participant Characteristic RR (95% CI) P RR (95% CI) P RR (95% CI) P RR (95% CI) P Age at consent, y 0–17 24.2 (7.3–80.4) <.0001 23.5 (7.2–76.6) <.0001 2.5 (0.3–20.1) .40 17.6 (7.2–42.9) <.0001 18–34 15.7 (7.9–31.4) <.0001 9.9 (5.4–18.2) <.0001 6.1 (2.8–13.2) <.0001 9.4 (6.2–14.1) <.0001 35–54 4.4 (2.2–8.8) <.0001 2.9 (1.6–5.2) .001 3.9 (1.8–8.1) .000 3.3 (2.2–4.9) <.0001 55+ Ref Ref Ref Ref Gender at consent Male Ref Ref Ref Ref Female 0.8 (0.5–1.3) .385 0.6 (0.4–1.2) .143 0.1 (0–0.3) <.0001 0.7 (0.5–1) .0316 Transgender female 1.3 (0.8–2.2) .335 1 (0.5–1.8) .945 1.3 (0.5–3.3) .53 1.2 (0.8–1.8) .3053 Race/ethnicity Non-Hispanic black Ref Ref Ref Ref Non-Hispanic white 1.3 (0.9–1.7) .12 1.5 (1.1–2) .009 1.3 (0.8–2) .23 1.2 (1–1.5) .05 Hispanic 1.4 (0.9–2.1) .130 1.7 (1.1–2.5) .009 1.7 (0.9–3) .095 1.5 (1.1–1.9) .008 Other 0.5 (0.2–1.5) .21 1 (0.4–2.4) .95 0.4 (0.1–2.7) .33 0.6 (0.3–1.2) .18 HIV risk behavior MSM Ref Ref Ref Ref HRH 0.3 (0.2–0.4) <.0001 0.1 (0.1–0.3) <.0001 1.3 (0.7–2.4) .325 0.2 (0.1–0.3) <.0001 IDU 0.1 (0–1.4) .088 0.1 (0–1) .045 0.2 (0–0.8) .022 0.1 (0–0.7) .03 Other 0.3 (0.1–0.8) .02 0.2 (0–0.5) .001 0.6 (0.4–0.9) .01 0.2 (0.1–0.5) <.001 Housing at consent Permanent/stable Ref Ref Ref Ref Temporary/unstable 1 (0.7–1.5) .84 1.2 (0.8–1.9) .29 1.8 (0.9–3.5) .12 1.2 (1–1.6) .089 Homeless 0.9 (0.4–2.3) .88 1.5 (0.4–6.3) .54 1.6 (0.9–2.6) .08 0.8 (0.4–1.6) .52 Primary insurance Public 1.3 (1–1.8) .039 1.5 (1.1–2) .020 1.3 (0.7–2.3) .444 1.2 (1–1.5) .062 Private Ref Ref Ref Ref Other 1.2 (0.6–2.4) .576 0.7 (0.2–2) .480 1.3 (0.7–2.5) .374 1.2 (0.8–2) .3727 Alcohol use 1.2 (0.8–1.9) .320 1.2 (0.8–1.7) .442 0.7 (0.4–1.4) .355 1.2 (0.9–1.6) .1598 Substance abuse 1.3 (0.8–2.1) .194 1.4 (1–2) .056 2.2 (1.1–4.4) .034 1.3 (1–1.7) .0345 Mental health diagnosis at consent 0.3 (0.1–1) .044 0.4 (0.1–1.1) .072 2 (1–4) .063 0.3 (0.1–0.6) .0028 Ever HBV infection prior to consent 0.9 (0.5–1.5) .631 0.7 (0.4–1.3) .316 2.6 (1.3–5.2) .009 0.9 (0.7–1.3) .7119 Ever HCV infection prior to consent 1 (0.6–1.5) .880 0.7 (0.4–1.2) .215 1.8 (0.9–3.8) .124 0.9 (0.7–1.3) .5952 Nadir CD4 cell count <50 Ref Ref Ref Ref 50–199 1.5 (0.9–2.6) .108 1.3 (0.8–2.2) .29 1.3 (0.8–2.2) .290 1.5 (1.1–2.1) .017 200–349 2.6 (1.6–4.2) <.0001 2.2 (1.4–3.5) .001 2.2 (1.4–3.5) .001 2.2 (1.6–3) <.0001 350–499 2.2 (1.4–3.6) .0015 1.8 (1.1–3) .014 1.8 (1.1–3) .014 1.9 (1.4–2.7) <.0001 500+ 2.4 (1.4–3.9) .0007 1.7 (1.1–2.9) .028 1.7 (1.1–2.9) .03 1.9 (1.4–2.7) .00 Abbreviations: HBV, hepatitis B virus; HCV, hepatitis C virus; HRH, heterosexual; IDU, injection drug user; MSM, men who have sex with men; Ref, reference group; RR, relative risk; STI, sexually transmitted infection. Transgender men were not included in this analysis due to the small number (n = 5). Other HIV transmission risk behavior includes persons who were perinatally infected or infected through blood transfusions, coagulation disorders, or occupational exposures. Temporary/unstable housing was defined as a housing unit in which persons who are without housing or a fixed address receive temporary housing or shelter. Public insurance includes Medicare, Medicaid, and other public insurance coverage plans; “Other” insurance includes self-pay, recently terminated plans, clinical trial. Mental health conditions diagnosed previously or at the time of consent include major depressive disorder, anxiety disorder, bipolar disorder, psychoses, other. Nadir CD4 is the lowest CD4 record available dated prior to enrollment into the DC Cohort. Seven participants had an unknown nadir CD4 cell count. A Bonferroni correction was applied to account for multiple testing, resulting in a significance level of .05/3 = .0167, and subsequent confidence intervals set at 98.33%. HIV diagnosis [25, 26]. Thus, though risk may be reduced com- incidence (3.8 cases per 100 P-Y) with other cohorts should be pared with before HIV diagnosis, this study demonstrates that interpreted with caution. There are several studies that examine ongoing STI and HIV transmission risk remains considerable. the incidence of bacterial STIs, but many of them focus on spe- er Th e is significant heterogeneity between previous studies cific groups (eg, men, MSM, women) or settings (eg, STI clin- of STIs among PLWH in other large metropolitan areas of the ics, military personnel). For example, a study on self-reported United States [24]. Hence, the comparison between our STI STIs via structured computer interviews in PLWH in Atlanta, prevalence (6.7% over a median follow-up of 32.5 months) and Georgia, showed that 14% of respondents had an STI diagnosed STIs in the DC Cohort • OFID • 7 Downloaded from https://academic.oup.com/ofid/article-abstract/5/2/ofy017/4823096 by Ed 'DeepDyve' Gillespie user on 16 March 2018 Table 4. HIV Viral Load in Participants With at Least 1 STI Episode (<LLOQ, LLOQ–<1500, 1500–<10 000, and ≥10 000 copies/mL) Within ±1 Month, ±3 Months, and ±6 Months of STI Diagnosis (n = 451) Within 1 mo Within 3 mo Within 6 mo Participants with at least 1 LLOQ– LLOQ– LLOQ– STI episode <LLOQ <1500 1500–9999 ≥10 000 <LLOQ <1500 1500–9999 ≥10 000 <LLOQ <1500 1500–9999 ≥10 000       451 195 (58.2%) 91 (27.2%) 18 (5.4%) 31 (9.3%) 241 (59.4%) 108 (26.6%) 19 (4.7%) 38 (9.4%) 253 (60.0%) 112 (26.5%) 19 (4.5%) 38 (9.0%) One hundred sixteen participants (25.7%) did not have a VL recorded within ±1 month, 44 participants (9.8%) did not have a VL recorded within ±3 months, and 29 (4.4%) participants did not have a VL recorded within ±6 months of STI diagnosis.  Abbreviations: LLOQ, lower limit of quantification; STI, sexually transmitted infection; VL, viral load. linkage to care and virologic suppression opportunities may also in the previous 6  months, with a high frequency of STIs ever require cross-site communication. We propose specifically that at since HIV diagnosis (20% had chlamydia, 13% had gonorrhea, each encounter for STI evaluation and/or treatment, even outside of and 36% had syphilis) [25]. In contrast, in a cohort of HIV- the usual site of HIV care, a focused discussion and intensive efforts infected Department of Defense beneficiaries, the prevalence of syphilis at the time of HIV diagnosis was 6%; the incidence rate toward engagement in care and virologic suppression should be was 1.3 cases per 100 P-Y [21]. As expected, published studies provided. This high-impact intervention among those potentially in which HIV-infected individuals were tested following STI transmitting HIV not only provides profound individual benefit, screening protocols reported higher STI rates [27, 28] and are but may also prevent new HIV cases in the community. more likely to approach a true STI incidence. This study has several limitations. First, the observational Virologic suppression with antiretroviral therapy has been nature of the DC Cohort precluded standardized STI screening widely recognized as the key intervention to prevent HIV for all participants. STIs are frequently asymptomatic, and dif- transmission, as recently confirmed in 2 large studies [11, 12]. ferences in screening practices can impact the observed STI fre- er Th e have been multiple attempts in the past to determine the quency [32, 33]. Subsequently, our reported STI incidence rates extent to which STI control could impact HIV transmission, are likely underestimating the true STI incidence in PLWH in with mixed results [29–31]. Nevertheless, even when we fail care in DC. Furthermore, STI screening may provide diagnosis to impact high-risk sexual behaviors, it is possible to interrupt dates distant from the actual time of STI acquisition with impli- HIV transmission if the VL is suppressed. Arguably the most cations in our estimation of HIV transmission risk. Similarly, important (and disappointing) finding of our analysis was the the study design also limited the availability of HIV VLs during fact that 41.8% of participants with at least 1 STI episode had a the same encounter of STI diagnosis. Second, we were unable to detectable VL within 1  month of STI diagnosis. Furthermore, distinguish genital or extragenital sites of chlamydia and gonor- when using ≥1500 copies/mL as a proxy for transmission risk rhea infection. Third, the population enrolled in the DC Cohort (albeit based on data in heterosexual transmission), 14.5% had may not be fully representative of the larger HIV-infected pop- ≥1500 copies/mL. Sustained virologic suppression among indi- ulation in DC, as enrollment requires some degree of engage- viduals with ongoing risk behaviors, signaled by the occurrence ment in care, and the demographics of those declining consent of an STI, may prevent HIV transmission from an infected differed slightly from those who provided consent. sexual partner, and thus new HIV cases. Additionally, a nota- Nonetheless, the strengths of this study include its city-wide, ble finding from our data is the absence of VL measurement prospective enrollment of participants, its longitudinal study on 25.7% of those with STIs within ±1 month of STI diagnosis, design, and the large sample size that is inclusive of male, female, 9.8% within ±3 months, and 6.4% at ±6 months. Yet our finding and transgender participants. Also, our study is unique in link- that 41.8% of participants within 1 month of STI diagnosis had ing data from multiple clinical sites with data reported to the a detectable VL should be an important reminder that presenta- local health department. Merging of the DC Cohort and the tion for STI evaluation is also a critical opportunity to address DC-DOH databases improved the accuracy of STI diagnosis fre- ART adherence and virologic suppression. quency and provided insight into care received for STIs outside e D Th C Cohort database is linked semi-annually with the DC of the primary HIV care site. Finally, to our knowledge, this is the Department of Health (DC-DOH) HIV/AIDS surveillance data- largest cohort to examine the occurrence of STIs and estimated base to enhance data accuracy, as individuals may receive care at HIV transmission risk in the DC metropolitan area, which has multiple clinical sites. Aer co ft mpleting our planned STI analyses, one of the highest incidence rates of HIV in the United States. we examined linked data and found a 9.2% increase in the number In conclusion, STIs are frequent among HIV-positive indi- of chlamydia cases (from 250 to 273 cases) and a 20.8% increase in viduals receiving care in DC; thus risk reduction interventions the number of cases of gonorrhea (from 212 to 256 cases) during the are needed for people living with HIV to help control the spread period of study (unpublished data). These findings highlight that of STIs, achieve durable HIV virologic suppression, and reduce 8 • OFID • Lucar et al Downloaded from https://academic.oup.com/ofid/article-abstract/5/2/ofy017/4823096 by Ed 'DeepDyve' Gillespie user on 16 March 2018 10. Politch JA, Mayer KH, Welles SL, et al. Highly active antiretroviral therapy does HIV transmission. These findings will help health care pro- not completely suppress HIV in semen of sexually active HIV-infected men who viders and policy makers provide high-impact interventions have sex with men. AIDS 2012; 26:1535–43. toward STI control and achievement of virologic suppression 11. Cohen MS, Chen YQ, McCauley M, et al; HPTN 052 Study Team. Antiretroviral therapy for the prevention of HIV-1 transmission. N Engl J Med 2016; 375:830–9. among PLWH with the goal of improving the health of the indi- 12. Rodger AJ, Cambiano V, Bruun T, et al; PARTNER Study Group. Sexual activity vidual and reducing the incidence of HIV in the community. without condoms and risk of HIV transmission in serodifferent couples when the HIV-Positive partner is using suppressive antiretroviral therapy. JAMA 2016; Acknowledgments 316:171–81. 13. DC Cohort Longitudinal HIV Study. 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STIs in the DC Cohort • OFID • 9 Downloaded from https://academic.oup.com/ofid/article-abstract/5/2/ofy017/4823096 by Ed 'DeepDyve' Gillespie user on 16 March 2018

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