Missed Prevention Opportunities: Why Young, Black MSM with Recent HIV Diagnosis did not Access HIV Pre-exposure Prophylaxis Services.

In the United States, HIV infection rate inequities persist, with new infections highest among young, Black men who have sex with men (YBMSM) in the South. We conducted 23 in-depth interviews with YBMSM newly diagnosed with HIV to explore awareness of and barriers to uptake of HIV pre-exposure prophylaxis (PrEP). Participants were recruited from two university-based HIV Clinics in Alabama and were: (1) 16-29 years of age, (2) diagnosed with HIV within the prior 365 days, (3) Black race, (4) self-identified as a cis-gender male reporting sex with men AND (5) did not report prior PrEP use. Interview guides were grounded in Anderson's Behavioral Healthcare Utilization Model (ABM), with embedded constructs from the situated Information, Motivation and Behavioral Skills theoretical framework. Coding was conducted by three independent coders using thematic analysis methods. Participants (N = 23) median age was 24, more than two-thirds reported annual incomes less than $15,000 and the majority (84%) identified as gay. Major themes that emerged as barriers to accessing PrEP included low prioritization and interests in using PrEP; low perceived HIV risk due to feelings of invincibility and trust in sex partners; lack of information about accessing PrEP; negative beliefs around PrEP; and the suggestion to change PrEP messaging from only targeting YBMSM. These findings indicate that there are important missed opportunities for HIV prevention with PrEP among YBMSM in the South. In these high-risk young men, tailored interventions are needed to better inform and frame perceptions around risk, knowledge, access and prioritization of PrEP.

En Estados Unidos, desigualdades en la tasa de infección por VIH persisten, y en el sur del pais, la tasa de nuevas infecciones hombres jóvenes Afro-americanos que tienen sexo con hombres son más altas. Realizamos veintitrés entrevistas en profundidad con YBMSM recién diagnosticado con VIH para explorar la conciencia y las barreras para la adopción de la profilaxis previa a la exposición al VIH (PrEP). Los participantes fueron reclutados de dos clínicas de VIH en centros medicos academicos en el estado de Alabama con los siguientes criterios: 1) 16-29 años de edad, 2) diagnostico VIH dentro de los 365 días, 3) raza afro-americana, 4) autoidentificados como un género cis-hombres que tienen sexo con hombres, y 5) no informaron el uso previo de PrEP. Las guías de la entrevista se basaron en el Modelo conductual de utilización de la salud (ABM) de Anderson, con construcciones integradas del marco teórico de Información, motivación y habilidades conductuales. Tres codificadores independientes codificaron utilizando métodos de análisis temáticos. La edad mediana de los participantes (N = 23) era de 24 años, más de dos tercios informaron ingresos anuales de menos de $15,000 (USD) y la mayoría (84%) se identificó como gay. Los temas principales que surgieron como barreras para acceder a PrEP incluyeron una baja priorización e interes en su; bajo riesgo percibido de VIH debido a sentimientos de invencibilidad y confianza en las parejas sexuales; falta de información sobre el acceso a PrEP; creencias negativas sobre PrEP; y la sugerencia de enfocar los mensajes sobre PreP no solo ha jovenes afro-americanos que tienen sexo con hombres. Estos hallazgos indican que hay importantes oportunidades perdidas para la prevención del VIH con PrEP entre esto jovenes en el Sur de EEUU. En estos hombres jóvenes de alto riesgo, se necesitan intervenciones personalizadas para mejor informar y enmarcar las percepciones sobre el riesgo, el conocimiento, el acceso y la priorización de PrEP.

Clinical Evaluation of the Cepheid Xpert TV Assay for Detection of Trichomonas vaginalis with Prospectively Collected Specimens from Men and Women.

Trichomoniasis is the most prevalent curable sexually transmitted disease (STD). It has been associated with preterm birth and the acquisition and transmission of HIV. Recently, nucleic acid amplification tests (NAAT) have been FDA cleared in the United States for detection of Trichomonas vaginalis in specimens from both women and men. This study reports the results of a multicenter study recently conducted using the Xpert TV (T. vaginalis) assay to test specimens from both men and women. On-demand results were available in as little as 40 min for positive specimens. A total of 1,867 women and 4,791 men were eligible for inclusion in the analysis. In women, the performance of the Xpert TV assay was compared to the patient infected status (PIS) derived from the results of InPouch TV broth culture and Aptima NAAT for T. vaginalis The diagnostic sensitivities and specificities of the Xpert TV assay for the combined female specimens (urine samples, self-collected vaginal swabs, and endocervical swabs) ranged from 99.5 to 100% and 99.4 to 99.9%, respectively. For male urine samples, the diagnostic sensitivity and specificity were 97.2% and 99.9%, respectively, compared to PIS results derived from the results of broth culture for T. vaginalis and bidirectional gene sequencing of amplicons. Excellent performance characteristics were seen using both female and male specimens. The ease of using the Xpert TV assay should result in opportunities for enhanced screening for T. vaginalis in both men and women and, hopefully, improved control of this infection.

Hormonal contraceptive use modulates the local inflammatory response to bacterial vaginosis.

OBJECTIVES: To compare cervical concentrations of numerous cytokines/chemokines in women with bacterial vaginosis (BV) compared with the levels detected after BV resolution and determine if hormonal contraceptive use modulates the local inflammatory response to BV. METHODS: Cervical secretions from 81 women with BV at enrollment and normal flora at one-month follow-up were analysed for 10 different cytokines/chemokines using multiplexed fluorescent bead-based immunoassays. RESULTS: BV was associated with significantly higher concentrations of IL-1 beta, tumour necrosis factor (TNF), interferon-gamma, IL-2, IL-4, and IL-10 compared with the levels detected in the presence of normal vaginal flora. Analysis of results stratified by contraceptive practice demonstrated significantly lower levels of numerous cytokines among women with BV using hormonal contraceptives compared with those women with BV not using hormonal contraceptives. Hormonal contraceptive use was also associated with a statistically significant lesser change in TNF levels between the two study visits compared with the amount of change detected between visits among women who denied their use. CONCLUSIONS: Despite increases in the levels of both pro and anti-inflammatory cytokines in the lower genital tract of women with BV, the overall balance of these two types of molecules was maintained. The character of this local inflammatory response may help explain the typical absence of overt signs of inflammation among women with BV. In addition, hormonal contraceptive use was associated with significantly lower levels of the pro-inflammatory molecules TNF, interferon-gamma, and granulocyte macrophage colony-stimulating factor in women with BV, but did not significantly reduce the levels of IL-10, a key anti-inflammatory cytokine. These results suggest the possibility of an association between hormonal contraceptive use and altered genital tract immunity.

Routine HIV testing in the context of syndromic management of sexually transmitted infections: outcomes of the first phase of a training programme in Botswana.

OBJECTIVE: In 2004, the Ministry of Health adopted revised protocols for the syndromic management of sexually transmitted infections (STI) that included routine HIV testing. A training programme for providers was developed on the revised protocols that featured interactive case studies and training videos. An objective of the first phase of the training programme was to test its effect on four measures of clinical practice: (1) routine HIV testing; (2) performance of physical examination; (3) risk-reduction counselling and (4) patient education. METHODS: Clinical practice in a district where providers were trained was compared with a district without training. The measures of clinical practice were reported by 185 patients of providers who had been trained and compared with reports by 124 patients at comparison clinics. RESULTS: Relative to patients at comparison clinics, a higher percentage of patients of trainees reported that the provider: (1) offered an HIV test (87% versus 29%; p<0.001); (2) conducted a physical examination (98% versus 64%; p<0.001); (3) helped them to make a plan to avoid future STI acquisition (95% versus 76%; p<0.001) and (4) provided patient-specific information about HIV risk (65% versus 32%; p<0.001). Among patients offered HIV testing, the percentage who accepted did not differ between groups (38% of 161 patients of trainees versus 50% of 36 comparison patients; p = 0.260). Overall, 33% of patients of trainees and 14% of comparison patients were tested (p<0.001). CONCLUSION: A multifaceted training programme was associated with higher rates of HIV testing, physical examination, risk-reduction counselling and better HIV risk education.

Clinical performance of the Solana® Point-of-Care Trichomonas Assay from clinician-collected vaginal swabs and urine specimens from symptomatic and asymptomatic women.

BACKGROUND: Solana® (Quidel) is a new rapid (<40 min.) point-of-care (POC) test for qualitative detection of Trichomonas vaginalis (TV) DNA. The assay has two steps: 1) specimen preparation, and 2) amplification and detection using isothermal Helicase-Dependent Amplification (HDA). The objective was to demonstrate the performance of Solana for vaginal swabs and female urines based on comparison to wet mount and TV culture. Performance was also compared to the Aptima-TV assay. METHODS: Urine and four clinician-collected vaginal swabs were collected. The first two were used for FDA composite reference (wet mount; InPouch TV Culture). The third swab was used for Solana. Sensitivity/specificity were based on the reference method. A specimen was considered positive if either test was positive. The fourth swab was for Aptima-TV. RESULTS: Vaginal swabs and urines were obtained from 501 asymptomatic and 543 symptomatic women. Prevalence of TV by was 11.5%. For swabs, Solana® demonstrated high sensitivity and specificity from asymptomatic (100%/98.9%) and symptomatic (98.6%/98.5%) women, as well as for urines from asymptomatic (98.0%/98.4%) and symptomatic (92.9%/97.9%) women, compared to the reference method. Compared to Aptima-TV, the sensitivity/specificity was 89.7%/99.0% for swabs and 100%/98.9% for urines. CONCLUSION: The Solana® assay performed well compared to the reference assays.

Characteristics of female sexually transmitted disease clinic clients who report same-sex behaviour.

Female STD clinic clients were categorized by report of sex partners' gender in the preceding 2 months and characterized with respect to HIV risk and STD diagnosis. Among 18,585 visits, 290 women (1.5%) reported sex exclusively with women, and 841 (4.5%) reported sex with both men and women. Relative to women reporting sex only with men, those reporting sex with both men and women reported more recent partners, sex with partners at high risk for HIV, injection drug and crack cocaine use, and exchange of sex for drugs or money. Women reporting sex exclusively with women more frequently reported prior sex with a bisexual man or an HIV-infected partner. Female STD clinic clients who report sex with both men and women may be at increased HIV risk relative to women reporting sex exclusively with men, and women who report sex only with women may be more likely to have had sex with men at high risk for HIV infection.

Genital human papillomavirus infection in women who have sex with women: a concern for patients and providers.

Certain types of the human papillomavirus (HPV) are sexually transmitted and cause genital warts and cervical neoplasia. Little is known about the epidemiology of HPV among women who have sex with women (WSW), but recent research using amplified techniques for HPV DNA strongly suggests that HPV is sexually transmitted between female sex partners. In a pilot study of 149 WSW in Seattle, Washington, prevalence of HPV as detected by DNA amplification assay was 30%, and was 19% among women reporting no prior sex with men. Although most cervical cancer can be prevented with Pap smear screening by detection of squamous epithelial lesions (SIL), some data suggest that the frequency of Pap smear screening is suboptimal in WSW. Reasons for this are unclear, but may include perceptions by patients and providers that WSW are not at risk for many STD and, by extension, cervical cancer. In our study, WSW who reported no prior sex with men had routine Pap smear screening less frequently than the comparative group, and had a prevalence of SIL of 14%. Combined with the work of other investigators, these data strongly suggest that current recommendations for Pap smear screening among WSW should not differ from those for heterosexual women. WSW and their providers should understand that sex between women may confer a risk of HPV transmission; risk of transmission of other STD, including HIV, deserves further study.