Treatment and outcomes of polymerase chain reaction-confirmed early syphilis.

UNLABELLED: Background Syphilis is resurgent among gay and bisexual men (GBM) despite effective treatment and widely available diagnostic serology. The polymerase chain reaction assay for Treponema pallidum (TP-PCR) is available, but little is known about the clinical features and outcomes for patients testing positive by TP-PCR. METHODS: Clinical data were collected from four medical practices for patients recording a positive TP-PCR result between 2004 and 2011. Demographic, serological, treatment and reinfection details were obtained. Results were stratified by HIV status and whether treatment conformed to international guidelines. RESULTS: 220 patients were positive for TP-PCR, of whom 92% were GBM. Seventeen (8.1%) were positive by TP-PCR before seroconversion. Almost one-third (32.1%) received treatment beyond that recommended in guidelines, and this was associated with HIV status (40.3% HIV positive vs 22.4% HIV negative, P<0.01). All but one patient with adequate follow up achieved serological cure. There was no significant difference in time to serological cure between the groups receiving standard therapy or enhanced therapy (95 vs 108 days; P=0.67) or between HIV positive and negative patients (93 vs 104 days, P=0.06). Nineteen patients were reinfected during follow up. CONCLUSION: TP-PCR aids early diagnosis of syphilis and may be reactive before conventional serological tests. Treatment outcomes for TP-PCR-positive early infection were excellent, but a significant proportion of patients received non-standard therapy. Expanded use of syphilis PCR testing in at-risk populations is recommended since early identification and treatment is likely to be important in controlling the current epidemic in GBM.

Fast-track services for all? The preferences of Chinese-, Korean-, and Thai-speaking women attending a sexual health service.

BACKGROUND: Sydney Sexual Health Centre (SSHC) Xpress clinic has significantly reduced the length of stay and waiting time for clients at SSHC but is currently only available to clients who can read and understand a high level of English. This reduces access for culturally and linguistically diverse (CALD) clients. This study sought to determine the acceptability of 4 proposed components of an express clinic model among CALD clients: computer-assisted self-interview (CASI), self-collection of swabs/urine specimens, not having a physical examination, and consultation with a health promotion officer rather than with a clinician. Differences in acceptability based on language group, new or return client status, sex worker status, clinic visited status, and age were analyzed. METHODS: A cross-sectional, anonymous questionnaire was offered to all female Chinese, Thai, and Korean clients attending SSHC between March and November 2012. Multivariate regression and Pearson χ statistical analyses were conducted using STATA 12 software. RESULTS: A total of 366 questionnaires were returned from 149 Thai, 145 Chinese, and 72 Korean participants. After multivariate analysis, the only predictor of willingness to use an express model of service provision was language group: overall, 67% Thai (odds ratio, 3.74: confidence interval [CI], 2.03-6.89; P < 0.01) and 64% Korean (odds ratio, 3.58; CI, 1.77-7.25, P < 0.01) said that they would use it compared with 35% Chinese. Age, history of sex work, new or returning clients, and general or language clinic attendance did not impact on choices. Within the preference for individual components of the model, more Thai women were happy with using a health promotion officer (43.2%) than Chinese (14.1%) or Korean (8.5%) (P < 0.001); no groups were happy with forfeiting a physical examination; Thai (48.6%) and Korean (40.9%) were happier with self-swabbing than Chinese women (23.9%, P < 0.001); and more Thai were happy to use a CASI (44.2%) than Chinese (12%) or Korean (11.1%; P < 0.001). CONCLUSIONS: This research shows that the components of an express model used at SSHC are not favorable to our CALD client base. Despite a CALD express clinic having the potential to reduce waiting times, most clients did not favor reduced waiting time over being physically examined or using a CASI.

One confirmed and one suspected case of pharyngeal gonorrhoea treatment failure following 500mg ceftriaxone in Sydney, Australia.

Emerging antimicrobial resistance within Neisseria gonorrhoeae (NG) is a significant global public health threat. Detection and investigation of treatment failures is a crucial component of the World Health Organisation's response to this challenge. We report the cases of two homosexual men, both treated for pharyngeal NG with 500mg intramuscular ceftriaxone, in whom a test of cure 1 week after treatment showed persisting infection. Both men denied further sexual activity. In the first case, treatment failure was confirmed, since the isolates before and after treatment were identical by auxotype, antibiogram, multilocus sequence type (MLST) and multi-antigen sequence type (NG-MAST). In the second case, the MLSTs before and after treatment were identical, but NG-MAST results were similar but not indistinguishable. These cases underline the importance of test-of-cure and molecular investigations in identifying treatment failure, but also highlight the complexity of distinguishing treatment failure from reinfection when relying on highly variable molecular targets that may be subject to drug pressure.

Community event-based outreach screening for syphilis and other sexually transmissible infections among gay men in Sydney, Australia.

UNLABELLED: Objectives Increased testing frequency is a key strategy in syphilis control, but achieving regular testing is difficult. The objective of this study is to describe a sexually transmissible infection (STI) testing outreach program (the Testing Tent) at a gay community event. METHODS: Gay men attending the testing tent in 2010-11 completed a computer-assisted self-interview and were screened for STIs. Clinical, demographic, behavioural and diagnostic data were compared with gay men attending a clinic-based service during 2009. The Testing Tent was marketed on social media sites and data were extracted on the number of times the advertisements were viewed. Staffing, laboratory, marketing and venue hire expenses were calculated to estimate the cost of delivering the service. RESULTS: Ninety-eight men attended the Testing Tent. They were older (median age: 42 years v. 30 years; P<0.001), had more sex partners (median: five in 3 months v. two; P<0.001) and more likely to inject drugs (9% v. 4%; P=0.034) than the 1006 clinic attendees, but were more likely to have previously tested for STIs (81% v. 69%; P=0.028) and to always use condoms for anal sex (59% v. 43%; P=0.005). Five cases of STIs were detected; the diagnostic yield was not significantly different from that of the clinic. The cost of the Testing Tent was A$28?440. CONCLUSION: Nonclinical testing facilities are an acceptable option and are accessed by gay men requiring regular testing, and may be an important addition to traditional testing environments.

Clients' preferred methods of obtaining sexually transmissable infection or HIV results from Sydney Sexual Health Centre.

Given the documented benefits of using text messaging (short message service; SMS), the internet and email to deliver sexually transmissible infection (STI) test results, including high acceptability among clients, Sydney Sexual Health Centre (SSHC) aimed to identify which methods our clients preferred for receiving their results, using a cross-sectional survey. There was a preference for SMS (32%) for negative STI results, and for SMS (27%), phone call (27%) and in-person (26%) for negative HIV results. An in-person preference was shown for receiving positive STI results (40%) and positive HIV results (56%, P<0.001). While many clients would prefer to receive STI test results via text messages or phone call, many also still prefer a return visit, with this preference is dependent on the type and nature of the results. Our study suggests that, ideally, several options for obtaining results should be available.

Client feedback and satisfaction with an express sexually transmissible infection screening service at an inner-city sexual health center.

BACKGROUND: Sydney Sexual Health Centre (SSHC) commenced a fast-track sexually transmissible infection clinic, the Xpress Clinic (Xpress) pilot for asymptomatic clients in March 2010, using a computer-assisted self-interview and self-collected samples. This study examines client satisfaction and changes in intended screening frequency among clients of Xpress. METHODS: This was a cross-sectional study of all clients attending Xpress clinics during the initial 6 months. All clients were requested to complete a survey based on a previously validated questionnaire. Results were stratified by sex, sex of sexual partners, age, and sex work status. RESULTS: Of the 243 clients who attended Xpress, 145 (60%) returned questionnaires. The 2 most common reasons for choosing Xpress clinic were reduced waiting time (n = 42/138 [30%]; 95% confidence interval [CI], 23%-38%) and reduced length of consultation (n = 16/138 [12%]; 95% CI, 7%-17%).When asked if they would have come to SSHC anyway if Xpress was not an option, men who have sex with men (MSM) were more likely than non-MSM to say that they would come for screening anyway (77% MSM vs. 59% non-MSM, P = 0.034). Youth younger than 25 were less likely than those 25 years and older to have come for screening anyway (53% vs. 79%, P = 0.012).Most (n = 101/138 [73%]; 95% CI, 65%-80%) considered that they would test for sexually transmissible infections more frequently in the future using the Xpress model. Client satisfaction levels were high, with most respondents reporting that they would return to Xpress (n = 119/142 [83%]; 95% CI, 77%-89%) and would recommend it to friends (n = 122/142 [86%]; 95% CI, 79%-90%). CONCLUSIONS: Most clients were highly satisfied with all aspects of Xpress and reported intentions to retest using this model of care.

Long-term survival in HIV positive patients with up to 15 Years of antiretroviral therapy.

BACKGROUND: Life expectancy has increased for newly diagnosed HIV patients since the inception of combination antiretroviral treatment (cART), but there remains a need to better understand the characteristics of long-term survival in HIV-positive patients. We examined long-term survival in HIV-positive patients receiving cART in the Australian HIV Observational Database (AHOD), to describe changes in mortality compared to the general population and to develop longer-term survival models. METHODS: Data were examined from 2,675 HIV-positive participants in AHOD who started cART. Standardised mortality ratios (SMR) were calculated by age, sex and calendar year across prognostic characteristics using Australian Bureau of Statistics national data as reference. SMRs were examined by years of duration of cART by CD4 and similarly by viral load. Survival was analysed using Cox-proportional hazards and parametric survival models. RESULTS: The overall SMR for all-cause mortality was 3.5 (95% CI: 3.0-4.0). SMRs by CD4 count were 8.6 (95% CI: 7.2-10.2) for CD4<350 cells/µl; 2.1 (95% CI: 1.5-2.9) for CD4 = 350-499 cells/µl; and 1.5 (95% CI: 1.1-2.0) for CD4≥500 cells/µl. SMRs for patients with CD4 counts <350 cells/µL were much higher than for patients with higher CD4 counts across all durations of cART. SMRs for patients with viral loads greater than 400 copies/ml were much higher across all durations of cART. Multivariate models demonstrated improved survival associated with increased recent CD4, reduced recent viral load, younger patients, absence of HBVsAg-positive ever, year of HIV diagnosis and incidence of ADI. Parametric models showed a fairly constant mortality risk by year of cART up to 15 years of treatment. CONCLUSION: Observed mortality remained fairly constant by duration of cART and was modelled accurately by accepted prognostic factors. These rates did not vary much by duration of treatment. Changes in mortality with age were similar to those in the Australian general population.

Unprotected fellatio between female sex workers and their clients in Sydney, Australia.

OBJECTIVES: To assess the frequency and predictors of inconsistent condom use for fellatio at work by female sex workers (FSW) in Sydney and the prevalence of pharyngeal gonorrhoea and other sexually transmitted infections in these women. METHODS: Cross-sectional study including all FSW attending the Sydney Sexual Health Centre for sexually transmitted infection screening between May 2009 and January 2011 and reporting fellatio at work. Univariate and multivariate regression was used to identify predictors of inconsistent condom use for fellatio. RESULTS: Of 1540 FSW who offered fellatio at work, 372 (25%) reported inconsistent condom use for this fellatio. In multivariate analysis, speaking Mandarin or Cantonese rather than English (adjusted OR (AOR) 2.03, 95% CI 1.44 to 2.86), reporting inconsistent condom use for vaginal sex at work (AOR 10.82, 95% CI 6.13 to 19.09), reporting no vaginal sex at work (AOR 7.48, 95% CI 2.42 to 23.12) and being a new client to the clinic (AOR 2.10, 95% CI 1.56 to 2.83) were associated with inconsistent condom use for fellatio. Thai-speaking women were less likely to report unprotected fellatio (AOR 0.36, 95% CI 0.23 to 0.57). 17 women were diagnosed with pharyngeal gonorrhoea (AOR 1.1%, 95% CI 0.6% to 1.7%). CONCLUSIONS: Condom use for fellatio by Sydney FSW varies by work location and language spoken. Health promotion targeting these at-risk women is warranted. Women working in brothels masquerading as massage parlours were particularly likely to report inconsistent condom use for fellatio. Local government reluctance to approve brothels may be contributing to this problem.

When should HAART be initiated in pregnancy to achieve an undetectable HIV viral load by delivery?

BACKGROUND: HAART dramatically reduces mother-to-child transmission of HIV allowing vaginal delivery if the viral load is low. This study provides data for the optimum timing of short-term HAART in pregnancy. METHODS: Retrospective multicentre cohort study of pregnant women commencing HAART in London and Brighton, UK. Demographics, gestation, drug class, CD4 cell count, and viral load results were collated. Survival curves for reaching a viral load less than 50  copies/ml were stratified by initial HIV viral load. Cox's proportional hazards regression model was adjusted for demographics and immunovirological parameters. RESULTS: Viral load was less than 50  copies/ml in 292 of 378 pregnancies (77.2%) by delivery. Pretreatment viral load was associated with the time taken, and the proportion achieving a viral load less than 50  copies/ml at (P≤0.001). When baseline viral load was less than 10 ,000  copies/ml, gestational age at HAART initiation did not affect success up to 26.3 weeks gestation. When viral load was more than 10 ,000  copies/ml, deferring HAART past 20.4 weeks reduced the probability of reaching less than 50  copies/ml by delivery (P=0.011). When baseline viral load was more than 100, 000  copies/ml the likelihood of reaching a viral load of less than 50  copies/ml was low (37%: hazard ratio 0.31), and dependent on the length of time on HAART. The hazard ratio for a nonnucleoside reverse transcriptase inhibitor regimen achieving a viral load less than 50  copies/ml compared with a protease inhibitor was 0.7 (95% confidence interval 0.52-0.94). CONCLUSION: With a viral load more than 10, 000  copies/ml and especially with a viral load more than 100 ,000  copies/ml, the probability of achieving either less than 50 copies/ml by the time of delivery is compromised by delaying initiation of short-term highly active antiretroviral therapy beyond 20.4 weeks gestation. Current UK and other guidelines for when to commence START may therefore limit the chance of vaginal delivery.

Infectious syphilis unmasking drug resistance in an individual with long-term virological suppression on antiretroviral therapy.

This case report describes the case of an HIV-positive individual who had long-term virological suppression on antiretroviral therapy, who manifested HIV drug resistance during a syphilis-induced HIV viral load increase. This highlights how the acquisition of a sexually transmitted infection can have important ramifications for HIV suppression and potential HIV transmission to sexual partners.