Already current practice? A snapshot survey on doxycycline use for prevention of sexually transmitted infections in parts of the German MSM community.

PURPOSE: Recent studies point toward a potential benefit of doxycycline use for post-exposure prophylaxis (PEP) or pre-exposure prophylaxis (PrEP) to prevent sexually transmitted infections (STIs). Although prescribing doxycycline in a prophylactic intention is not generally recommended yet, we noticed an increasing number of inquiries from individuals within the LGBTQ community for doxycycline prescriptions. METHODS: We conducted an anonymous online survey to evaluate the current extent of doxycycline use for PEP or PrEP within the LGBTQ community using REDCap electronic data capture tools. Participants gained access to the online survey through a QR code on posters in the premises of our STI outpatient department and at LGBTQ community-related events in the south-western region of Germany. Additional access was provided by a direct link shared on social media profiles for men having sex with men (MSM), transgender, and queers. RESULTS: 96 of 99 responses were eligible for analysis. Twenty-two participants (23%) indicated to have already used doxycycline for PEP and six participants (6%) used doxycycline for PrEP. The majority of participants used pills left over from previous doxycycline treatment. Forty percent of indicated modes of access were without a regular prescription, e.g., by provision from acquaintances (with or without healthcare profession) or by ordering online. CONCLUSION: Our study shows that the concept of doxycycline use for prevention of STIs is already well known and applied in the LGBTQ community. Further analysis, especially modeling studies, are needed to evaluate strategies aiming to reduce doxycycline intake (PEP/PrEP versus repeated targeted therapies) and improve sexual health outcomes within the community.

Long-term follow-up after introduction of a systematic sexually transmitted infection screening program for men having sex with men living with HIV in a primary care setting: uptake, STI incidence, and risk factors for infection and reinfection.

PURPOSE: Annual screening for asymptomatic infections with Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) is recommended by international guidelines in people living with HIV but uptake in routine care remains poor. This study analyzed the effects of the implementation of a CT/NG screening program in a primary HIV treatment center. METHODS: In this single-center cohort study, we included men having sex with men (MSM) living with HIV during the study period from January 2016 to December 2019. From January 2018 on, annual sexual health counseling including CT/NG screening was proactively offered to all MSM presenting at the center. CT/NG screening rates, test positivity rates and case detection rates in the years 2018 and 2019 were compared to those in the years 2016 and 2017. RESULTS: A total of 234 patients were enrolled in the study contributing to 798.7 patient years (py) during the four-year study period. Screening rates increased from 3.1% and 3.9% in 2016 and 2017 to 51.1% in 2018 and decrease to 35.4% in 2019. Over the study period, 19.7% (46/234) had at least one positive CT/NG result. After the intervention, case detection per 100 py increased for CT (2016: 2.6, 2017: 3.7, 2018: 7.7, 2019: 7.1) and NG (2016: 3.2, 2017: 3.1, 2018: 5.3, 2019: 7.6). The number needed to test was 8.9 for CT and 10.4 for NG. CONCLUSION: Regular CT/NG screening is feasible in a primary care setting, leads to an increase in case detection and may contribute to decrease transmission and complications of CT/NG. TRIAL REGISTRATION: The trial is registered in ClinicalTrials.gov (NCT02149004).

Assessing the differential impact of chronic CMV and treated HIV infection on CD8+ T-cell differentiation in a matched cohort study: is CMV the key?

BACKGROUND: Cytomegalovirus (CMV) infection is one of the main driving forces of T-cell senescence in the general population, whereas its differential impact in people living with HIV (PLWH) is less well characterized. The study explores the effect of latent CMV infection on T-cell subsets, monocyte/macrophages activation markers, and CRP in PLWH on long-term ART. METHODS: Cross-sectional cohort study including PLWH on long-term suppressive ART. Individuals of 4 groups (HIV+CMV-, HIV+CMV+, HIV-CMV+, and HIV-CMV-) were matched 1:1:1:1 for age and sex. Immunophenotyping of lymphocyte and T-cell subsets by multicolor flow cytometry was performed in fresh blood samples collected from patients and healthy donors. RESULTS: Both, latent CMV and treated HIV infection were associated with an expansion of CD8 T cells, a reduced CD4/CD8 ratio, and with CD8 T-cell activation with a cumulative effect in CMV/HIV-coinfected individuals. CMV was associated with elevated numbers of late effector and terminally differentiated CD8 T-cells. Compared to CMV monoinfection, CMV/HIV coinfection showed to be associated with lower proportion of CD28-CD8+ T cells expressing CD57 suggesting that HIV preferentially expands CD28-CD57-CD8+ T cells and impedes terminal differentiation of CD28-CD8+ T cells. We could not show any association between HIV or CMV infection status and concentration of CRP and CD163. CONCLUSIONS: CMV infection is associated with phenotypic signs of T-cell senescence, promoting exacerbation and persistence of alterations of the T-cell compartment in PLWH on effective ART, which are associated with adverse clinical outcomes and may be an attractive target for therapeutic interventions.

High SYK Expression Drives Constitutive Activation of CD21low B Cells.

Human CD21low B cells present with an activated phenotype and accumulate in distinct disorders connected with chronic immune stimulation. Signaling studies had revealed an increased basal phosphorylation of spleen tyrosine kinase (SYK) and phospholipase Cγ2. Additional BCR stimulation of these constitutively active cells, however, led to reduced activation of these signaling molecules and subsequently NF-κB and Ca2+ activation. In this article, we demonstrate that high SYK expression is a common feature of CD21low B cells independent of the underlying disorder, and that this high expression is sufficient to drive constitutive phosphorylation of SYK and its immediate targets Bruton's tyrosine kinase and phospholipase Cγ2. Inhibition of SYK activity eliminated features of the constitutive activation in these cells and partly restored BCR signaling. High SYK expression is especially induced by CpG or CD40L in combination with IL-21, but not BCR stimulation, suggesting the importance of the immune-stimulatory context for the induction of this B cell phenotype. In summary, high SYK expression is a common feature of human CD21low B cells and presumably results from chronic activation in inflammatory environments present in a subgroup of patients with heterogeneous disorders like chronic infection, autoimmunity, and immunodeficiency. High SYK expression by itself drives the constitutive activation observed in these B cells, which in turn may contribute to the hyporesponsiveness upon BCR stimulation. Given the high prevalence of autoreactive clones among CD21low B cells in autoimmune disorders, the dominant role of SYK in CD21low B cells may provide a new option for therapeutic interventions in patients with expanded CD21low B cells and humoral autoimmunity.

Disturbed canonical nuclear factor of κ light chain signaling in B cells of patients with common variable immunodeficiency.

BACKGROUND: Most patients with common variable immunodeficiency (CVID) present with severely reduced switched memory B-cell counts, and some display an increase of CD21low B-cell counts (CVID 21low), whereas others do not (CVID 21norm). Altered B-cell receptor (BCR) signaling might contribute to the defective memory formation observed in patients with CVID. OBJECTIVE: We sought to investigate canonical nuclear factor of κ light chain (NF-κB) signaling in B cells from patients with CVID as a central pathway in B-cell differentiation. METHODS: Degradation of inhibitor of κBα (IκBα) and p65 phosphorylation, nuclear translocation of p65, and regulation of target genes and cell function were investigated after different modes of B-cell stimulation. RESULTS: BCR-mediated canonical NF-κB signaling was impaired in all mature naive CVID-derived B cells. This impairment was more profound in naive B cells from CVID 21low patients than CVID 21norm patients and most pronounced in CD21low B cells. The signaling defect translated into reduced induction of Bcl-xL and IκBα, 2 bona fide target genes of the canonical NF-κB pathway. CD40 ligand- and Toll-like receptor 9-mediated signaling were less strongly altered. Signaling in CD21low B cells but not CD21+ B cells of patients with HIV was similarly affected. CONCLUSION: Combined with the previous description of disturbed Ca2+ signaling, the discovery of NF-κB signaling defects, especially in CVID 21low patients, suggests a broad underlying signaling defect affecting especially BCR-derived signals. Given the immune phenotype of monogenic defects affecting Ca2+ and NF-κB signaling, the latter is more likely to contribute to the humoral deficiency. The strongly disturbed BCR signaling of CD21low B cells is characteristic for this cell type and independent of the underlying disease.

Transmission characteristics, replication patterns and clinical manifestations of human monkeypox virus-an in-depth analysis of four cases from Germany.

OBJECTIVE: Since April 2022, increasing numbers of monkeypox (MPX) cases have been reported outside endemic areas as part of an international outbreak. Our study shows aspects of clinical manifestations as well as epidemiological and virological features impacting transmission, for which only scarce data are available so far. METHODS: We present a descriptive study consisting of epidemiological, clinical and virological data of four patients with confirmed MPX diagnosis. Follow-up examinations included in-depth virological investigations, including MPX virus-specific quantitative PCR and virus isolation. RESULTS: Between 22 May 2022, and 21 June 2022, four patients with MPX were evaluated. The number of lesions ranged between one and more than 30, with asynchronous eruptions. The periorificial distribution of initial lesions together with the case histories strongly suggest human-to-human transmission during intimate contacts in sexual activities. None of the patients reported about memorable lesions on the skin of potential risk contacts. Virological sampling showed positive MPX virus-specific quantitative PCR results from swabs of the primary lesions (until day 22 after symptom onset), pharyngeal and anal mucosa, urine, seminal fluid, blood and samples of non-affected skin. Virus isolation was positive in 6/14 samples (lesional skin, anal and pharyngeal mucosa). One patient required inpatient treatment for bacterial superinfection; in another patient, three sexually transmitted co-infections were present. CONCLUSIONS: Our report demonstrates asynchronous multiple-site lesions of MPX with prolonged PCR positivity in mucosal swabs, swabs of non-affected skin, urine and seminal fluid. In addition, infectious virus was confirmed on lesional skin and mucosal swabs. The observed virological kinetics together with the suspected pre-symptomatic transmission may lead to effective and sustained human-to-human transmission, particularly in sexual networks. Preventive measures such as vaccination and post-exposure prophylaxis may become important for MPX control in vulnerable groups.

Closing Sexual Health Service Gaps With a New Service Model in Germany: Performance of an on-Site Integrated, Cross-Sectoral, Low Threshold Sexually Transmitted Infections/HIV Counseling and Treatment Service.

Purpose: In Germany, the incidence of bacterial sexual transmitted infections (STI) is on the rise and still high for HIV infections. The Center for Sexual Health Freiburg (CSHF) was established to offer low threshold access for STI/HIV counseling, testing, HIV pre-exposure prophylaxis (PrEP), and on-site treatment. The objective of this study was to analyze the performance of CSHF. Methods: Longitudinal study that includes all clients presenting between 1 May 2020 and 28 February 2021 at CSHF and willing to sign informed consent. Results: In the study period, 536 clients presented at CSHF of whom 417 clients were included in the study resulting in 668 client contacts. Clients' median age was 28.1 years (range: 18.0-73.1), 55.9% were men, 42.0% were women, 0.3% were transman, and 1.7% were not binary. Clients' sexual orientation was heterosexual (56.6%), homosexual men (26.2%), and bisexual (13.6%). STI screening resulted in the detection of any STI in 3.4% (95% confidence interval (CI): 0.7-6.1) of women, in 3.1% (95% CI: 0.0-6.5) of heterosexual men, and in 22.2% (95% CI: 13.0-31.5) of men having sex with men (MSM) not taking PrEP. Eighty-one MSM received PrEP with a total follow-up of 57.3 person-years and 0.44 STIs per person-year. Conclusion: The substantial burden of STI in the study population emphasizes the need for regular and low threshold STI screening services. The concept of CSHF may facilitate access to STI/HIV counseling, testing, and PrEP for a wide spectrum of people and may prove to be an important contribution to the efforts to reduce STI and HIV incidence in Germany.

Proportion of patients eligible for statin therapy substantially varies between different cardiovascular disease risk calculators and guidelines used.

Because people living with HIV (PLWH) have an elevated risk for cardiovascular disease (CVD), prevention of CVD should be integrated in to HIV care. In this study, we compared the agreement between three risk scores and evaluated the indication for statin therapy based on guidelines of the American Heart Association and European AIDS Clinical Society. This study is a cross-sectional, single-center study. All PLWH ≥ 30 years without CVD and statin therapy were consecutively enrolled. Agreement between CVD risk estimates was assessed using Cohen's kappa coefficient. Of 488 PLWH, 41.2% were female with a median age of 47.8 years. D:A:D-R classified the highest proportion of patients in the categories of high/very high risk for CVD (17.8%) compared to SCORE (4.7%) and FRS (13.7%). D:A:D-R and SCORE (κ = 0.11) as well as D:A:D-R and FRS (κ = 0.33) showed poor agreement. Based on different CVD risk equations and guidelines, indication for statin therapy ranged from 34.8% to 92.0% of patients. In conclusion, a high proportion of PLWH is at high risk for CVD likely underestimated by treating physicians. Inconsistencies in the evaluation of CVD risk and primary prophylaxis should be tackled by an interdisciplinary approach.

The expansion of human T-bethighCD21low B cells is T cell dependent.

Accumulation of human CD21low B cells in peripheral blood is a hallmark of chronic activation of the adaptive immune system in certain infections and autoimmune disorders. The molecular pathways underpinning the development, function, and fate of these CD21low B cells remain incompletely characterized. Here, combined transcriptomic and chromatin accessibility analyses supported a prominent role for the transcription factor T-bet in the transcriptional regulation of these T-bethighCD21low B cells. Investigating essential signals for generating these cells in vitro established that B cell receptor (BCR)/interferon-γ receptor (IFNγR) costimulation induced the highest levels of T-bet expression and enabled their differentiation during cell cultures with Toll-like receptor (TLR) ligand or CD40L/interleukin-21 (IL-21) stimulation. Low proportions of CD21low B cells in peripheral blood from patients with defined inborn errors of immunity (IEI), because of mutations affecting canonical NF-κB, CD40, and IL-21 receptor or IL-12/IFNγ/IFNγ receptor/signal transducer and activator of transcription 1 (STAT1) signaling, substantiated the essential roles of BCR- and certain T cell­derived signals in the in vivo expansion of T-bethighCD21low B cells. Disturbed TLR signaling due to MyD88 or IRAK4 deficiency was not associated with reduced CD21low B cell proportions. The expansion of human T-bethighCD21low B cells correlated with an expansion of circulating T follicular helper 1 (cTfh1) and T peripheral helper (Tph) cells, identifying potential sources of CD40L, IL-21, and IFNγ signals. Thus, we identified important pathways to target autoreactive T-bethighCD21low B cells in human autoimmune conditions, where these cells are linked to pathogenesis and disease progression.

[Sexually Transmitted Infections - What's New, What's Different?] / Aktuelles zu sexuell übertragbaren Infektionen.

The incidence of sexually transmitted infections like syphilis or gonorrhea is still rising, particularly in the high-risk population of men having sex with men (MSM). Neisseria gonorrhoeae is capable to develop resistance to all antibiotics previously or currently used for treatment. Dual antimicrobial therapy with ceftriaxone and azithromycin is considered the current empirical first-line therapy. Since 2011 ceftriaxone-resistant strains have emerged in many countries and in 2018 the first case with high-level resistance to azithromycin and resistance to ceftriaxone was documented in the UK, making the development of new antimicrobials against gonorrhea a public health priority. HIV-pre-exposure-prophylaxis (HIV-PrEP) has recently been approved in Germany and may become an important complementary approach to reduce HIV transmission. However, appropriate counselling and STI testing has to be secured in PrEP users. The German Standing Committee on Vaccination (STIKO) now recommends human papillomavirus (HPV) vaccination for boys aged 9 - 14 years. The Centers for Disease Control and Prevention (CDC) shortens the recommended interval from leaving a zika virus-endemic country until conception to 3 months.