The Impact of Selected Bacterial Sexually Transmitted Diseases on Pregnancy and Female Fertility.

Sexually transmitted infections (STIs) caused by Neisseria gonorrhoeae, Chlamydia trachomatis and Mycoplasma genitalium are a common cause of pelvic inflammatory disease (PID) which can lead to tubal factor infertility (TFI). TFI is one of the most common causes of infertility, accounting for 30% of female fertility problems. STIs can also have an impact on pregnancy, leading to adverse pregnancy outcomes. Escalating antibiotic resistance in Neisseria gonorrhoeae and Mycoplasma genitalium represents a significant problem and can be therapeutically challenging. We present a comprehensive review of the current treatment options, as well as the molecular approach to this subject. We have given special attention to molecular epidemiology, molecular diagnostics, current and new treatments, and drug resistance.

Gonococcal Adaptation to Palmitic Acid Through farAB Expression and FadD Activity Mutations Increases In Vivo Fitness in a Murine Genital Tract Infection Model.

Neisseria gonorrhoeae is a bacterial pathogen that colonizes mucosal epithelia that are rich in antimicrobial molecules such as long-chain fatty acids. Here we studied the mechanisms involved in palmitic acid resistance and their impact on in vivo biological fitness in a murine genital tract infection model. A stable palmitic acid-resistant derivative was obtained by serial passage with incremental palmitic acid concentrations. This derivative outcompeted its parent strain for colonization and survival in the murine infection model. Subsequent whole-genome sequencing resulted in the identification of the 3 resistance-related SNPs ihfAC5T, fadDC772T, and farAG-52T (promoter) that were verified for resistance against palmitic acid. Subsequent characterization of the associated resistance determinants showed that ihfAC5T and farAG-52T induced gene expression of the FarAB efflux pump, whereas fadDC772T increased the maximum enzyme activity of the FadD long-chain fatty acid-coenzyme A ligase. Our results highlight the mechanisms involved in gonococcal adaptation to the murine host environment.

Factors associated with repeat rectal Neisseria gonorrhoeae and Chlamydia trachomatis screening following inconclusive nucleic acid amplification testing: A potential missed opportunity for screening.

OBJECTIVE: Given rising incidence of Neisseria gonorrhoeae and Chlamydia trachomatis (GC/CT), development of efficacious screening strategies is critical to interruption of the infection cycle. However, a small proportion of nucleic acid amplification testing (NAAT) results are inconclusive-resulting in delays in diagnosis and treatment. As such, this study seeks to evaluate factors associated with inconclusive rectal GC/CT NAAT. METHODS: This is a retrospective chart review of individuals who received an inconclusive rectal GC/CT NAAT result at a single institution from 3/2016-6/2018. Inconclusive GC/CT NAAT was defined as presence of PCR amplification inhibitors using Roche Cobas v2.0 CT/NG assay. Clinical charts were abstracted for age, gender, HIV status, GC/CT (urogenital, rectal, pharyngeal) and syphilis screening results during the study period, clinic type (HIV clinic, university student health center, other), and whether repeat testing occurred within 6 months following an inconclusive result. Logistic regression analysis was used to calculate adjusted and unadjusted odds ratios of factors associated with receipt of repeat testing following an inconclusive rectal GC/CT NAAT result. RESULTS: During the study period, 6.1% (852/14,015) of rectal GC/CT NAAT were inconclusive for one or both of GC and CT. Among the 413 patients whose inconclusive rectal GC/CT NAAT results that were included in our analysis, 66.6% (275/413) received repeat testing within 6 months, of which 8.7% (24/275) were positive (compared to 5.4% positivity rate of all rectal samples). In multivariable analysis, individuals living with HIV had lower odds of receiving repeat testing following inconclusive rectal GC/CT NAAT compared to HIV uninfected individuals (adj OR 0.25; p = 0.001). CONCLUSIONS: Despite being disproportionately affected by the STI epidemic, individuals living with HIV had 75% lower odds of receiving repeat testing following inconclusive rectal GC/CT NAAT compared to HIV-uninfected individuals, representing potentially missed opportunities for treatment and prevention of ongoing STI transmission.

Assessing Sexually Transmitted Infections and HIV Risk Among Transgender Women in Lima, Peru: Beyond Behavior.

Purpose: The purpose of this study was to explore risk factors for HIV and sexually transmitted infections (STIs) among transgender women (TW) in Lima, Peru. Methods: HIV-negative or serostatus unknown TW reporting recent condomless receptive anal intercourse underwent testing for STIs and HIV and completed a sociobehavioral survey. Results: Among 120 TW, 29.6% had rectal Neisseria gonorrhoeae (GC) or Chlamydia trachomatis (CT) and 12.6% had HIV. Age and migrant status were associated with rectal GC/CT, and rectal GC/CT predicted HIV infection. Conclusions: Further study is needed to understand individual and social factors that contribute to HIV/STI vulnerability among TW.

Risk factors for urethral gonorrhoea infection among heterosexual males in Melbourne, Australia: 2007-17.

Background Since 2014 there has been an increase in gonorrhoea among heterosexuals in Australia. Sex with a partner from a country with high gonorrhoea prevalence has been identified as a risk factor for gonorrhoea in heterosexual females, but risk factors for heterosexual males remain unclear. This study determined risk factors for gonorrhoea among heterosexual males. METHODS: Retrospective analysis was performed among heterosexual males attending Melbourne Sexual Health Centre (MSHC) between 1 January 2007 and 31 December 2017. Countries for overseas sexual partners were stratified as high-prevalence countries (HPC) or low-prevalence countries (LPC) based on the incidence of gonorrhoea. RESULTS: The annual gonorrhoea positivity increased from 0.72% in 2007 to 1.33% in 2017 (Ptrend <0.001). Males attending MSHC as a contact of gonorrhoea had the highest odds of testing positive (adjusted odds ratio (aOR) 7.46; 95% confidence interval (CI) 4.46-12.49), followed by males identifying as Aboriginal and Torres Strait Islander (aOR 2.57; 95% CI 1.30-5.09), males who had injected drugs in the past 12 months (aOR 2.44; 95% CI 1.39-4.30) and males who had sex with a female from an HPC (aOR 2.18; 95% CI 1.77-2.68). Males aged ≥35 were at higher risk than those aged ≤24 years (aOR 1.44; 95% CI 1.14-1.82). Gonorrhoea positivity increased among males who had sex with females from an LPC (from 0.60% to 1.33%; Ptrend = 0.004) but remained the same over time among males who had sex with females from an HPC (2.14%; Ptrend = 0.143). CONCLUSIONS: There was an 80% increase in urethral gonorrhoea among heterosexual males between 2007 and 2017. Having sex with a female from an HPC is a significant risk factor for gonorrhoea. Gonorrhoea positivity among men having sex with a female from an HPC did not change over time, suggesting this risk factor has become less important.

Gonorrhoea and chlamydia in persons with HIV: number needed to screen.

OBJECTIVES: Current guidelines recommend screening sexually active persons with HIV (PWH) for Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) at least annually. Yet, screening rates in many HIV clinics remain low. In this study, we estimated the number needed to screen (NNS) to detect a NG and/or CT infection at each anatomic site among different subpopulations of PWH. NNS provides a concrete, practical measure to aid in assessing the practical impact of screening. METHODS : We included adults in care at three HIV Research Network sites in 2011-2014. Restricting to first tests within each year, annual NNS was defined as number of persons tested divided by number positive. We computed urogenital and extragenital NNS by age and risk group (women, men who have sex with women (MSW) and men who have sex with men (MSM)). RESULTS : A total of 16 864 NG/CT tests were included. Among patients aged ≤25 years, urogenital NNS was similar among women (15 (95% CI 6 to 71)), MSW (21 (95% CI 6 to 167)) and MSM (20 (95% CI 12 to 36)). Over 25, urogenital NNS increased to a greater extent for women (363 (95% CI 167 to 1000)) and MSW (160 (95% CI 100 to 333)) than MSM (46 (95% CI 38 to 56)). The increase for women versus MSM >25 remained significant (p<0.01) in multivariable analysis. Among MSM, rectal NNS was 5 (95% CI 3 to 7) and 10 (95% CI 9 to 12) for ≤25 and for >25 years and pharyngeal NNS values were 8 (95% CI 5 to 13) and 20 (95% CI 16 to 24). CONCLUSIONS: These findings suggest the importance of regular, at least annual NG/CT screening, particularly extragenital, of HIV positive MSM of all ages. They provide some support for age-based cutoffs for women and MSW (eg, universal screening for those aged ≤25 and targeted screening for those aged >25 years).

[Perianal abscess after anal intercourse should raise suspicion of rectal gonorrhoeae infection].

Neisseria gonorrhoeae infection is a sexually transmitted disease. Rectal gonorrhoea is often asymptomatic, the most common symptoms are anal pain, bleeding and purulent discharge. This case report describes a younger man, who experienced increasing anal pain and later fever after anal intercourse. N. gonorrhoeae infection was verified, before a clinical examination revealed a perianal abscess. During incision of the abscess an anal fistula was suspected, and six weeks after primary surgery and treatment with relevant antibiotics, transanal ultrasonography showed perianal scarring and no signs of anocutaneous fistula.

Cross-sectional analysis of chemsex drug use and gonorrhoea diagnosis among men who have sex with men in the UK.

Background Illicit drug use among men who have sex with men (MSM) has been associated with sexual risk and HIV. Less is documented about associations with other sexually transmissible infections (STIs). The aim of the present study was to determine whether the use of drugs commonly associated with chemsex is associated with increased risk of gonorrhoea among MSM. METHODS: Using data from 16065 UK-based respondents to the European MSM Internet Survey (2010), we examined associations between a recent diagnosis of gonorrhoea and three chemsex drugs (crystal methamphetamine, γ-hydroxybutyric acid (GHB)/γ-butyrolactone (GBL) and mephedrone). Univariate logistic regression identified determinants of gonorrhoea diagnosis and multivariate logistic regression models calculated adjusted odds ratios (aORs) for independent associations between chemsex drugs and gonorrhoea. RESULTS: MSM who reported using crystal methamphetamine and GHB/GBL in the previous year had 1.92- and 2.23-fold higher odds of gonorrhoea respectively over the same period (P=0.0001 and P<0.0001; n=15137) after adjusting for age, recruitment website, HIV status, residence and use of other chemsex drugs. MSM reporting the use of all three chemsex drugs had the highest increased odds (aOR 3.58; P<0.0001; n=15174). Mephedrone alone was not associated with gonorrhoea in multivariate models. CONCLUSIONS: Use of chemsex drugs is associated with a higher risk of gonorrhoea. The results of this study complement existing research about crystal methamphetamine and indicate a role for GHB/GBL in adverse sexual health outcomes. The use of mephedrone alongside other chemsex drugs may account for its lack of association with gonorrhoea in multivariate models. Future research should use encounter-level data, examine other STIs and attribute pathways through which chemsex leads to infection.

The Denominator problem: estimating the size of local populations of men-who-have-sex-with-men and rates of HIV and other STIs in Switzerland.

OBJECTIVES: There is no estimate of the current number of men who have sex with men (MSM) in Switzerland, or of their geographical distribution. We aimed to (1) estimate MSM concentration factors and population sizes for 83 Swiss postal code areas (PCA), including the nine largest Swiss cities, and (2) calculate MSM-specific local HIV prevalence and yearly rates of diagnosed HIV, hepatitis C virus (HCV), syphilis and gonorrhoea. METHODS: We triangulated data from general population estimates, MSM online surveys, published data on HIV prevalence and Swiss notification data for HIV and STDs. We compared two different formulae for the estimation of local MSM populations and calculated Bayesian 95%-credible-intervals (CrI) for each PCA. RESULTS: Across Switzerland, we estimate the MSM population aged 15-64 at roughly 80 000 men (95% CrI 64 000-96 000). (1) MSM in Switzerland were most concentrated in the five largest cities of Zurich, Geneva, Lausanne, Bern and Basel. (2) We estimate that in 2012, 6300 MSM, or 8.0%, were living with HIV, both diagnosed and undiagnosed and 1700 MSM, or 2.2%, had non-suppressed HIV infection. Between 2010 and 2013, average yearly rates of diagnosed HIV, HCV, syphilis and gonorrhoea were 0.3%, 0.02%, 0.4 % and 0.4 %, respectively. CONCLUSIONS: Combining general population data, MSM online surveys and notification data allows the calculation of realistic estimates of local MSM populations and thus proportions of MSM with diagnosed HIV and other STIs, with implications for prevention planning, commissioning of health services and counselling MSM on HIV/STI risk. Our methodology for Switzerland is transferable to other countries with similar data sources.

Risk Perception and Interest in HIV Pre-exposure Prophylaxis Among Men Who Have Sex with Men with Rectal Gonorrhea and Chlamydia Infection.

Rectal gonorrhea and chlamydia infections are associated with significantly increased risk of HIV transmission among gay, bisexual, and other men who have sex with men (MSM). MSM diagnosed with rectal gonorrhea or chlamydia may benefit from pre-exposure prophylaxis (PrEP) for HIV prevention. We analyzed HIV risk perception, PrEP interest, and sexually transmitted infection (STI) test results among MSM presenting to a publicly funded STI clinic from 2014 to 2016. A total of 401 MSM were tested for rectal STIs during the study period: 18% were diagnosed with rectal gonorrhea or chlamydia infection. Patients who perceived themselves to be at medium or high risk for HIV were significantly more likely to express interest in PrEP compared to those who reported low or no perceived risk (OR 1.88, 95% CI 1.13-3.11; p = .014). However, there was no significant difference in perceived HIV risk between those who were diagnosed with a rectal STI and those who were not. Although rectal STIs are a significant risk factor for HIV infection, MSM diagnosed with a rectal STI did not perceive themselves to be at increased risk for HIV infection, indicating a potential barrier to successful PrEP implementation in this population.

Prevalence and correlates of and a risk score to identify asymptomatic anorectal gonorrhoea and chlamydia infection among men who have sex with men in Kisumu, Kenya.

OBJECTIVES: In settings where laboratory capacity is limited, the WHO recommends presumptive treatment for Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) in asymptomatic men who have sex with men (MSM) at high risk for these infections. However, little is known about how best to target this intervention. We aimed to identify correlates of anorectal NG/CT infection in Kenyan MSM with and without anorectal symptoms and evaluate the performance of an empirical, model-based risk score to identify cases in asymptomatic men. METHODS: Anorectal NG/CT infections were diagnosed by the Abbott RealTime NG/CT nucleic acid amplification testamong 698 MSM at enrolment into the Anza Mapema study. Multivariable logistic regression was used to identify correlates of anorectal NG/CT infection in men with and without anorectal symptoms. Using coefficients from the final multivariable model for asymptomatic men, we calculated a risk score for each participant. Risk score performance was determined by calculating the sensitivity, specificity and number needed to treat (NNT) to identify one NG/CT infection. RESULTS: Overall anorectal NG/CT infection prevalence was 5.2% (n=36), of which 58.3% (n=21) were asymptomatic. Factors associated with anorectal NG/CT infection in asymptomatic men were aged 18-24 years (aOR=7.6; 95% CI: 1.7 to 33.2), HIV positive serostatus (aOR=6.9; 95% CI: 2.2 to 21.6) and unprotected anal sex in the past 3 months (aOR=3.8; 95% CI: 1.2 to 11.9). Sensitivity and specificity were optimal (81.0% and 66.1%, respectively) at a model-derived risk score cut-point ≥3, and the NNT was 12. CONCLUSIONS: A model-derived risk score based on correlates of anorectal NG/CT infection in asymptomatic participants would be sensitive and efficient (i.e, low NNT) for targeting presumptive treatment. If validated in other settings, this risk score could improve on the WHO algorithm and help reduce the burden of asymptomatic anorectal NG/CT infections among MSM in settings where diagnostic testing is not available.

Disseminated Gonococcal Infections in Patients Receiving Eculizumab: A Case Series.

BACKGROUND: Gonorrhea is the second most commonly reported notifiable condition in the United States. Infrequently, Neisseria gonorrhoeae can cause disseminated gonococcal infection (DGI). Eculizumab, a monoclonal antibody, inhibits terminal complement activation, which impairs the ability of the immune system to respond effectively to Neisseria infections. This series describes cases of N. gonorrhoeae infection among patients receiving eculizumab. METHODS: Pre- and postmarketing safety reports of N. gonorrhoeae infection in patients receiving eculizumab worldwide were obtained from US Food and Drug Administration safety databases and the medical literature, including reports from the start of pivotal clinical trials in 2004 through 31 December 2017. Included patients had at least 1 eculizumab dose within the 3 months prior to N. gonorrhoeae infection. RESULTS: Nine cases of N. gonorrhoeae infection were identified; 8 were classified as disseminated (89%). Of the disseminated cases, 8 patients required hospitalization, 7 had positive blood cultures, and 2 required vasopressor support. One patient required mechanical ventilation. Neisseria gonorrhoeae may have contributed to complications prior to death in 1 patient; however, the fatality was attributed to underlying disease per the reporter. CONCLUSIONS: Patients receiving eculizumab may be at higher risk for DGI than the general population. Prescribers are encouraged to educate patients receiving eculizumab on their risk for serious gonococcal infections and perform screening for sexually transmitted diseases (STDs) per the Centers for Disease Control and Prevention STD treatment guidelines or in suspected cases. If antimicrobial prophylaxis is used during eculizumab therapy, prescribers should consider trends in gonococcal antimicrobial susceptibility due to emerging resistance concerns.

The Additive Value of Pelvic Examinations to History in Predicting Sexually Transmitted Infections for Young Female Patients With Suspected Cervicitis or Pelvic Inflammatory Disease.

STUDY OBJECTIVE: We evaluate the additive value of pelvic examinations in predicting sexually transmitted infection for young female patients with suspected cervicitis or pelvic inflammatory disease in a pediatric emergency department (ED). METHODS: This was a prospective observational study of female patients aged 14 to 20 years who presented to an urban academic pediatric ED with a complaint of vaginal discharge or lower abdominal pain. Enrolled patients provided a urine sample for chlamydia, gonorrhea, and trichomonas testing, which served as the criterion standard for diagnosis. A practitioner (pediatric ED attending physician, emergency medicine or pediatric resident, pediatric ED fellow, or advanced practice provider) obtained a standardized history from the patient to assess for cervicitis or pelvic inflammatory disease according to the Centers for Disease Control and Prevention criteria. They then recorded the likelihood of cervicitis or pelvic inflammatory disease on a 100-mm visual analog scale. The same practitioner then performed a pelvic examination and again recorded the likelihood of cervicitis or pelvic inflammatory disease on a visual analog scale with this additional information. Using the results of the urine sexually transmitted infection tests, the practitioner calculated and compared the test characteristics of history alone and history with pelvic examination. RESULTS: Two hundred eighty-eight patients were enrolled, of whom 79 had positive urine test results for chlamydia, gonorrhea, or trichomonas, with a sexually transmitted infection rate of 27.4% (95% confidence interval [CI] 22.6% to 32.8%). The sensitivity of history alone in diagnosis of cervicitis or pelvic inflammatory disease was 54.4% (95% CI 42.8% to 65.5%), whereas the specificity was 59.8% (95% CI 52.8% to 66.4%). The sensitivity of history with pelvic examination in diagnosis of cervicitis or pelvic inflammatory disease was 48.1% (95% CI 36.8% to 59.5%), whereas the specificity was 60.7% (95% CI 53.8% to 67.3%). The information from the pelvic examination changed management in 71 cases; 35 of those cases correlated with the sexually transmitted infection test and 36 did not. CONCLUSION: For young female patients with suspected cervicitis or pelvic inflammatory disease, the pelvic examination does not increase the sensitivity or specificity of diagnosis of chlamydia, gonorrhea, or trichomonas compared with taking a history alone. Because the test characteristics for the pelvic examination are not adequate, its routine performance should be reconsidered.

Determining the Most Likely Source of Infection: An Application to Neisseria Gonorrhoeae Among Men Who Have Sex with Men.

BACKGROUND: The source of an infection is often unknown. To inform directed prevention measures, it is useful to know the location and partner type with the highest transmission risk. We developed a method to estimate infection risk of Neisseria gonorrhoeae per meeting location among men who have sex with men (MSM). METHODS: In 2008-2009, we collected information from 2,438 MSM attending the sexually transmitted infections clinic of Amsterdam. For up to four partners per participant (8,028 in total), we asked for details on meeting location, partner, and partnership characteristics. We used logistic regression to relate these to the participant's infection risk, accounting for unobserved transmission information in the likelihood. Based on the model estimates, we predicted the probability of a partner having N. gonorrhoeae. The probability that a partner was the source was proportional to his predicted infection risk. Each source was linked to the meeting location. We used a Bayesian method. RESULTS: Rectal N. gonorrhoeae was diagnosed in 157 MSM who reported data on 422 possible source partners, urethral N. gonorrhoeae in 126 reporting 285 possible sources, and pharyngeal N. gonorrhoeae in 162 reporting 451 possible sources. We estimated that most infections were acquired from long-lasting steady partners (21%; 95% CI = 17, 24). Partners met in an Amsterdam street with gay venues posed the highest transmission risk (13%; 95% CI = 7.9, 18). CONCLUSIONS: The presented method estimates the source of infection when there are multiple possible sources and enables the summation over various kinds of epidemiologic characteristics (here, meeting locations) that are relevant for prevention.

Prevalence and Risk Factors for Infections in a Pregnant Adolescent Population.

STUDY OBJECTIVE: Our objective was to identify risk factors associated with maternal infections and placental inflammation in pregnant adolescents attending an urban adolescent maternity clinic. DESIGN: This cross-sectional, descriptive study used survey and medical chart data collected at entry and prospectively across gestation. The prevalence of maternal infections and placental inflammation was determined and potential risk factors were identified. SETTING: Rochester Adolescent Maternal Program (RAMP) in Rochester, NY. PARTICIPANTS: Racially and ethnically diverse pregnant adolescents (n = 158 ≤ 18 y at entry) were recruited. INTERVENTIONS AND MAIN OUTCOME MEASURES: Main outcome measures were diagnosis of an infection or inflammatory condition in relation to demographic, anthropometric, dietary, socioeconomic, and health data. RESULTS: The three most prevalent infections diagnosed in this study population were recto-vaginal colonization of group B Streptococcus (GBS) (38%), bacterial vaginosis (BV) (40%) and candida (42%). African-American teens (AOR = 4.6; 95% CI: 1.74-13.02) and those with higher pre-pregnancy BMI (ppBMI; AOR = 1.2; 95% CI: 1.04-1.31) were more likely to test positive for BV across gestation. Older maternal age decreased the likelihood of positive tests for trichomoniasis (OR = 0.51; 95% CI: 0.26-0.92) and gonorrhea (OR = 0.38; 95% CI: 0.16-0.82). Higher mean dietary vitamin D intake (mcg/d) was associated with a lower likelihood of testing positive for recto-vaginal GBS (OR = 0.87; 95% CI: 0.77-0.98). CONCLUSION: Addressing modifiable risk factors associated with dietary intake and pre-pregnancy weight may help reduce health disparities among pregnant minority adolescents. Additionally, targeted sexual health education may greatly benefit younger female adolescents.

Risk Factors associated with Paraurethral Duct Dilatation following Gonococcal Paraurethral Duct Infection in Men.

No studies have explored the risk factors for paraurethral duct dilatation following paraurethral duct infection by Neisseria gonorrhoeae in men undergoing ceftriaxone therapy. The present study was performed to explore the risk factors for paraurethral duct dilatation following paraurethral duct infection by N. gonorrhoeae in men undergoing ceftriaxone therapy and thus guide clinical interventions. We compared the demographic, behavioral, and clinical data of men with paraurethral duct infection by N. gonorrhoeae with and without dilatation of the paraurethral duct. Univariate analysis showed significant differences in age, disease course of the infected paraurethral duct, Chlamydia trachomatis infection in the paraurethral duct, and a history of paraurethral duct infection by N. gonorrhoeae between the patient and control groups (P<0.05). Multivariate logistic regression analysis showed consistent results (P<0.05). This study that shows delayed treatment may be a major risk factor for paraurethral duct dilatation secondary to paraurethral duct infection by N. gonorrhoeae in men. Age, C. trachomatis infection in the paraurethral duct, and a history of paraurethral duct infection by N. gonorrhoeae are also risk factors. Thus, educating patients to undergo timely therapy and treating the C. trachomatis infection may be effective interventions.

STI tests and proportion of positive tests in female sex workers attending local public health departments in Germany in 2010/11.

BACKGROUND: In Germany, local public health departments (LPHD) are required to offer low-threshold access to confidential counselling and testing for sexually transmitted infections (STI) for sex workers. We collected data from LPHD in Germany to estimate the number of performed STI tests and the proportion of positive STI tests among attending female sex workers (FSW) in order to formulate recommendations for improving STI testing and care for FSW in Germany. METHODS: We recruited LPHD across Germany to collect aggregated data on attending FSW between January 2010 and March 2011. Baseline characteristics, the number of attending FSW, STI tests (HIV, Chlamydia trachomatis, Neisseria gonorrhoea, syphilis and Trichomonas vaginalis) and the number of positive results were provided by participating LPHD. We described the number of STI tests per FSW visit and the proportion of positive test results, including interquartile range (IQR). We tested whether baseline characteristics of LPHD were associated with the proportion of positive test results. RESULTS: Overall, 28 LPHD from 14 of the 16 federal states reported 9284 FSW visits over the study period, with a median of 188 FSW visits (IQR 45-440) per LPHD. Overall, a median of 77.1% (IQR 60.7-88.0) of visiting FSW received a test for Neisseria gonorrhoea, followed by HIV (66.0%, IQR 47.9-86.8), Chlamydia trachomatis (65.4%, IQR 50.7-83.6) and syphilis (61.6, IQR 48.6-78.6). In total, 22,914 STI tests were performed. The proportion of positive tests was 3.1% (IQR 1.3-4.8), with the highest proportion of positive tests for Chlamydia trachomatis (6.8%, IQR 2.5-10.4), followed by Neisseria gonorrhoea (3.2%, IQR 0.0-5.3), Trichomonas vaginalis (3.0%, IQR 0.0-15.4), syphilis (1.1%, IQR 0.0-1.3) and HIV (0.2%, IQR 0.0-0.4). The proportion of positive tests varied between 0 and 13.9% between LPHD, with a higher variation of proportion of positive tests in LPHD with a smaller number of reported STI tests. CONCLUSIONS: Participating LPHD varied in terms of performed STI tests and FSW visits. The proportion of positive STI tests was low, but varied between LPHD. This variation likely reflects different testing strategies. Existing testing guidelines should be used by all LPHD to ensure high quality care for FSW.