Sexually Transmitted Infections

BackgroundCore groups, characterized by high levels of sexual activity and disease prevalence, are critical to the transmission dynamics of sexually transmitted infections (STIs) like gonorrhea. Understanding core group dynamics is essential for developing targeted interventions and understanding their potential effect on outcomes for gonorrhea. We assessed core group composition among gonorrhea cases in Guilford County, North Carolina, where gonorrhea rates are elevated, and antimicrobial resistance is a growing concern. MethodsWe used Neisseria gonorrhoeae surveillance data collected in both public health clinics and emergency departments in Guilford County to characterize core groups. Data including demographics, behavioral risks, and longitudinal gonorrhea test results, were reviewed for specimens submitted for gonorrhea testing. Statistical analyses, including descriptive statistics and univariate logistic regression, were performed to assess factors influencing core group membership within three subpopulations: teens, adult men who have sex with men (MSM), and adult heterosexuals. ResultsThe study included 25,520 patients, with 1,718 (6.7%) classified as part of the core group. The core group accounted for 68% of all gonorrhea cases, with subgroups such as teen, adult MSM, and adult heterosexual core groups contributing disproportionately to their respective gonorrhea cases (66%, 79%, and 67%, respectively). Demographic and behavioral risk factors are explored and factors increasing odds ratios of core group inclusion are identified among the general population as well as three subpopulations: teens, adult MSM, and adult heterosexual core groups. Notable risk factors for gonorrhea core group inclusion across all subgroups include increased number of sexual partners, drug use, and HIV status. Notably, there is variation in some risk factors among subpopulations including race/ethnicity and sex while traveling internationally. DiscussionAmong other factors, variations in public health policies and population level behavioral norms change the way gonorrhea spreads through a population. We report gonorrhea core group composition for a region with high gonorrhea rates. In particular, we discuss the role of teenagers in gonorrhea transmission dynamics, a typically under reported group. Understanding population specific dynamics is essential for formulating effective and targeted interventions.

ObjectivesMany countries recommend 3-monthly chlamydia/gonorrhoea screening for men-who-have-sex-with-men (MSM). New evidence about the limited impact of frequent, asymptomatic gonorrhoea/chlamydia screening on population prevalence, coupled with concerns about overburdened health services and antimicrobial resistance (from over-treatment), calls into question current approaches to asymptomatic screening. We explored sexual health professionals/experts arguments in favour/against reducing asymptomatic screening using Polis (www.Pol.is), an online, crowdsourcing tool for understanding what large groups think. MethodsRecruited via global peak bodies/networks, 99 sexual health professionals/experts (43.4.% clinicians, 35.4% researchers) primarily from Oceania (41.4%), UK/Europe (29.4%) and North America (22.2%) submitted 83 statements in favour/against reduced screening for men-who-have-sex-with-men (e.g. Bisexual men who dont test regularly risk putting women at risk). Participants voted on submitted statements (agree/disagree/pass). We considered statements with [≥]80 agreement as strong support, 70-79% moderate support, [≤]69% mixed support. We used content analysis to group clusters of related statements, and examined associations between participant demographics and votes for/against. ResultsThere was mixed support for statements on :1) the impact of screening in reducing prevalence; 2) whether asymptomatic infections pose clinical harm/necessitate treatment; and risk of antimicrobial resistance. Statements advocating for 6-monthly screening received moderate support, with arguments centering on resource use. Participants strongly supported the need for community engagement and maintaining frequent HIV/syphilis screening. UK/Europe participants were more likely to favour reduced chlamydia/gonorrhoea screening. ConclusionsWhile there were mixed opinions about relative utility, risks, and harms of reducing chlamydia/gonorrhoea screening for MSM, arguments relating to resource use may provide common ground for policy changes.

OBJECTIVEClinical trials have shown that doxycycline as post-exposure prophylaxis after sexual contact (doxy-PEP) prevents sexually transmitted bacterial infections (STI). We investigated current awareness about informal use of antibiotics as pre- and post-exposure prophylaxis to prevent STI (STI-PrEP/PEP) among men who have sex with men (MSM). In addition, we investigated psychosocial determinants of its use. METHODSData were collected in the Amsterdam Cohort Study among MSM, the Netherlands, between October 2021 and October 2022. In an online questionnaire, we assessed socio-demographics, sexual behavior, bacterial STI diagnoses, STI-PrEP/PEP awareness, perceived effectiveness of, and beliefs and attitudes towards STI-PrEP/PEP, and intention to use it. STI-PrEP/PEP users were described and (ordinal) logistic regression analysis was conducted to identify factors associated with STI-PrEP/PEP awareness (yes/no) and intention to use STI-PrEP/PEP (7-point Likert scale). RESULTSAmong 593 MSM with median age 46 years (IQR 36-53), 102 (17.2%) were aware of STI-PrEP/PEP and 15 (2.5%) had ever used it. STI-PrEP/PEP awareness was associated with living with HIV, HIV-PrEP use in the preceding 6 months, and sexualized drug use with casual partner(s). Median intention to use STI-PrEP-PEP was 3 (IQR 2-4). Higher intention to use STI-PrEP/PEP was associated with HIV-PrEP use, sexual contact with casual partners, being worried to get an STI, self-protection as reason to use it, the intention to reduce STI testing and sexual experimenting. Stigmatizing beliefs regarding STI-PrEP/PEP users were associated with lower use intentions. CONCLUSIONPreventive use of antibiotics for STI prevention is limited among MSM in the Netherlands in 2021/2022. Some men have a high intention for future use. Self-protection and a wish for sexual experimenting are amongst the intrinsic motivators for higher intention to use STI-PrEP/PEP. More studies on the safe use of STI-PrEP/PEP are required as well as a strategy to educate those who have already adopted STI-PrEP/PEP or have a high intention to do so, and their healthcare providers.

BackgroundOnline pharmacies offer an alternative approach for patients to manage their sexual health. Our aim was to determine the type of antimicrobials sold as treatment for sexually transmitted infections (STIs) by UK internet pharmacies and if providers were adhering to national guidelines. MethodsA search engine results page (SERP) generated a list of registered UK online pharmacies offering treatment for the following infections: Chlamydia trachomatis, Neisseria gonorrhoeae, Herpes simplex and Trichomonas vaginalis. An initial audit in 2017 benchmarked each provider against the British Association of Sexual Health & HIV (BASHH guidelines. Results were fed back to each provider before re-audit in 2020. Websites selling antibiotics for non-gonococcal urethritis (NGU) and Mycoplasma genitalium were included at re-audit. ResultsThere were 30 pharmacies identified in 2017 of which, five were excluded. Treatment could be obtained for Neisseria gonorrhoeae from five pharmacies without providing a culture result; three (60%) pharmacies sold BASHH approved antibiotics for Neisseria gonorrhoeae. All 25 pharmacies sold Chlamydia trachomatis treatment; 22 (88%) offered first line treatment options but no website assessed for proctitis. Herpes simplex treatment was sold on 22 websites of which, 13 (59%) offered treatment recommended by BASHH. Trichomonas vaginalis treatment was sold by four websites in line with BASHH. Results at re-audit showed an improvement in standards, although advice before, during and after treatment remained variable. DiscussionOur work has allowed us to engage with providers to improve prescribing within the UK online pharmacy industry. However, tougher regulation is needed in order to embed sustainable change for patients who choose to access treatment online.

BackgroundSquamous cell carcinoma of the anus (SCCA) annual incidence among sexual minority men (SMM) with and without HIV is 85/100,000 and 19/100,000 persons, respectively, which is significantly higher than the overall incidence (2/100,000). Since SCCA tumours average [≥]30 mm at diagnosis, we assessed the accuracy of individuals to self-detect anal abnormalities. MethodsThe study enrolled 714 SMM and transgender women (SMM/TW), aged 25 to 81 years, in Chicago, Illinois and Houston, Texas during 2020-2022. Individuals were taught the anal self- and companion examinations (ASE/ACE). Then, a clinician performed a digital anal rectal examination (DARE) before participants conducted the ASE or ACE. Accuracy was measured along with factors associated with ASE/ACE and DARE concordance. FindingsThe median age was 40 years (interquartile range, 32-54), 36.8% were living with HIV, and 47.0%, 23.4%, and 23.0% were non-Hispanic white, non-Hispanic Black, and Hispanic. Clinicians detected 245 individuals with abnormalities (median diameter 3 mm). Sensitivity and specificity of the ASE/ACE was 59.6% (95%CI 53.5-65.7%) and 80.2% (95%CI 76.6-83.8%), respectively. Overall concordance was 0.73 (95% CI 0.70-0.76) between ASE/ACE and DARE and increased with increasing anal canal lesion size (p=0.02). However, concordance was lower for participants aged [≥]55 years (compared to 25-34 years) and when the ASE/ACE trainer was a lay person rather than a clinician. InterpretationSMM/TW who complete an ASE or ACE are likely to detect SCCA at an early stage when malignant lesions are much smaller than the current median dimension at presentation of [≥]30 mm. FundingNational Cancer Institute Research in contextO_ST_ABSEvidence before this studyC_ST_ABSWhile squamous cell carcinoma of the anus (SCCA) incidence is substantially elevated in people with HIV, there are currently no consensus recommendations on how to screen for it, nor is there widespread technological infrastructure for one prevailing method, high-resolution anoscopy. In the absence of screening programs, the size of SCCA tumours at diagnosis are > 30 mm. We searched PubMed for articles between January 1, 2000 and June 15, 2023 using the search terms anus neoplasm and self-examination. We found no studies assessing the accuracy of self-examinations to detect anal masses other than our prior feasibility study. Added value of this studyThe primary goal of the Prevent Anal Cancer Palpation Study was to assess the accuracy of lay self-examinations and companion examinations to recognise abnormalities in the anal region. Clinicians conducted a digital anal rectal examination and recorded all lesions observed at the perianus or anal canal. The median size of lesions was 3 mm. Participants conducted lay examinations and these results were judged against a clinicians examination. The sensitivity and specificity of the lay examinations, for any lesion at the anal canal or perianal region was 59.6% and 80.1%, respectively. As lesions increased in size, concordance increased between clinicians exam and the lay exam. Implications of all the available evidenceIt is now known that high-resolution anoscopy can reduce the risk for SCCA but the infrastructure using this technology is very limited in high-resource settings and almost non-existent in low resource settings, especially where HIV prevalence is highest. The evidence suggests that self- and partner examination of the anal region is feasible and that lay persons can detect lesions that are much smaller than the prevailing size of SCCA tumours.

BackgroundSexually transmitted infections (STIs) and bacterial vaginosis (BV) are frequently asymptomatic in women. They cause genital inflammation and can increase transmission and acquisition of HIV. GIFT (Genital InFlammation Test) is a novel, point-of-care (POC) device under development for detecting genital inflammation in women. We aimed to obtain consensus to inform the development of GIFT and its integration into management guidelines. MethodsWe employed a Delphi technique through two rounds of online surveys. Respondents included service providers, health programmers, researchers, and policy makers. Round one questions generated ideas, and round two built consensus on the strategies from round one. Survey sections included demographics, implementation of the test, integration into current guidelines and purpose. Round two survey employed a five-point Likert scale from strongly agree to strongly disagree. Consensus was reached if [≥]70% of participants selected strongly agree or agree. ResultsWe received 28 to the first and 68 to the second round. From both rounds, participants were healthcare providers (41%) or researchers (26%), residing in Africa (57%), Europe (21%) and America (10%). Most participants agreed that GIFT should be used as a screening tool to be followed by confirmatory STI testing before treatment: 75% (round 1), 69% (round 2). There was consensus that populations to benefit most from GIFT were young asymptomatic women (16-24 years) in high HIV prevalence settings, and high-risk women like female sex workers and those with multiple partners of any age. Attributes of GIFT ranked as most important included ease-of-use, stability at room temperature, high diagnostic accuracy and barriers were test stock-outs, complexity of use and high cost, ConclusionWhile the Delphi process suggests the purpose of GIFT is as a POC screening tool, factors like supply chain, storage and stakeholder engagement are crucial for its integration into management guidelines. Key messagesO_LIThere is a need to identify BV and STIs in asymptomatic women, however, laboratory diagnostics services are severely limited in most low- and middle-income countries C_LIO_LIIf the GIFT test has high diagnostic accuracy, it promises to be a valuable point-of-care screening tool for detecting genital inflammation in asymptomatic women and may be useful to inform the management of women with symptoms. C_LIO_LIIt is important to obtain feedback from a variety of stakeholders when considering test design and implementation to increase the tests utility and likely adoption in policy and routine care. C_LI

BackgroundRectal sexually transmitted infections (STI) are prevalent among men who have sex with men (MSM) and transgender women (TGW). Self-collection of rectal specimens is widely used globally, but limited data exist on its implementation in Africa. We report experiences of MSM/TGW self-collecting rectal STI specimens in Kigali. MethodsFrom March to August 2018, 738 MSM/TGW were recruited in a cross-sectional study using respondent-driven sampling in Kigali. We tested for Neisseria gonorrhea and Chlamydia trachomatis using the Cepheid GeneXpert CT/NG platform on self-collected rectal swabs. Likert scales assessed self-collection difficulty and comfort. Ordered logistic regression analyses were performed to characterize factors associated with self-collection difficulty. ResultsOverall, 14%(106) identified as TGW. In total, 78%(577) found rectal swab self-collection easy/very easy, while 15%(108) found it difficult/very difficult. Most, 92%(679), were comfortable/very comfortable with the test, and 98%(730) said they would repeat the test in the future. In multivariable RDS-adjusted analyses, discomfort with the swab was positively associated with difficulty in self-collection (adjusted cumulative odds ratios ((aCOR): 7.9(95%CI: 4.9-12.8)) and having a prevalent rectal STI (aCOR: 4.19, 95%CI: 2.02-8.72) was significantly associated with difficulty. Furthermore, 10%(75) of rectal swabs returned indeterminate results (65 invalid results and 10 errors). ConclusionMost MSM/TGW found self-collection of rectal swabs easy, comfortable, and collected valid samples. Self-collection of rectal swabs could be used alongside clinic- and community-based STI testing to improve diagnosis and treatment in Rwanda. However, measures to optimize sample collection and processing are needed to reduce the cost and clinical implications of indeterminate results

ObjectivesGay, bisexual and other men who have sex with men (GBMSM) and trans and gender diverse (TGD) people are disproportionately affected by poorer sexual health outcomes compared to heterosexual populations. We aimed to explore the preferences of GBMSM and TGD for using eHealth for sexual health (eSexualHealth). MethodsWe distributed an anonymous online survey among the lesbian, gay, bisexual, transgender, intersex, queer and other people of diverse sexuality or gender (LGBTIQA+) community in Australia. The survey collected data on sociodemographic characteristics and sexual behaviours, their preferences for app/website functions and preferred HIV and sexually transmitted infection (STI) testing reminders. We used descriptive statistics to summarise the characteristics of the study population. Free-text responses were thematically analysed. ResultsOf 466 participants included, most identified as cisgender males (92.7%). The median age was 48 (interquartile range [IQR]: 37-56). For accessing sexual health-related information, 160 (34.6%) would use either a website or an app, 165 (32.7%) would prefer a website, 119 (25.8%) would prefer an app, and 33 (7.1%) would not use either platform. There was no significant difference between GBMSM and TGD people. Participants were most interested in information about STI clinics, HIV/STI hotspots, and sexual health education. Participants stressed the need for privacy and anonymity when using eHealth. Regarding reminders to test for HIV/STIs, receiving regular SMS was most popular (112/293, 38.2%), followed by regular emails (55/293 18.8%) and a reminder function on their phone (48/293, 16.4%). ConclusionOur study suggests a promising future for eHealth among GBMSM and TGD people. Sexual health is still a stigmatised area, and eHealth may circumvent barriers this population faces. What is already known about the topicO_LIGay, bisexual, and other men who have sex with men (GBMSM) and trans- and gender diverse people (TGD) have poorer sexual health outcomes compared to heterosexuals C_LIO_LIeHealth (or digital interventions) to improve sexual health is a growing area C_LI What this study addsO_LIOur survey among Australian GBMSM and TGD individuals document their preferences for using eHealth to optimize their sexual health C_LI How this study might affect research, practice or policyO_LIBeing aware of preferences for eHealth can inform resource allocation and future development of features wanted by target populations C_LI

IntroductionSelf-collected samples (SCS) for sexually transmitted infection (STI) testing have been shown to be feasible and acceptable in high-resource settings. However, few studies have assessed the acceptability of SCS for STI testing in a general population in low-resource settings. This study explored the acceptability of SCS among adults in south-central Uganda. MethodsNested within the Rakai Community Cohort Study, we conducted semi-structured interviews with 36 symptomatic and asymptomatic adults who self-collected samples for STI testing. We analyzed the data using an adapted version of the Framework Method. ResultsOverall, participants did not find SCS physically uncomfortable. Reported acceptability did not meaningfully differ by gender or symptom status. Perceived advantages to SCS included increased privacy and confidentiality, gentleness, and efficiency. Disadvantages included the lack of provider involvement, fear of self-harm and the perception that SCS was unhygienic.Most participants preferred provider-collected samples to SCS. Nevertheless, almost all said they would recommend SCS and would do it again in the future. ConclusionDespite a preference for provider-collection, SCS are acceptable among adults in this setting and support expanded access to STI diagnostic services. Key QuestionsO_ST_ABSWhat is already known on this topicC_ST_ABSTimely diagnosis is critical for STI control, with testing being the gold standard for diagnosis. Self-collected samples (SCS) for STI testing offer an opportunity to expand STI testing services and are well accepted in high-resource settings. However, patient acceptability of self-collected samples in low-resource settings is not well described. What this study addsWe found that SCS was acceptable to both male and female participants in our population, regardless of whether they reported STI symptoms. Perceived advantages to SCS included: increased privacy and confidentiality, gentleness, and efficiency; disadvantages included lack of provider involvement, fear of self-harm and the perception that SCS was unhygienic. Overall, most participants preferred provider collection over SCS. How this study might affect research, practice or policyPatient education addressing perceived disadvantages may increase SCS acceptability and support the use of SCS as a means to identify cases and control STIs in low-resource settings.

In the United States, gay, bisexual, and other men who have sex with men (MSM) experience a disproportionate burden of sexually transmitted infections (STIs), with notable racial/ethnic disparities. Doxycycline post-exposure prophylaxis (doxy-PEP) has emerged as a promising strategy to prevent bacterial STIs. This study analyzed 2023 National HIV Behavioral Surveillance data to examine doxy-PEP awareness, use, and intent to use among MSM in New York City (NYC), in a predominantly Hispanic/Latino sample. Among 134 participants, awareness and prior use were low (38.8% and 9.0%, respectively), but intent to use was high (75.4%). In Poisson regression models, intent was higher among participants reporting non-injection drug use and 2-10 partners in the past 12 months, while marginally lower among those above the Federal Poverty Level and recent migrants. Findings suggest doxy-PEP is acceptable for MSM in NYC, but addressing barriers among low-income groups and recent migrants is critical to reducing disparities.

Background. The objective was through an analysis of longitudinal data from the DepIST-H cohort to estimate the incidence, describe the dynamics and factors associated with CT/NG infection in MSM in Togo. Methods. A total of 200 MSM in Lome, Togo, were included in the ANRS I MIE 12400/DepIST-H cohort, half living with HIV. After inclusion in the study, participants received follow-up clinical visits at 6 and 18 months, and laboratory tests were performed at baseline (M0) and at 12 and 24 months (M12 and M24). PCR tests for CT and NG were performed from pharyngeal, anal and urine samples collected using the Xpert(R) CT/GC kit (Sunnyvale, CA, USA). To identify the factors associated with anal bacterial STIs, offset term Poisson regression models were performed. Results. Among 200 MSM (median age 24 years), CT and NG incidence rates were high ({approx}22 cases per 100 person-years), particularly at the anal site. Multiple partners significantly increased anal NG incidence (aIRR 2.35). Anal NG incidence was significantly lower among participants with income-generating activity (aIRR 0.57). Trends suggested higher anal CT and NG incidence in the presence of pharyngeal infection, but associations were not statistically significant Conclusion. This study confirms that MSM remain highly exposed to STIs in Togo and highlights the need to strengthen prevention efforts within this population. Postexposure doxycycline prophylaxis and multisite pooled-sample screening represent promising avenues to strengthen prevention efforts within these populations.

In the UK, gay, bisexual, and other men who have sex with men (GBMSM) at risk of sexually transmitted infections (STIs) are recommended quarterly testing, but it is not known how many are following this recommendation. We described the prevalence and correlates of frequent STI testing amongst GBMSM. We analysed data on participants of the community-based Reducing Inequalities in Sexual Health (RiiSH) online survey of GBMSM, recruited in November-December 2024 via social media and dating apps. Participants were UK residents aged [≥]16 years who reported sex with a man in the previous year. We described the frequency of STI testing amongst individuals recommended quarterly testing, using proxies for national guidelines for quarterly testing eligibility (over the past three months: new male sexual partner, condomless anal sex, [≥]10 male partners, or chemsex). We explored factors associated with frequent testing ([≥]4 tests/past year) using univariate and multivariable logistic regression, adjusting for country of birth and residence, ethnicity, employment, and education. Among 2758 participants (median age 45 years, 88% white), we estimated that 2366 (86%) would be recommended quarterly STI testing. Over the past year, 562 individuals (24%) met or exceeded this recommendation (testing [≥]4 times), 1107 (47%) had 1-3 tests, and 673 (28%) no tests. Factors associated with frequent testing were: reporting using PrEP in the past year (adjusted odds ratio 7.66 (95% confidence intervals 5.77-10.30)), STI diagnosis in the past three months (1.96 (1.45-2.64)), and younger age (1.50 (1.04-2.16), aged 16-29 years vs [≥]45 years). Straight/bisexual orientation was associated with less frequent testing than gay/homosexual (0.71 (0.52-0.96)). Overall, data from a large UK community survey suggest that only 1 in 4 GBMSM who are recommended frequent STI testing meet this recommendation, and testing levels vary by PrEP use, STI history, age, and sexual orientation. Interventions are needed to address these inequalities.

Evidence from real-world studies suggests that 3-monthly screening for asymptomatic chlamydia/gonorrhoea is not reducing incidence and is driving increased antibiotic use and antimicrobial resistance (AMR). While some countries are recommending less screening, changes to guidelines require clinician buy-in. This study explored the views of Australian sexual health clinicians to changing practices around asymptomatic screening for chlamydia/gonorrhoea in gay, bisexual and other men-who-have-sex-with-men (GBMSM) and attitudes to not automatically treating positive diagnoses. We conducted thematic analysis of 16 semi-structured interviews with clinicians working in a range of settings. Interviews covered: evidence on test and treat, perspectives on reducing screening and treatment for chlamydia/gonorrhoea in GBMSM, AMR, and managing patient conversations. Clinicians had variable knowledge about the limited effectiveness of asymptomatic screening. Many were open to reduced screening, if provided supporting evidence. Given challenges in reducing medical interventions, they recommended public education to drive changes. While some clinicians supported patient dialogue in treatment decision-making, most felt uncomfortable not treating. Concerns included: ideas about their role as doctors; onward transmission (particularly to women); and, complications/uncomfortable symptoms/patient psychological well-being. AMR considerations were less salient. While the test and treat paradigm is engrained, clinicians were open to reduced screening, if provided with clear evidence, but were generally reluctant to not treat. A flexible approach that supports patient empowerment in decision-making about screening frequency and choices around treatment could present a way forward. Changing practice requires education to shift patient/clinician mindsets around what it means to have a positive chlamydia/gonorrhoea diagnosis.

BackgroundRecent increases in syphilis diagnoses among heterosexual individuals are a growing public health concern. We aimed to qualitatively assess the risk factors, lifestyles, and contexts facilitating syphilis transmission among heterosexually-identifying individuals in England through the NEXUS study. Methods and FindingsNEXUS was a qualitative study based on semi-structured one-to-one interviews conducted between December 2023 and September 2024. Heterosexually-identifying individuals diagnosed with primary, secondary, or early latent syphilis in the previous year at a sexual health service in one of three regions in England were recruited. Interviews were also conducted with healthcare professionals involved in syphilis management. An analytical framework approach identified salient themes from interview transcripts. The service-user data were triangulated using healthcare professional data. Interviews were conducted with 19 service-users and seven healthcare professionals. Syphilis acquisition was primarily associated with condomless vaginal or oral sex. Half (10/19) reported multiple partners around the time of diagnosis; other known risk factors, like swinging (multiple concurrent partners) (1/19), sex work (3/19), or transmission among heterosexually-identifying men who have sex with men (1/19), were linked to a minority of infections. Of those reporting a single partner (9/19), four were in a believed exclusive relationship. Many had low perceptions of STI risk but intended to alter sexual behaviours post-diagnosis. Syphilis knowledge was limited among heterosexual individuals and initially seeking medical advice for symptoms from non-sexual health specialists sometimes led to diagnosis delays. Service-users suggested information on syphilis epidemiology, symptoms, and prevention, conveyed through National Health Service sources and mass media, would have been beneficial. ConclusionsWe identified a range of contexts associated with syphilis transmission. While multiple partners were common, infections also occurred through infrequent or novel practices or among those with few sexual encounters. Increasing awareness of syphilis among heterosexually-identifying individuals and healthcare professionals working in specialties other than sexual health is important to improve detection, facilitate treatment, and reduce transmission.

BackgroundGuidelines recommend three-site (urine, anal, pharynx) three-monthly (3X3 screening) screening for Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) in men who have sex with men (MSM) taking HIV pre-exposure prophylaxis (PrEP). We present the first randomized controlled trial to compare the effect of screening versus non-screening for NG/CT on the incidence of these infections in MSM taking PrEP. MethodsA multicenter, randomized, controlled trial of 3X3 screening for NG/CT versus non-screening was conducted among MSM taking PrEP in five HIV reference centers in Belgium. Participants attended the PrEP clinics quarterly for 12 months. NG/CT was tested at each visit in both arms, but results were not provided to the non-screening arm. The primary outcome was the incidence rate (IR) of NG/CT infections in each arm, assessed in the per-protocol population. Non-inferiority of the non-screening arm was proven if the upper limit of the 95% confidence interval of the IR ratio (IRR) was lower than 1.25. The trial protocol was registered at clinicaltrials.gov (NCT04269434). FindingsBetween September 2020 and June 2021, 508 subjects were randomized to the 3X3 screening arm and 506 to the non-screening arm. The overall IR of NG/CT was 0.155 cases/100 person-days (95%CI 0.128-0.186) in the 3x3 screening arm and 0.205 (95%CI 0.171-0.246) in the non-screening arm. The IR was significantly higher in the non-screening arm (IRR 1.318, 95%CI 1.068-1.627). Participants in the non-screening arm had a higher incidence of CT infections and symptomatic CT infections. There were no significant differences in NG infections. Participants in the non-screening arm consumed significantly less antimicrobials. No serious adverse events were reported. InterpretationWe failed to show that non-screening for NG/CT is non-inferior to 3-site 3-monthly screening in MSM taking PrEP in Belgium. However, screening was associated with higher antibiotic consumption and had no effect on the incidence of NG. Therefore, our findings do not provide strong support for screening for NG/CT in this population. FundingBelgian Healthcare Knowledge Center (KCE - INV18-1133)

ObjectivesWe determined the frequency of sexually transmitted infection (STI) testing among people accessing sexual health services (SHS) in England. MethodsWe assessed STI testing frequency in face-to-face and online SHSs in England using data from the GUMCAD STI surveillance system. We quantified different combinations of tests (e.g. single chlamydia test or full STI screen), number of tests completed in 2024 and test positivity by sociodemographic and behavioural characteristics, as well as clinical setting and outcomes. ResultsOverall, there were 2,222,028 attendances at SHS in England in 2024 that involved tests for chlamydia, gonorrhoea, syphilis and/or HIV. Most of these attendances involved tests for all four of these STIs. Most people accessing SHS in England tested once (80.1%), and a small minority (1.9%) tested at least quarterly (4+ times). Some groups had a comparably larger proportion of quarterly testers; these included gay, bisexual, and other men who have sex with men (GBMSM) (6.7%), London residents (3.6%), online testers (2.5%), people using HIV-PrEP (13%), and people with 5+ partners in the previous 3 months (10.6%). Only 10.5% of GBMSM reporting higher-risk sexual behaviours tested quarterly despite recommendations for quarterly testing in this group. ConclusionsThe majority of those who tested for STIs in England in 2024 only tested once. The minority who tested at least quarterly had a higher proportion of GBMSM, people using HIV-PrEP, London residents and people reporting higher risk behaviours. Quarterly testing often appears to be aligned with current testing recommendations in England; however, we also observed that only a low proportion of behaviourally high-risk GBMSM and HIV-PrEP users are meeting these recommendations. It is important to acknowledge groups with lower or higher testing frequency when developing interventions and updating guidelines related to STI testing. WHAT IS ALREADY KNOWN ON THIS TOPICThe effectiveness of asymptomatic testing for chlamydia and gonorrhoea in gay, bisexual and other men who have sex with men (GBMSM), and the potential impact of the consequent increased antibiotic use on rising antimicrobial resistance and individual harm has recently been questioned. Testing and treatment remains a key pillar of STI prevention and management; despite this, there is limited evidence of STI testing frequency within sexual services (SHS) on a national level. WHAT THIS STUDY ADDSThis analysis shows that the majority of people attending SHSs in England in 2024 tested once, and only a small proportion of behaviourally high-risk people tested frequently. HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICYAwareness of groups that are behaviourally high risk but testing infrequently is important to guide interventions and messaging regarding STI testing. The low levels of frequent testing, even among those who would be recommended quarterly testing under UK guidelines, provides important context for wider discussion around asymptomatic STI screening.

IntroductionHPV causes oral, cervicovaginal, and anogenital cancer, and cervical cancer screening options include HPV testing of a physician-collected sample. Transgender and gender diverse (TGD) people assigned female at birth (AFAB) face discrimination and stigma in many healthcare settings; are believed to be a lower risk for cervical cancer by many physicians; are less likely to be up to date on preventive health care services such as pelvic health exams; and are more likely to have inadequate results from screening tests. Self-sampling options may increase access and participation in HPV testing and cancer screening. MethodsWe recruited 137 TGD individuals AFAB for an observational study, mailing them a kit to self-collect cervicovaginal, oral, and anal samples at home. We tested samples for HPV genotypes 6, 11, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68, 73 and 90 using a PCR mass array test. Results102 participants completed the study. Among those with valid tests, 8.8% were positive for oral HPV, 30.5% were positive for cervicovaginal HPV, and 39.6% were positive for anal HPV. A large fraction of anal (50.0%) and oral (71.4%) infections were concordant with a cervicovaginal infection of the same type. ConclusionsHPV infection in TGD people AFAB may be just as high, if not higher, than in cisgender women. It is essential that we reduce barriers to cancer screening for TGD populations, such as through the development of a clinically approved self-screening HPV test.

IntroductionHIV pre-exposure prophylaxis (PrEP) demonstrates the value of biomedical interventions as part of combination prevention. Some gay, bisexual and other men who have sex with men (GBMSM) use antibiotics to prevent sexually transmitted infections (STIs), primarily as post-exposure prophylaxis (PEP). We aimed to understand variations in awareness and use of HIV PrEP and STI PEP/PrEP among people attending specialist sexual health services (SHS) in England. MethodsWe collected data from SHS attendees aged >16 years in London and the East of England using an online questionnaire between April 2022 and December 2023, including awareness and use of HIV-PrEP and STI PEP/PrEP. We ran regression analyses: one to identify demographic factors associated with STI PEP/PrEP use among all SHS attendees, and a second to identify behavioural factors (controlling for socio-demographic factors) associated with antibiotic prophylaxis use among GBMSM. ResultsThe study recruited 1,732 participants (50% GBMSM, 12% men who had reported sex with women only [MSW], 31% women). 74% had heard of HIV-PrEP but this varied by group (GBMSM:98%, MSW:39%, women:49%). 34% of GBMSM had heard of STI PEP/PrEP and 11% reported using it (MSW:15%/5%, women:18%/4%). 61% of STI PEP/PrEP users reported taking doxycycline, mostly to prevent chlamydia, gonorrhoea and syphilis. 80% of all participants reported being somewhat/very likely to use event-based STI PEP/PrEP, with a higher proportion of GBMSM saying they would be likely to use STI PEP/PrEP in this way. In the behavioural regression model of GBMSM, use was independently associated with reporting higher-risk sexual behaviour. ConclusionWe found that a sizeable minority of GBMSM already use STI PEP/PrEP but some MSW and women also use or have an interest in antibiotic prophylaxis, suggesting potential benefits may exist for populations other than GBMSM. Communication should therefore should emphasise appropriate antibiotic use and the risks of antibiotic resistance among all populations. Key messagesO_ST_ABSKWhat is already known on this topicC_ST_ABSO_LIDespite widespread availability of HIV-PrEP, heterosexual men and women with a need for HIV-PrEP are less likely to have this met than GBMSM C_LIO_LISome GBMSM use antibiotics to prevent bacterial STI infections in the absence of guidelines on STI PEP/PrEP in England C_LI What this study addsO_LIAwareness of HIV-PrEP is low among heterosexual men and women C_LIO_LIThe study shows that some heterosexual men and women are currently using or have an interest in STI PEP/PrEP C_LI How this study might affect research, practice or policyO_LIThis study could inform HIV-PrEP awareness activities for people at risk of HIV C_LIO_LIIt could also inform communication strategies for any future introduction of STI PEP/PrEP C_LI

BackgroundHuman papillomavirus (HPV) infection is the most common sexual transmitted disease (STD) and a risk factor for penile, oral and anal cancer. Human immunodeficiency virus (HIV) coinfection increases the risk of cancer. While HPV anal infection is well studied in men-who-have-sex-with-men (MSM), HPV genitalia and oral infection is less known. MethodsThis prevalence study of HPV infection in genitalia and oral cavity in HIV-MSM patients included 107 HPV non-vaccinated subjects. HPV-DNA was detected with Anyplex II HPV28 method. Participants completed a questionnaire on lifestyle and sexual behavior. ResultsMedian age was 43 years (range 35-54 years); 97 patients were on antiretroviral treatment (ART); 81 (75.7%) had undetectable HIV-RNA; median CD4-lymphocyte count was 746 cell/mm3; 70 (65.4%) participants had a previous STD. HPV was detected in genitalia in 37 (34.6%) subjects; 26 (24.3%) in oral cavity and 12 (11.2%) in both locations. High-risk HPV genotypes were detected in 24 (22.4%) patients in genitalia and 15 (14%) in oral cavity. ConclusionsHPV infection is common in unvaccinated HIV-MSM patients. Detectable HIV-RNA was associated with higher HPV prevalence in genitalia. High oncogenic risk HPV genotypes were more common in genitalia than in mouth. Summary textHPV infection is common in HIV infected subjects and it is a risk factor for many types of cancer. Although anal conduct is the most studied location, HPV can also infect genitalia and oral cavity. However, the frequency and distribution of HPV strains is different in both locations.

ObjectivesSexual decision-making and STI prevention are influenced not only by individuals characteristics, but also those of their partners and their relationship with each other. To inform tailored STI prevention and better understand STI transmission dynamics, this study aimed to understand the characteristics of sexual partners and partnerships among UK GBMSM, for whom there has been limited information beyond partner numbers. MethodsWorking with community-based organisations, we co-designed a sexual partnerships module for the UKs annual online cross-sectional community-based RiiSH GBMSM survey, undertaken November-December 2023. We collected data about [≤]3 most recent male sex partners since August 2023 and analysed variations in relative demographic characteristics (age, ethnicity), sexual behaviours (sexual practices, condom use, HIV-PrEP use) and communication (talking about sexual health, sharing HIV status) by partner type. ResultsAltogether 1106 participants described 2342 partners: 12%, 20%, 11% and 57% reporting 0, 1, 2 and 3 partners, respectively, of varying combinations. Casual partner types were most commonly reported (43%) vs. one-time (36%), established (14%) and uncertain relationships defined (7%). Concurrency was common with the mean number of ongoing partnerships >1 (1.23, 95%CI:1.17-1.30). Age-mixing varied by partner type, from median 2 (established partners) to 10 (one-time partners) years difference. Sexual health communication differed by partner type. While highest among established partners, it was twice as common to be unaware of one-time partners HIV status and not to have discussed sexual health (both 68%) vs. among casual partners (30% and 28%, respectively). Condom use was low across all partnership types, though HIV-PrEP was used in 49% of one-time partnerships involving condomless anal intercourse. DiscussionGBMSM in the UK have diverse types of male sexual partners and partnerships, which vary in their demographic mixing, sexual behaviour and sexual health communication. STI prevention and sexual wellbeing programmes targeting GBMSM should consider partnership and partner type. Key messagesO_ST_ABSWhat is already knownC_ST_ABSSexual behaviours vary across individuals and also partnership types. Understanding the timing, behaviours and characteristics of partnerships, and therefore the sexual contact network, may inform STI prevention efforts. What this study addsThis study of GBMSM from a large, UK-wide community sample show their sexual partnerships are diverse in their behaviour, characteristics and communication, varying both between and within individuals. What are the implicationsFurther research and practice should consider partnership type when designing and delivering STI prevention interventions to maximise their effectiveness among GBMSM and potentially more broadly.