Human T-cell leukaemia virus type 1 and Adult T-cell leukaemia/lymphoma in Queensland, Australia: a retrospective cross-sectional study.

OBJECTIVES: Human T-cell leukaemia virus type 1 (HTLV-1), an STI, is reported to be highly prevalent in Indigenous communities in Central Australia. HTLV-1 is an incurable, chronic infection which can cause Adult T-cell leukaemia/lymphoma (ATL). ATL is associated with high morbidity and mortality, with limited treatment options. We studied the prevalence of HTLV-1 and ATL in the state of Queensland, Australia. METHODS: Serum samples stored at healthcare services in Brisbane, Townsville and Cairns and at haemodialysis units in Brisbane (2018-2019) were screened for HTLV-1/2 antibodies using the Abbott ARCHITECT chemiluminescent microparticle immunoassay (CMIA) for antibodies against gp46-I, gp46-II and GD21 (Abbott CMIA, ARCHITECT). Reactive samples were confirmed through Western blot. Pooled Australian National Cancer Registry surveillance data reporting on cases coded for ATL (2004-2015) were analysed. RESULTS: Two out of 2000 hospital and health services samples were confirmed HTLV-1-positive (0.1%, 95% CI 0.02% to 0.4%), both in older women, one Indigenous and one non-Indigenous. All 540 haemodialysis samples tested negative for HTLV. All samples were HTLV-2-negative. Ten out of 42 (24.8%) reported cases of ATL in Australia were from Queensland (crude incidence rate 0.025/100 000; 95% CI 0.011 to 0.045); most cases were seen in adult men of non-Indigenous origin. Nineteen deaths due to ATL were recorded in Australia. CONCLUSION: We confirm that HTLV-1 and ATL were detected in Queensland in Indigenous and non-Indigenous people. These results highlight the need for HTLV-1 prevalence studies in populations at risk of STIs to allow the implementation of focused public health sexual and mother-to-child transmission prevention strategies.

Urological Society of Australia and New Zealand (USANZ) and Australasian Chapter of Sexual Health Medicine (AChSHM) for the Royal Australasian College of Physicians (RACP) clinical guidelines on the management of erectile dysfunction.

INTRODUCTION: These clinical practice recommendations by the Urological Society of Australia and New Zealand (USANZ) and the Australasian Chapter of Sexual Health Medicine (AChSHM) for the Royal Australasian College of Physicians (RACP) provide evidence-based clinical guidelines on the management of erectile dysfunction (ED) in Australia. MAIN RECOMMENDATIONS: A comprehensive clinical history and a tailored physical examination are essential (Level of evidence [LoE] 3; GRADE B). Laboratory testing should include fasting glucose, lipid profile and total testosterone level (LoE 3; GRADE A). Specialised diagnostic tests are recommended in selected cases and the patient should be counselled accordingly (LoE 4; GRADE B). Lifestyle changes and optimisation of existing medical conditions should accompany all ED treatment regimens (LoE 1; GRADE A). Oral phosphodiesterase type 5 inhibitor (PDE5i) is an effective first line medical therapy (LoE 1; GRADE A). Intracavernosal injections and vacuum erection devices are recommended as second line therapy (LoE 1; GRADE B). A penile prosthesis implant can be considered in men who are medically refractory or unable to tolerate the side effects of medical therapy (LoE 4; GRADE B). Pro-erectile regenerative therapy remains largely experimental (LoE 3; GRADE B). CHANGES IN MANAGEMENT AS A RESULT OF THESE GUIDELINES: Modification of lifestyle behaviour, management of reversible risk factors and optimisation of existing medical conditions remain pivotal, and existing standard ED therapies are often effective and safe following cardiovascular risk stratification. Caution should be exercised on the use of regenerative technology in ED due to unknown long term outcomes.

Genital ulcer disease in India: etiologies and performance of current syndrome guidelines.

BACKGROUND: In India, genital ulcer disease (GUD) syndrome is clinically classified as herpetic or nonherpetic and managed accordingly; laboratory support is unavailable at most health facilities. We undertook a study to determine the etiology of GUDs in men presenting to sexually transmitted infection (STI) clinics and assess the performance of the national algorithm for syndromic management of herpetic and nonherpetic GUDs in India. METHOD: A cross-sectional study was conducted among men with complaints of genital ulcers attending 8 STI clinics in 4 states. Ulcer swabs were collected and tested by the multiplex polymerase chain reaction method to determine the etiology of GUD. RESULTS: Of the 194 men recruited, etiology was confirmed in 121 GUD cases (62%). Herpes simplex virus (48%) was the most common etiological agent identified, followed by Treponema pallidum (23%) and mixed infections (9%). One case of Haemophilus ducreyi was confirmed in this series. The overall sensitivity and specificity of the national syndromic management algorithm for GUD were 68% and 52%, respectively. Using the national algorithm, 52 (42%) cases clinically misclassified as either herpetic (18 cases) or nonherpetic (34 cases) GUD resulting in incorrect treatment. CONCLUSIONS: Our findings suggest a revision of existing national STI treatment guidelines in India to include treatment of syphilis infections of all GUD patients. Periodic studies are required to monitor changing spectrum of GUD etiologies in India.

Large-scale STI services in Avahan improve utilization and treatment seeking behaviour amongst high-risk groups in India: an analysis of clinical records from six states.

BACKGROUND: Avahan, the India AIDS Initiative, implemented a large HIV prevention programme across six high HIV prevalence states amongst high risk groups consisting of female sex workers, high risk men who have sex with men, transgenders and injecting drug users in India. Utilization of the clinical services, health seeking behaviour and trends in syndromic diagnosis of sexually transmitted infections amongst these populations were measured using the individual tracking data. METHODS: The Avahan clinical monitoring system included individual tracking data pertaining to clinical services amongst high risk groups. All clinic visits were recorded in the routine clinical monitoring system using unique identification numbers at the NGO-level. Visits by individual clinic attendees were tracked from January 2005 to December 2009. An analysis examining the limited variables over time, stratified by risk group, was performed. RESULTS: A total of 431,434 individuals including 331,533 female sex workers, 10,280 injecting drug users, 82,293 men who have sex with men, and 7,328 transgenders visited the clinics with a total of 2,700,192 visits. Individuals made an average of 6.2 visits to the clinics during the study period. The number of visits per person increased annually from 1.2 in 2005 to 8.3 in 2009. The proportion of attendees visiting clinics more than four times a year increased from 4% in 2005 to 26% in 2009 (p<0.001). The proportion of STI syndromes diagnosed amongst female sex workers decreased from 39% in 2005 to 11% in 2009 (p<0.001) while the proportion of STI syndromes diagnosed amongst high risk men who have sex with men decreased from 12% to 3 % (p<0.001). The proportion of attendees seeking regular STI check-ups increased from 12% to 48% (p<0.001). The proportion of high risk groups accessing clinics within two days of onset of STI-related symptoms and acceptability of speculum and proctoscope examination increased significantly during the programme implementation period. CONCLUSIONS: The programme demonstrated that acceptable and accessible services with marginalised and often difficult-to-reach populations can be brought to a very large scale using standardized approaches. Utilization of these services can dramatically improve health seeking behaviour and reduce STI prevalence.

Tobacco Harm Reduction with Vaporised Nicotine (THRiVe): The Study Protocol of an Uncontrolled Feasibility Study of Novel Nicotine Replacement Products among People Living with HIV Who Smoke.

Smoking is a leading cause of morbidity and premature mortality among people living with HIV (PLHIV), who have high rates of tobacco smoking. Vaporised nicotine products (VNPs) are growing in popularity as a quit aid and harm reduction tool. However, little is known about their acceptability and use among PLHIV. Using a pragmatic, uncontrolled, mixed methods design this exploratory clinical trial aims to examine the feasibility of conducting a powered randomised clinical trial of VNPs as a smoking cessation and harm reduction intervention among vulnerable populations, such as PLHIV who smoke tobacco. Convenience sampling and snowball methods will be used to recruit participants (N = 30) who will receive two VNPs and up to 12 weeks' supply of nicotine e-liquid to use in a quit attempt. Surveys will be completed at weeks 0 (baseline), 4, 8, 12 (end of treatment) and 24 (end of the study) and qualitative interviews at weeks 0 and 12. As far as we are aware, this feasibility study is the first to trial VNPs among PLHIV for smoking cessation. If feasible and effective, this intervention could offer a new approach to reducing the high burden of tobacco-related disease among PLHIV and other vulnerable populations.

Brief Report: Long-term Outcomes and Their Determinants in Patients on Antiretroviral Treatment in Ethiopia, 2005/6-2011/12: A Retrospective Cohort Study.

BACKGROUND: Antiretroviral treatment (ART) programs in many resource-limited settings have expanded treatment toward universal access. Ethiopia is one of the countries that has been scaling up ART toward universal access, but with very few data on long-term outcomes and their determinants. The objective of this study was to identify the level of long-term outcomes and their determinants in patients on ART in Ethiopia. METHODS: A retrospective cohort study was conducted in 3 health facilities (2 hospitals and 1 health center) between July and September, 2014. Loss to follow-up, death, attrition, and retention were the primary outcomes. Data were collected from patient registers and medical records for the period 2005/6-2011/12. RESULTS: A total of 11,731 patients were included in the study. The overall retention rate was 78 per 100 person-months. Retention rates were 82%, 74%, and 72% at 24, 60, and 84 months on ART, respectively. Retention was associated with male sex, adolescent age, marital status, advanced HIV disease, illiteracy, and peer-support services; however, long-term retention was associated independently with only male sex [with adjusted hazard ratio (aHR) 0.68 (0.56 to 0.77)], married patients [with aHR 0.62 (0.54 to 0.72)], and peer-support services [with aHR 1.62 (1.58 to 1.66)]. DISCUSSION AND CONCLUSIONS: ART programs have lost most of their patients during the first 24 months on ART. It is, therefore, imperative that HIV/ART programs ensure people are tested, linked to care, and initiated on ART early. ART programs should also design and implement interventions, including peer-support services, which are targeted to male, adolescent, unmarried, and illiterate patients.

Prevention and control of sexually transmissible infections among hotel-based female sex workers in Dhaka, Bangladesh.

BACKGROUND: Hotel-based sex workers in Bangladesh have high rates of sexually transmissible infections (STIs), high client turnover and low condom use. Two monthly clinic-based strategies were compared: periodic presumptive treatment (PPT) and enhanced syndromic management (ESM) - one round of presumptive treatment followed by treatment based on assessment and laboratory tests. METHODS: A randomised controlled trial compared PPT and ESM by prevalence and incidence, behaviour, retention, cost and STI incidence and prevalence. Demographic, behavioural and clinical data were collected from women at two clinics in Dhaka. All women received presumptive treatment and were randomised to receive PPT or ESM at nine monthly visits. RESULTS: In total, 549 women (median age: <20 years) were enrolled. At baseline, the prevalence of chlamydia (Chlamydia trachomatis) and gonorrhoea (Neisseria gonorrhoeae) was 41% (ESM: 41%; PPT: 42%). After 9 months, chlamydia and gonorrhoea decreased to 7% overall, (ESM: 7.4%; PPT: 6.8%). At each visit, 98% of women receiving ESM met the therapy criteria and were treated. Retention was low (50%). Total costs were 50% lower per visit for each woman for PPT (ESM: $11.62 v. PPT: $5.80). The number of sex work sessions was reduced from 3.3 to 2.5 (P<0.001), but income did not change. Coercion was reduced but condom use at last sex did not change significantly. CONCLUSIONS: Monthly PPT and ESM were effective approaches for STI control. PPT offered a feasible, low-cost alternative to ESM. Educational aspects led to a reduction in coercion and fewer sessions. Implementation studies are needed to improve condom use and retention.

Periodic presumptive treatment of curable sexually transmitted infections among sex workers: a systematic review.

BACKGROUND: Unprotected sex work remains a major driver of HIV/sexually transmitted infection (STI) epidemics in many countries. STI treatment can lower disease burden, complications and prevalence of HIV cofactors. Periodic presumptive treatment (PPT) has been used with sex workers to reduce their high burden of largely asymptomatic STIs. The objective of this review is to assess benefits and harms of PPT among female sex workers. METHODS: We searched MEDLINE for studies related to sex work and STIs during 1990-2010, extracted data from eligible studies in duplicate and conducted meta-analysis by study design using random effects models. RESULTS: Two thousand, three hundred and fifteen articles were screened, 18 studies met inclusion criteria and 14 were included in meta-analyses. One published randomized controlled trial (RCT) reported significant reductions of gonorrhoea (Neisseria gonorrhoeae) [rate ratio (RR) 0.46, 95% confidence interval (CI) 0.31-0.68] and chlamydia (Chlamydia trachomatis) (RR 0.38, 95%CI 0.26-0.57), but no effect on serologic syphilis (RR 1.02, 95%CI 0.54-1.95). Similar results were seen for N. gonorrhoeae and C. trachomatis in pooled analyses, including data from one unpublished RCT and across study designs, and correlated with initial prevalence (R(2) = 0.155). One observational study reported genital ulcer disease (GUD) declines in sex workers, and two reported impact among male client populations for N. gonorrhoeae [odds ratio (OR) 0.60, 95% CI 0.38-0.94], C. trachomatis (OR 0.47, 95% CI 0.31-0.71) and GUD (OR 0.21, 95% CI 0.11-0.42). No studies reported evidence of risk compensation or antibiotic resistance. CONCLUSION: PPT can reduce prevalence of gonorrhoea, chlamydia and ulcerative STIs among sex workers in whom prevalence is high. Sustained STI reductions can be achieved when PPT is implemented together with peer interventions and condom promotion. Additional benefits may include impact on STI and HIV transmission at population level.

Falling through the cracks: contraceptive needs of female sex workers in Cambodia and Laos.

BACKGROUND: Condom is the only method promoted for dual protection among female sex workers (FSWs) in most Asian countries, which may be insufficient to prevent pregnancies given FSWs' high frequency of sexual intercourse. STUDY DESIGN: Data were obtained from independent cross-sectional surveillance surveys conducted in Cambodia and Laos. Random samples of FSWs provided behavioral information. RESULTS: Respondents numbered 592 in Cambodia and 1421 in Laos. In Cambodia, 28.2% had abortions in the past year despite reporting 99.0% condom use at last commercial sex. Abortion increased with the number of clients, inconsistent condom use, recent condom breakage and recent forced unprotected sex with clients. In Laos, 26.0% of all FSWs had ever aborted as had 89.4% of those who had been pregnant in the past 6 months. CONCLUSIONS: FSWs experience higher frequency of abortion than women from the general population. FSWs' reportedly high rate of condom use is insufficient to prevent pregnancies.

Simultaneous use of multiple condoms among male Cambodian military personnel visiting female sex workers.

OBJECTIVES: To estimate the prevalence of simultaneous use of multiple condoms (SUMC) and identify the characteristics of the multiple condoms users. STUDY DESIGN: Cross-sectional survey among military men from a purposively selected Cambodian military region. Military men were interviewed face to face. RESULTS: From the 1638 respondents, 40% never had sex with female sex workers (FSWs), 55% had used condom(s), and 5% had unprotected sex at their last encounter with a FSW. Among those reporting sex with FSWs, 21% had used multiple condoms simultaneously at their last sex with a FSW. CONCLUSION: Compared with single condom users, multiple condom users were younger, had lower rank, had first sex more recently, had lower knowledge of HIV transmission, had received less HIV peer-education sessions, were more likely to have visited multiple FSWs, and were more likely to have sought their HIV serostatus. As it is unknown if SUMC increases or decreases condom effectiveness, more research is needed to investigate the effect of SUMC on condom failure rates.

On-site rapid antenatal syphilis screening with an immunochromatographic strip improves case detection and treatment in rural South African clinics.

OBJECTIVES: Congenital syphilis is a significant cause of adverse pregnancy outcomes. In South Africa, rural clinics perform antenatal screening offsite, but unreliable transport and poor client follow up impede effective treatment. We compared 3 syphilis screening strategies at rural clinics: on-site rapid plasma reagin (RPR), on-site treponemal immunochromatographic strip (ICS) test, and the standard practice offsite RPR with Treponema pallidum hemagglutination assay (RPR/TPHA). METHODS: Eight rural clinics performed the on-site RPR and ICS tests and provided immediate treatment. Results were compared with RPR/TPHA at a reference laboratory. Chart reviews at 8 standard practice clinics established diagnosis and treatment rates for offsite RPR/TPHA. FINDINGS: Seventy-nine (6.3%) of 1,250 women screened on-site had active syphilis according to the reference laboratory. The on-site ICS resulted in the highest percentage of pregnant women correctly diagnosed and treated for syphilis (89.4% ICS, 63.9% on-site RPR, 60.8% offsite RPR/TPHA). The on-site RPR had low sensitivity (71.4% for high-titer syphilis). The offsite approach suffered from poor client return rates. One percent of women screened with the ICS may have received penicillin unnecessarily. There were no adverse treatment outcomes. CONCLUSIONS: The on-site ICS test can reduce syphilis-related adverse outcomes of pregnancy through accurate diagnosis and immediate treatment of pregnant women with syphilis.

Efforts to Control Sexually Transmitted Infections As a Means to Limit HIV Transmission: What Is the Evidence?

There is overwhelming and compelling evidence that control efforts for sexually transmitted infection (STI) have a major role to play in the prevention of HIV transmission. Community-based randomized controlled trials are set as the highest standard of evidence for showing the efficacy of STI interventions to prevent HIV transmission. The negative results of recent randomized controlled trials have cast doubt on the positive findings of the Mwanza study. Deeper analysis of the result of these trials has improved understanding of the role of STI interventions and augmented the wealth of evidence provided by numerous epidemiologic and biomedical studies. Apart from the biologic impact of effective treatment of curable STIs on HIV transmission, clinical services also support the reduction of HIV risk behaviors. STI interventions should limit the scale of the impending epidemics in Asia and Eastern Europe, depending on the priority that they are given by governments and major donor agencies.

Sexually transmitted infections among female sex workers in Kupang, Indonesia: searching for a screening algorithm to detect cervical gonococcal and chlamydial infections.

BACKGROUND AND GOAL: Notifications of HIV infection in Indonesia are increasing, but there are few data on other sexually transmitted infections (STIs), especially in the eastern islands of Indonesia. We aimed to measure the prevalence of STIs among female sex workers (FSWs) in Kupang, West Timor, and to develop screening algorithms to detect cervical infections with Neisseria gonorrhoeae and/or Chlamydia trachomatis (NG/CT). STUDY DESIGN: During 6 months in 1999, we recruited all the FSWs at Kupang's only brothel complex and a smaller number of independent FSWs. The women were examined at dedicated clinics and most laboratory tests were performed at provincial laboratories. Algorithms based on the strongest associations of variables with NG/CT were compared with the laboratory diagnoses. RESULTS: We recruited 288 women. The prevalence of N gonorrhoeae infection was 31%, that of C trachomatis infection was 24%, that of Trichomonas vaginalis infection was 5%, and that of syphilis was 13%. No case of HIV infection was detected. Few women had symptoms of STI. The only variables significantly associated with NG/CT after logistic regression analysis were the presence of cervical discharge (either yellow or clear) and a high count of polymorphonuclear leukocytes on gram-stained endocervical smear. Several algorithms to screen for NG/CT achieved high (>80%) sensitivity, but the highest specificity among these was only 50%. CONCLUSIONS: Although several of the generated algorithms may be useful in the absence of simple, accurate, affordable diagnostic tests, the high rates of STIs in this population could justify a more aggressive strategy incorporating periodic presumptive treatment to rapidly reduce prevalence.