Temporary adaptations to sexual behaviour during the mpox outbreak in 23 countries in Europe and the Americas: findings from a retrospective cross-sectional online survey.

BACKGROUND: After rapid epidemic growth between May and August, 2022, new mpox diagnoses declined in Europe and the Americas, with low-level transmission continuing thereafter. Characterising the extent of behavioural adaptation, mpox vaccination, and mpox prevalence across these regions could improve our understanding of the transmission dynamics of the virus. We aimed to characterise the presence and duration of adaptations to sexual behaviour related to the emergence of mpox during the first year of the outbreak among affected communities in Europe and the Americas. METHODS: This retrospective, cross-sectional online survey was conducted in 23 countries in Europe and the Americas between May 19 and May 31, 2023. The survey was advertised via four geospatial dating apps used by affected communities. Eligible participants were aged 18 years or older and identified as a gay man, a bisexual man, a man who has sex with men, as transgender, or as non-binary. We described and regionally compared the mpox prevalence, mpox vaccination rates (one dose or two doses of modified vaccinia virus Bavarian Nordic), and the extent and duration of behavioural adaptation during the outbreak. For these behavioural outcomes, we used regression analyses to estimate crude prevalence ratios (PRs) and adjusted prevalence ratios (aPRs) with 95% CIs. FINDINGS: Of 17 428 individuals who completed the survey, 16 875 (96·8%) met the eligibility criteria and were included in the study. 1086 (6·4%) participants reported having mpox during the outbreak. Vaccination with at least one dose was reported by 4987 (29·6%) participants; 3502 (20·8%) reported two doses. Vaccination rates in Latin America and eastern Europe and the western Balkans were significantly lower than in western Europe and northern America (p<0·0001). Adaptations to sexual behaviour were reported by 8583 (50·9%) of 16 875 participants and across all regions; 3045 (35·5%) of these 8583 participants said they continued adapting their sexual behaviour until May, 2023. Participants who reported concerns about mpox (9884 [58·6%] of 16 875) were more likely to adapt their behaviour than those who did not report concerns (PR 2·43 [95% CI 2·34-2·53]). In adjusted regression models, participants who reported vaccination (aPR 0·25 [95% CI 0·21-0·28] for two doses and 0·43 [0·37-0·51] for one dose) or having had mpox (0·37 [0·30-0·44]) were less likely to continue adaptations than those who did not. Participants in Latin America or northern America were significantly more likely to adapt their sexual behaviour and to continue with adaptations than those in western Europe. INTERPRETATION: Adaptations to sexual behaviour due to mpox were widespread, dynamic, and responded to evolving individual risk perceptions. We propose that the decline in mpox transmission seen at the end of 2022 resulted primarily from a combination of behavioural adaptation and naturally acquired immunity. As mpox vaccination is an important preventive measure, stark vaccine inequity highlights the need to increase access to mpox vaccines. FUNDING: WHO Contingency Fund for Emergencies.

Missed opportunities for guidance on sexually transmitted infection services: a global review of national HIV PrEP guidance.

OBJECTIVES: People who use or would benefit from pre-exposure prophylaxis (PrEP) for HIV infection are disproportionately affected by sexually transmitted infections (STIs). Integrating STI services when offering PrEP fosters synergies and efficiencies in response to HIV/STI and promotes people-centred care. Including guidance on STI interventions for people on PrEP may facilitate implementation and uptake. We conducted a global review of national PrEP guidance documents and analysed the inclusion of recommendations for the provision of STI services by country level of income. METHODS: We searched national PrEP guidance documents published by WHO Member States through the WHO, the Joint United Nations Programme on HIV/AIDS (UNAIDS) databases, the PrEPWatch repository and Google. Information on a range of STI-related interventions was extracted from documents available by October 2023. RESULTS: Of the 113 national PrEP guidance documents retrieved, STIs were mentioned in 77% (90/117). Viral hepatitis B testing and vaccination were recommended by most high-income countries (HICs) and low-income and middle-income countries (LMICs). Recommendation for syphilis testing was prominent in HICs (91%) and moderately noted in LMICs (68%). Gonorrhoea and chlamydia testing was recommended frequently in HICs (88%) and 42% in LMICs. However, the review noted that, to a much lesser extent, specific type of testing for these pathogens was mentioned. Recommendation for quarterly STI testing for syphilis, gonorrhoea and chlamydia was ubiquitous, while the need to offer STI partner services was rarely mentioned. CONCLUSIONS: PrEP services offer an opportunity for improved and expanded STI services, increasing person-centred care and addressing STI epidemics alongside HIV. Our review highlights the strengths and gaps in incorporating critical STI interventions into national PrEP normative guidance. Addressing these gaps through a stepwise approach and increasing targeted testing and partner services can help improve quality of care and support an effective response to HIV and other STIs.

Experiences of mpox illness and case management among cis and trans gay, bisexual and other men who have sex with men in England: a qualitative study.

Background: The 2022-2024 global mpox outbreak, occurring primarily in the sexual networks of gay, bisexual and other men who have sex with men (GBMSM), has not been accompanied by a focus on patient perspectives of illness. We explore the experiences of GBMSM diagnosed with mpox in England to understand needs for social and clinical support. Methods: In-depth interviews (March/July 2023) were conducted with 22 GBMSM diagnosed with mpox in 2022, randomly selected from a national mpox surveillance database, and 4 stakeholders from clinical/community-based organisations. Interviews covered experiences of illness, testing, diagnosis, treatment and contact tracing, and were recorded, transcribed and analysed with a thematic framework. Findings: Media coverage drawing on homophobic stereotypes around sex between men contributed to feelings of stigma and shame. GBMSM living with HIV appeared to cope better with mpox stigma, drawing on their experiences of being diagnosed with HIV for resilience. Younger GBMSM with less experience of stigmatising illness found mpox diagnosis more traumatic and sometimes required support beyond what was provided. Accessing testing could be complicated when healthcare professionals did not recognise mpox symptoms. Men felt information on course of illness, isolation and vaccination after recovery was often inconsistent and contradictory. GBMSM described that care from sexual health and infectious disease units usually better met their emotional and medical needs. This was frequently linked by men to these services having skills in working with the GBMSM community and managing infection risk sensitively. General hospital services and centralised contact tracing could increase feelings and experiences of stigma as some staff were perceived to lack skills in supporting GBMSM and, sometimes, clinical knowledge. Long-term impacts described by men included mental health challenges, urethral/rectal symptoms and life-changing disability. Interpretation: In this study stigma was a central feature of mpox illness among GBMSM and could be exacerbated or lessened depending on the clinical and social support provided. Involving communities affected by outbreaks in co-producing, planning and delivering care (including contact-tracing) may help improve support provided. Funding: TCW, AJR, AS and FMB received support from the National Institute for Health and Care Research (NIHR) under its Programme Grants for Applied Research Programme (Ref: NIHR202038). CS and JS receive support from the National Institute for Health and Care Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections at UCL in partnership with UKHSA; RV receives support from the NIHR HPRU in Emerging and Zoonotic Infections and NIHR HPRU in Gastrointestinal Infections. The views expressed are those of the author(s) and not necessarily those of the NIHR, UK Health Security Agency, World Health Organization or the Department of Health and Social Care.

Tuberculosis Knowledge among Persons Living with HIV Attending a Tertiary Hospital in Lima, Peru.

Tuberculosis (TB) is the leading cause of death among people living with HIV (PLWH). Limited TB knowledge has been associated with delayed TB diagnosis and low adherence to TB treatment. A cross-sectional study was conducted among PLWH at the largest HIV-referral center in Lima, Peru, to describe TB knowledge among PLWH and potential associated sociodemographic factors. Participants answered a self-administered survey on TB knowledge, which consisted of five questions about TB cure, transmission, treatment, symptoms, and prevention. Of 179 PLWH enrolled, most participants did not know that isoniazid (85%) and antiretrovirals (78%) are preventive measures for TB, and 56 (31.3%) knew that TB can be asymptomatic in PLWH. We did not find statistical differences in TB knowledge based on gender, education, marital status, and time on HIV care. We identified important gaps in TB knowledge among PLWH. Addressing these gaps could empower PLWH to reduce their TB risk.

Surveillance of Mpox Cases Attending Sexual Health Services in England (SOMASS): design, implementation and initial findings from the SOMASS data collection tool, 2022.

OBJECTIVES: We aimed to design and implement a data collection tool to support the 2022 mpox (monkeypox) outbreak, and to describe clinical and epidemiological data from individuals with mpox attending sexual health services (SHSs) in England. METHODS: The UK Health Security Agency and the British Association for Sexual Health and HIV established the Surveillance of Mpox Cases Attending Sexual Health Services in England (SOMASS) system.Descriptive data were collected via a secure web-based data collection tool, completed by SHS clinicians following consultation with individuals with suspected mpox. Data were collected on patient demographics, clinical presentation and severity, exposures and behavioural characteristics. RESULTS: As of 17 November 2022, 276 SOMASS responses were submitted from 31 SHSs in England.Where recorded, most (245 of 261; 94%) individuals identified as gay, bisexual or men who have sex with men (GBMSM), of whom two-thirds were HIV negative (170 of 257; 66%) and taking HIV pre-exposure prophylaxis (87 of 140; 62%), with a median age of 37 years (IQR: 30-43). Where known, thirty-nine per cent (63 of 161) had a concurrent sexually transmitted infection (STI) at the time of their mpox diagnosis.For 46% of individuals (127 of 276), dermatological lesions were the initial symptom. Lesions were mostly asymmetrical and polymorphic, predominately affecting the genital area and perianal areas.Nine per cent (24 of 276) of individuals were hospitalised. We report an association between receptive anal intercourse among GBMSM and proctitis (27 of 115; 24% vs 7 of 130; 5%; p<0.0001), and the presence of perianal lesions as the primary lesion site (46 of 115; 40% vs 25 of 130; 19%; p=0.0003). CONCLUSIONS: We demonstrate multidisciplinary and responsive working to develop a robust data collection tool, which improved surveillance and strengthened the knowledge base. The SOMASS tool will allow data collection if mpox resurges in England. The model for developing the tool can be adapted to facilitate the preparedness and response to future STI outbreaks.

Emergence of extensively drug-resistant and multidrug-resistant Shigella flexneri serotype 2a associated with sexual transmission among gay, bisexual, and other men who have sex with men, in England: a descriptive epidemiological study.

BACKGROUND: Shigellosis, also known as bacillary dysentery, is caused by Shigella spp that spread through fecal-oral contact and was traditionally associated with international travel in England. However, sexual transmission of Shigella flexneri and Shigella sonnei among gay, bisexual, and other men who have sex with men (MSM) is now common. In September, 2021, emergence of extensively drug-resistant (XDR) S sonnei harbouring plasmid-encoded blaCTX-M-27 raised concerns over further spread of this extended-spectrum ß-lactamase-producing gene. Using national surveillance in England, we identified and characterised isolates of S flexneri harbouring blaCTX-M-27. METHODS: In this epidemiological study, we identified and phylogenetically characterised S flexneri isolates harbouring blaCTX-M-27 that were referred to the Gastrointestinal Bacterial Reference Unit (GBRU) at the UK Health Security Agency. All isolates referred to the GBRU undergo whole-genome sequencing, enabling antimicrobial resistance determination using genetic markers. Cases were defined as individuals diagnosed with S flexneri harbouring blaCTX-M-27 in England, with a specimen date between Sept 1, 2015, and June 12, 2022, who were phylogenetically confirmed as part of two t10 (approximately ten single nucleotide polymorphisms) clusters. Long-read sequencing elucidated the genomic location of blaCTX-M-27. Laboratory data, integrated with available demographic and clinical information from patient questionnaires, were summarised using descriptive statistics. FINDINGS: A sustained increase in cases of S flexneri harbouring blaCTX-M-27 (n=26) occurred from September, 2021, having been sporadically reported (n=11) in the preceding 6 years. blaCTX-M-27 acquisition events within S flexneri 2a established an XDR paraphyletic (n=8) cluster and a multidrug-resistant monophyletic (n=18) cluster. Cases were among adult male individuals (median age 37 years [IQR 31-46]) and, of the 13 individuals who completed a patient questionnaire, ten (77%) identified as MSM. Antimicrobial treatment was received by seven (54%) of 13 individuals, and four (31%) individuals were admitted to hospital. The IncFII plasmids harbouring blaCTX-M-27 showed high similarity to the XDR S sonnei outbreak plasmid, with 82% and 99% nucleotide similarity between the cluster plasmids and the XDR S sonnei outbreak plasmid. INTERPRETATION: We report emergence of XDR and multidrug-resistant S flexneri 2a harbouring blaCTX-M-27 among MSM in England. Epidemiological and plasmid similarities with the XDR S sonnei outbreak support horizontal acquisition events, emphasising the importance of mobilisable antimicrobial resistance and the need for genomic-based surveillance. FUNDING: National Institute for Health and Care Research Health Protection Research Unit in Gastrointestinal Infections at the University of Liverpool in partnership with the UK Health Security Agency.

Epidemiology of Early Monkeypox Virus Transmission in Sexual Networks of Gay and Bisexual Men, England, 2022.

After community transmission of monkeypox virus was identified in Europe, interviews of 45 case-patients from England indicated transmission in international sexual networks of gay and bisexual men since April 2022. Interventions targeting sex-on-premises venues, geospatial dating applications, and sexual health services are likely to be critical for outbreak control.

Outbreak of sexually transmitted, extensively drug-resistant Shigella sonnei in the UK, 2021-22: a descriptive epidemiological study.

BACKGROUND: Shigellosis, traditionally a foodborne and waterborne infection, causes substantial morbidity globally. It is now a leading cause of sexually transmitted gastroenteritis among gay, bisexual, and other men who have sex with men (MSM). We describe an ongoing outbreak of extensively drug-resistant (XDR) Shigella sonnei in the UK. METHODS: Routine laboratory surveillance (Second Generation Surveillance System, Gastrointestinal Data Warehouse) identified an exceedance of S sonnei clade 5 in England, first detected in September, 2021. Cases within this clade were subsequently reported from Scotland, Wales, and Northern Ireland. Confirmed cases in this outbreak were defined as individuals diagnosed with S sonnei clade 5 in the UK, with a specimen date between Sept 1, 2021, and Feb 9, 2022, who were genomically confirmed as part of a ten-single nucleotide polymorphism (SNP) linkage cluster. We used whole-genome sequencing with SNP typing to identify genomic clusters and antimicrobial-resistance determinants, analysing cases across the UK. We collected demographic, epidemiological, and clinical data from people infected with S sonnei clade 5 in England using questionnaires (standard and bespoke outbreak questionnaires). We used descriptive summary statistics to characterise cases. FINDINGS: 72 cases (70 [97%] male, median age 34 years [IQR 27-39]) belonging to the ten-SNP single linkage cluster of S sonnei clade 5 were identified between Sept 4, 2021, and Feb 9, 2022. Isolates were predominantly XDR, with 66 (92%) of 72 harbouring blaCTX-M-27, a plasmid-mediated gene for production of extended-spectrum ß-lactamases (ESBLs). Of 33 cases with clinical data, 19 (58%) received antibiotics and eight (24%) were hospitalised. 21 (78%) of 27 cases with completed bespoke outbreak questionnaires were HIV-negative MSM taking HIV pre-exposure prophylaxis (PrEP) who reported sexual contacts in the UK and Europe within the incubation period. INTERPRETATION: We highlight the rapid dissemination of XDR ESBL-producing S sonnei in sexual networks of MSM. We recommend strengthening shigella testing where clinically indicated, antimicrobial-resistance surveillance, and integrated health promotion messaging among all MSM, including PrEP users, to reduce the burden of shigellosis. FUNDING: National Institute for Health Research Health Protection Research Unit in Gastrointestinal Infections at the University of Liverpool in partnership with the UK Health Security Agency.

Community transmission of monkeypox in the United Kingdom, April to May 2022.

Between 7 and 25 May, 86 monkeypox cases were confirmed in the United Kingdom (UK). Only one case is known to have travelled to a monkeypox virus (MPXV) endemic country. Seventy-nine cases with information were male and 66 reported being gay, bisexual, or other men who have sex with men. This is the first reported sustained MPXV transmission in the UK, with human-to-human transmission through close contacts, including in sexual networks. Improving case ascertainment and onward-transmission preventive measures are ongoing.

Emergence of novel strains of Shigella flexneri associated with sexual transmission in adult men in England, 2019-2020.

National surveillance of shigellosis in England revealed an increase in sexually transmitted Shigella flexneri in adult males in 2019 that persisted throughout 2020. We observed a resurgence of azithromycin-resistant S. flexneri serotype 3a, and the emergence of two novel multidrug-resistant clades of S. flexneri 2a and S. flexneri 1b.

Rapid Increase in Lymphogranuloma Venereum among HIV-Negative Men Who Have Sex with Men, England, 2019.

Incidence of lymphogranuloma venereum increased in England during 2018-2019, after a period of decline. Our retrospective analysis of national surveillance data identified a rapid increase in diagnoses among HIV-negative men who have sex with men. These findings indicate a need for sustained surveillance and targeted public health action.

Implementer and recipient perspectives of community-wide mass drug administration for soil-transmitted helminths in Kwale County, Kenya.

Soil-transmitted helminthiases (STH) are one of 17 neglected tropical diseases (NTDs) earmarked for control or elimination by 2020 in the WHO's Roadmap on NTDs. Deworming programs for STH have thus far been focused on treating pre-school and school-aged children; however, there is a growing consensus that to achieve elimination of STH transmission, programs must also target adults, potentially through community-wide mass drug administration (MDA). There is currently a gap in the literature on what components are required to deliver community-wide MDA for STH in order to achieve high intervention reach and uptake. Nested within the TUMIKIA Project, a cluster randomized trial in Kenya evaluating the effectiveness of school-based deworming versus community-wide MDA, we collected qualitative data from program implementers and recipients in eight clusters where community-wide MDA was delivered. Data collection included semi-structured in-depth interviews (n = 72) and focus group discussions (n = 32). A conceptual framework for drug distribution was constructed to help build an analysis codebook. Case memos were developed for each top-level theme. Community-wide MDA for STH was perceived as a complex intervention with key administrative and social mobilization domains. Key actionable themes included: (1) developing an efficient strategy to allocate reasonable workload for implementers to cover all targeted households; (2) maximizing community drug distributors' motivation through promoting belief in the effectiveness of the intervention and providing sufficient financial incentives; (3) developing effective capacity building strategies for implementers; and (4) implementing a context-adapted community engagement strategy that leverages existing community structures and takes into consideration past community experiences of MDAs. Transitioning from STH control to elimination goals requires significant planning and action to ensure community-wide MDA is delivered with sufficient reach and uptake. We present findings that can inform national deworming programs to increase intervention delivery capacity.

"Buruli ulcer and leprosy, they are intertwined": Patient experiences of integrated case management of skin neglected tropical diseases in Liberia.

BACKGROUND: Skin neglected tropical diseases (NTDs) such as Buruli ulcer (BU) and leprosy produce significant stigma and disability. Shared clinical presentations and needs for care present opportunities for integrated case management in co-endemic areas. As global policies are translated into local integrated services, there remains a need to monitor what new configurations of care emerge and how individuals experience them. METHODS: To explore patient experiences of integrated case management for skin NTDs, in 2018, we conducted a field-based qualitative case series in a leprosy rehabilitation centre in Ganta, Liberia where BU services were recently introduced. Twenty patients with BU (n = 10) and leprosy (n = 10) participated in in-depth interviews that incorporated photography methods. We contextualised our findings with field observations and unstructured interviews with health workers. FINDINGS: The integration of care for BU and leprosy prompted new conceptualisations of these diseases and experiences of NTD stigma. Some patients felt anxiety about using services because they feared being infected with the other disease. Other patients viewed the two diseases as 'intertwined': related manifestations of the same condition. Configurations of inter-disease stigma due to fear of transmission were buffered by joint health education sessions which also appeared to facilitate social support between patients in the facility. For both diseases, medication and wound care were viewed as the cornerstones of care and appreciated as interventions that led to rehabilitation of the whole patient group through shared experiences of healing, avoidance of physical deformities and stigma reduction. Patient accounts of intense pain during wound care for BU and inability of staff to manage severe complications, however, exposed some shortcomings of medical care for the newly integrated service, as did patient fears of long-lasting disability due to lack of physiotherapy services. SIGNIFICANCE: Under integrated care policies, the possibility of new discourses about skin NTD identities emerging along with new configurations of stigma may have unanticipated consequences for patients' experiences of case management. The social experience of integrated medication and wound dressing has the potential to link patients within a single, supportive patient community. Control programmes with resource constraints should anticipate potential challenges of integrating care, including the need to ameliorate lasting disability and provide adequate clinical management of severe BU cases.

Patient-nominated supporters as facilitators for engagement in HIV care in a referral hospital in Peru: A retrospective cohort study.

Patient-nominated supporters can potentially improve the continuum of HIV care. We retrospectively determined factors associated with having a patient-nominated supporter among people living with HIV (PLWH), and its association with retention in care and viral suppression. We analysed registries of adults evaluated by social workers (n = 1345) at a referral hospital in Peru between 2011-2014. Nondisclosure of HIV status was associated with lacking supporters (aPR: 5.41, 95% CI: 3.83-7.64). Retention in care was 76.4% and 34.2% after one and two years of enrolment, respectively. PLWH with supporters were more likely to be retained in care after two years (aRR = 1.36, 95% CI: 1.02-1.81), but not after one year (aRR = 1.10, 95% CI: 0.98-1.23) compared to PLWH without supporters. Having supporters who were parents or friends was associated with an increased probability of being retained in care after one and two years of enrolment. Viral suppression after one year of enrolment was 58.7%. Having a supporter was not associated with viral suppression (aRR = 1.18, 95% CI: 0.99-1.41), but PLWH with supporters were more likely to have viral load measurements (p = 0.005). Patient-nominated supporters appear beneficial for engagement in HIV care; these benefits may be related to the nature of their relationship with PLWH.