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1.  Prevalence of Sexually Transmitted Co-Infections in People Living with HIV/AIDS: Systematic Review with Implications for using HIV Treatments for Prevention 
Sexually transmitted infections  2011;87(3):183-190.
Sexually transmitted co-infections increase HIV infectiousness through local inflammatory processes. The prevalence of STI among people living with HIV/AIDS has implications for containing the spread of HIV in general and the effectiveness of HIV treatments for prevention in particular.
A systematic review of studies examining STI co-infections in people living with HIV/AIDS. The review focuses on STI contracted after becoming HIV infected. Electronic database and manual searches located clinical and epidemiological studies of STI that increase HIV infectiousness.
Thirty seven studies of STI-HIV co-infection prevalence were located. Studies of adults living with HIV/AIDS from developed and developing countries reported STI rates for 46 different samples (33 samples had clinical/laboratory confirmed STI). The overall mean point-prevalence for confirmed STI was16.3% (SD = 16.4), and median 12.4% STI prevalence in people living with HIV/AIDS. The most common STI studied were Syphilis with median 9.5% prevalence, gonorrhea 9.5%, Chlamydia 5%, and Trichamoniasis 18.8% prevalence. STI prevalence was greatest at the time of HIV diagnosis, reflecting the role of STI in HIV transmission. Prevalence of STI among individuals receiving HIV treatment was not appreciably different from untreated persons.
The prevalence of STI in people infected with HIV suggests that STI co-infections could undermine efforts to use HIV treatments for prevention by increasing genital secretion infectiousness.
PMCID: PMC4317792  PMID: 21330572
HIV STI co-infection; test and treat; HIV treatment for prevention; sexual health
2.  [No title available] 
PMCID: PMC3927726  PMID: 24052337
3.  Recent partner violence and sexual and drug-related STI/HIV risk among adolescent and young adult women attending family planning clinics 
Sexually transmitted infections  2013;90(2):145-149.
Adolescent and young adult women are at high risk for both STI/HIV and intimate partner violence (IPV). We evaluate the prevalence of IPV in the past three months and its associations with STI/HIV risk, STI, and related care-seeking over the same time period.
Female family planning clinic patients ages 16–29 (n=3,504) participated in a cross-sectional survey in 2011–2012 as a baseline assessment for an intervention study. We examined associations of recent IPV with sexual and drug-related STI/HIV risk behavior, self-reported STI, and STI-related clinical care seeking via logistic regression.
Recent physical or sexual IPV (prevalence 11%) was associated with recent sexual and drug-related STI/HIV risk, specifically unprotected vaginal sex (AOR 1.93, 95% CI 1.52, 2.44), unprotected anal sex (AOR 2.22, 95% CI 1.51, 3.27) and injection drug use, both their own (AOR 3.39, 95% CI 1.47, 7.79) and their partner’s (AOR 3.85, 1.91, 7.75). IPV was also linked with coercive sexual risk: involuntary condom non-use (AOR 1.87, 95% CI 1.51, 2.33), and fears of requesting condoms (AOR 4.15, 95% CI 2.73, 6.30) and refusing sex (AOR 11.84, 95% CI 7.59, 18.45). STI-related care-seeking was also more common among those abused (AOR 2.49, 95% CI 1.87, 3.31).
Recent IPV is concurrent with sexual and drug-related STI/HIV risk, including coercive sexual risk, thus compromising women’s agency in STI/HIV risk reduction. Clinical risk assessments should broaden to include unprotected heterosexual anal sex, coercive sexual risk, and IPV, and should promote safety and harm reduction.
PMCID: PMC4305329  PMID: 24234072
intimate partner violence; sexual risk; injection drug use; STI/HIV risk; adolescent
4.  HPTN 035 Phase II/IIb Randomized Safety and Effectiveness Study of the Vaginal Microbicides BufferGel and 0.5% PRO 2000 for the Prevention of Sexually Transmitted Infections in Women 
Sexually transmitted infections  2014;90(5):363-369.
To estimate the effectiveness of candidate microbicides BufferGel and 0.5% PRO 2000 Gel (P) (PRO 2000) for prevention of non-ulcerative sexually transmitted infections (STIs).
Between 2005 and 2007, 3099 women were enrolled in HIV Prevention Trials Network (HPTN) protocol 035, a phase II/IIb evaluation of the safety and effectiveness of BufferGel and PRO 2000 for prevention of sexually transmitted infections, including Neisseria gonorrhoeae (GC), Chlamydia trachomatis (CT), and Trichomonas vaginalis (TV). Incidences of STIs were determined by study arm, and hazard ratios (HRs) of BufferGel and PRO 2000 versus placebo gel or no gel control groups were computed using discrete time Andersen-Gill proportional hazards model.
The overall incidence rates were 1.6/100 person-years at risk (PYAR) for GC, 3.9/100 PYAR for CT, and 15.3/100 PYAR for TV. For BufferGel versus placebo gel, HRs were 0.99 (95% CI 0.49–2.00), 1.00 (95% CI 0.64–1.57), and 0.95 (95% CI 0.71–1.25) for prevention of GC, CT, and TV respectively. For PRO 2000, HRs were 1.66 (95% CI 0.90–3.06), 1.16 (95% CI 0.76–1.79), and 1.18 (95% CI 0.90–1.53) for prevention of GC, CT, and TV respectively.
The incidence of STIs was high during HPTN 035 despite provision of free condoms and comprehensive risk-reduction counselling, highlighting the need for effective STI prevention programmes in this population. Unfortunately, candidate microbicides BufferGel and PRO2000 had no protective effect against gonorrhoea, Chlamydia, or trichomoniasis.
PMCID: PMC4278566  PMID: 24898857
Neisseria gonorrhoeae; Chlamydia trachomatis; Trichomonas; microbicides; prevention
5.  ru2hot?: A public health education campaign for men who have sex with men to increase awareness of symptoms of acute HIV infection 
Sexually transmitted infections  2013;89(5):409-414.
Teach HIV-negative men who have sex with men (MSM) symptoms of acute HIV infection (AHI) and direct them to nucleic acid amplification testing (NAAT) though Public Health—Seattle & King County (PHSKC).
Cross-sectional surveys, retrospective database analysis and chart review.
Beginning in June 2009, the ru2hot? campaign described AHI symptoms and NAAT. Two preintervention and two postintervention surveys assessed campaign visibility, symptom knowledge, and healthcare-seeking behaviour. Regression analyses evaluated secular trends in case-finding.
366 MSM completed surveys. In survey 4, 23% of 100 men reported seeing the campaign, and 25% knew ‘ru2hot?’ referred to AHI. From survey 1 to survey 4, the proportion of subjects who knew ≥2 symptoms or that AHI was a ‘flu-like’ illness was unchanged (61% vs 57%, p=0.6). However, in survey 4, 13 (72%) of 18 subjects who saw the campaign named fever as a symptom of AHI compared with 19 (35%) of 55 subjects who had not seen the campaign (p=0.005). From 9/2003 to 12/2010, 622 (2.2%) of 27 661 MSM tested HIV-positive, and 111 (18%) were identified by the Public Health—Seattle & King County NAAT programme. In terms of the impact of the campaign on case-finding, diagnosis of EIA-negative/NAAT-positive and OraQuick-negative/EIA-positive cases increased from six in 2004 to 20 in 2010 (p=0.01), but postcampaign numbers were unchanged. 23 (51%) of 45 cases identified before and 8 (44%) of 18 cases identified after the campaign reported symptoms at initial testing (p=0.6).
Although a quarter of MSM surveyed saw the campaign and knowledge of fever (the symptom of emphasis) was high, case-finding was unchanged. Increasing campaign visibility could have had greater impact.
PMCID: PMC4257701  PMID: 23349338
6.  Sex On-Demand: Geosocial Networking Phone Apps and Risk of Sexually Transmitted Infections among a Cross-Sectional Sample of Men who have Sex with Men in Los Angeles County 
Sexually transmitted infections  2014;90(7):567-572.
Geosocial networking applications (GSN apps) used to meet sexual partners have become increasingly popular with men who have sex with men (MSM) since 2009. The current study aimed to determine if self-identified HIV negative, MSM clinic attendees who used GSN apps have an increased incidence of sexually transmitted infections (STIs) compared to self-identified HIV negative, MSM attendees who met sexual partners via in-person venues such as bars or clubs or through MSM-specific hook-up websites.
Data were collected between August 2011 and January 2013 on all self-identified HIV-negative, MSM clients visiting the L.A. Gay & Lesbian Center for STI screening. A total of 7,184 individuals tested for STIs and self-reported behaviours on drug use and social networking methods to meet sexual partners. Multivariate logistic regression models were used to analyze the results.
Individuals who used GSN apps to meet sexual partners had greater odds of testing positive for gonorrhoea (OR: 1.25; 95% CI: 1.06–1.48) and for chlamydia (OR: 1.37; 95% CI: 1.13–1.65) compared to individuals who met partners through in-person methods only. There were no significant differences in syphilis and HIV incidence between those who met partners via in-person venues only, on the internet or through GSN apps.
The present study concludes that sexual health clinic MSM attendees who are meeting on GSN apps are at greater risk for gonorrhoea and chlamydia than MSM attendees who meet in-person or on the internet. Future interventions should explore the use of these novel technologies for testing promotion, prevention and education.
PMCID: PMC4198579  PMID: 24926041
7.  Association between Mycoplasma genitalium infection and HIV acquisition among female sex workers in Uganda: evidence from a nested case–control study 
Sexually Transmitted Infections  2014;90(7):545-549.
Cross-sectional studies have shown a strong association between Mycoplasma genitalium and HIV infections. We previously reported that in a cohort of female sex workers in Uganda, M genitalium infection at baseline was associated with HIV seroconversion. Here we examine the temporal association between the M genitalium infection status shortly before HIV seroconversion and HIV acquisition.
A nested case-control study was conducted within a cohort of women at high risk for HIV in Kampala. Cases were those of women acquiring HIV within 2 years of enrolment. For each of the 42 cases, 3 controls were selected from women HIV negative at the visit when the corresponding case first tested HIV seropositive. The association between HIV acquisition and M genitalium infection immediately prior to HIV testing was analysed using conditional logistic regression.
There was weak evidence of an association between M genitalium infection and HIV acquisition overall (crude OR=1.57; 95% CI 0.67 to 3.72, aOR=2.28: 95% CI 0.81 to 6.47). However, time of M genitalium testing affected the association (p value for effect-modification=0.004). For 29 case-control sets with endocervical samples tested 3 months prior to the first HIV-positive result, M genitalium infection increased the risk of HIV acquisition (crude OR=3.09; 95% CI 1.06 to 9.05, aOR=7.19; 95% CI 1.68 to 30.77), whereas there was little evidence of an association among the 13 case-control sets with samples tested at an earlier visit (crude OR=0.30: 95% CI 0.04 to 2.51; aOR=0.34; 95% CI 0.02 to 5.94).
Our study showed evidence of a temporal relationship between M genitalium infection and HIV acquisition that suggests that M genitalium infection may be a co-factor in the acquisition of HIV infection.
PMCID: PMC4215342  PMID: 24687129
8.  Two cross-sectional studies in south India assessing the effect of an HIV prevention programme for female sex workers on reducing syphilis among their clients 
Sexually Transmitted Infections  2014;90(7):556-562.
To assess the impact of the Avahan HIV prevention programme for female sex workers (FSWs) in south India on reducing syphilis prevalence among their clients, by comparing rates of syphilis over time as reported in two large-scale surveys of FSWs’ clients.
A random-effect multilevel logistic regression analysis was performed using syphilis as the dependent variable, with individual independent variables (from the two survey rounds) at level 1 and the district-level programme (from the Avahan computerised monitoring and information system) and contextual variables (from Indian government datasets) at level 2. Programme variables included their 2006 value and their difference in value between 2008 and 2006, as well as the interaction between the latter and the study round. The analysis also controlled for baseline syphilis prevalence and its interaction with the study round.
Syphilis decreased significantly among FSWs’ clients, from 4.8% (round 1) to 2.6% (round 2), p<0.001. The OR of the interaction term between the difference in programme coverage of FSWs and the round was 0.98 (p=0.023), suggesting that increased coverage was associated with a reduced incidence of syphilis.
This study suggests that the Avahan intervention programme among FSWs reduced syphilis rates among their clients.
PMCID: PMC4215352  PMID: 24812406
9.  Frequency and risk factors for incident and redetected Chlamydia trachomatis infection in sexually active, young, multi-ethnic women: a community based cohort study 
Sexually Transmitted Infections  2014;90(7):524-528.
To investigate the frequency and risk factors for incident and redetected Chlamydia trachomatis infection in sexually active, young, multi-ethnic women in the community.
Cohort study.
20 London universities and Further Education colleges.
954 sexually experienced women, mean age 21.5 years (range 16–27), 26% from ethnic minorities, who were recruited to the Prevention of Pelvic Infection (POPI) chlamydia screening trial between 2004 and 2006, and returned repeat postal self-taken vaginal swabs 11–32 (median 16) months after recruitment.
The estimated annual incidence of chlamydia infection among 907 women who tested negative at baseline was 3.4 per 100 person-years (95% CI 2.5 to 4.6 per 100 person-years), but 6.6 per 100 person-years (95% CI 4.5 to 9.3 per 100 person-years) in the 326 teenagers (<20 years). Predictors of incident chlamydia infection were age <20 years (relative risk (RR) 4.0, 95% CI 2.1 to 7.5), and (after adjusting for age) a new sexual partner during 12 months follow-up (RR 4.4, 95% CI 2.0 to 9.9), smoking (RR 2.2 95% CI 1.2 to 3.9), concurrent bacterial vaginosis (RR 2.0 95% CI 1.1 to 3.9) and high risk carcinogenic human papillomavirus (RR 2.2, 95% CI 1.1 to 4.3). Of 47 women positive for chlamydia at baseline, 12 (25.5%, 95% CI 13.9% to 40.3%) had redetected infection at a median of 16 months follow-up. Taking into account follow-up time (65 person-years), the annual redetection rate was 18.5 per 100 person-years (95% CI 9.9 to 30.0 per 100 person-years).
One in four women with chlamydia infection at baseline retested positive, supporting recent recommendations to routinely retest chlamydia positives.
PMCID: PMC4215355  PMID: 25100744
Chlamydia Infection; Chlamydia Trachomatis; Public Health; Sexual Health; Testing
10.  Examining the relationship between alcohol use and high-risk sex practices in a population of women with high HIV incidence despite high levels of HIV-related knowledge 
Sexually transmitted infections  2014;90(3):216-222.
Alcohol use has been linked to risky sexual behaviour and it has been identified as an important modifiable factor to prevent HIV infection. However, the evidence of a link between alcohol use and risky sexual behaviour is mixed. In this paper, we examine the role of alcohol use in sexual risk taking among women in Botswana.
Participants were recruited by stratified proportional random sampling and were administered a survey interview that collected information on HIV/AIDS knowledge, risky sexual behaviour and alcohol use. Logistic regression and bivariate probit analyses were used to examine the association between alcohol use and high-risk sexual behaviour.
239 women were interviewed. 168 (70%) had high levels of HIV/AIDS knowledge. We found no significant protective effect of good HIV/AIDS knowledge over high-risk sex behaviour (adjusted OR 0.74, 95% CI 0.38 to 1.42). However, alcohol use before sex was associated with high-risk sex behaviour (adjusted OR 3.04, 95% CI 1.11 to 6.45). However, bivariate probit analysis that simultaneously estimates risky sexual behaviour and alcohol use revealed an insignificant association between alcohol use and risky sex, highlighting the potential presence of other unobserved individual factors that are associated with alcohol use and risky sex.
Knowledge about HIV may not be sufficient to decrease risky sexual behaviour. Alcohol consumption was associated with an increased probability of high-risk sexual intercourse. However, the relationship between alcohol use and risky sex may also be a marker of a third omitted variable (such as overall risk-taking propensity). Further research is needed to identify factors associated with alcohol use and high-risk sex.
PMCID: PMC4150918  PMID: 24431186
11.  Modern diagnosis of Trichomonas vaginalis infection 
Sexually transmitted infections  2013;89(6):434-438.
Recent advances in tests for the sexually transmitted protozoan parasite Trichomonas vaginalis have increased opportunities for diagnosis and treatment of this important sexually transmitted infection. This review summarises currently available tests, highlighting their performance characteristics, advantages and limitations. The recent development of molecular tests for the detection of T vaginalis, including rapid antigen detection and nucleic acid amplification tests, has significantly improved the quality of diagnostics for trichomoniasis, particularly in women. In light of the expanded menu of testing options now available, improved recognition and better control of trichomoniasis are in sight, which should enable the eventual reduction of adverse reproductive consequences associated with T vaginalis infection.
PMCID: PMC3787709  PMID: 23633669
12.  Female users of internet-based screening for rectal STIs: descriptive statistics and correlates of positivity 
Sexually transmitted infections  2014;90(6):485-490.
Internet-based screening for vaginal sexually transmitted infections (STI) has been shown to reach high-risk populations. Published studies of internet-based screening for rectal STIs in women are needed. Our objectives were to describe the female users of a rectal internet-based screening intervention and assess what factors correlated with rectal positivity for STIs.
The website offers free STI testing via home self-sampling kits. Women could order vaginal and rectal kits, both containing questionnaires. Rectal and vaginal swabs were tested for Chlamydia trachomatis, Neisseria gonorrhoeae and Trichomonas vaginalis using nucleic acid amplification tests. Data were analysed from 205 rectal kits from January 2009 through February 2011. Self-reported characteristics of participants were examined, and correlates of rectal STI positivity were analysed.
Of the 205 rectal samples returned and eligible for testing, 38 (18.5%) were positive for at least one STI. The women were young (mean age 25.8 years), mostly African–American (50.0%), and only 14.0% always used condoms. After adjusting for age and race, Black race (AOR=3.06) and vaginal STI positivity (AOR=40.6) were significantly correlated with rectal STI positivity. Of women testing positive for rectal STIs who also submitted vaginal swabs, 29.4% were negative in the vaginal sample.
Internet-based rectal screening can reach populations that appear to be at high risk for rectal STIs (18.5% prevalence) and led to the diagnosis of STIs in women who would not have been diagnosed vaginally. Black race and vaginal STI positivity were highly correlated with rectal STI positivity.
PMCID: PMC4134381  PMID: 24604333
13.  Rectal Douching and Implications for Rectal Microbicides among Populations Vulnerable to HIV in South America: A Qualitative Study 
While gel-formulated Rectal Microbicides (RM) are the first to enter clinical trials, rectal douching in preparation for anal intercourse is a common practise, thus RMs formulated as douches may be a convenient alternative to gels. Nonetheless, little is known about potential users’ thoughts regarding douche-formulated RMs or rectal douching practises, data needed to inform the advancement of douche-based RMs. This qualitative study examined thoughts regarding douches, their use as a RM and current douching practises among men who have sex with men and transgender women.
Ten focus groups and 36 in-depth interviews were conducted (N=140) to examine the overall acceptability of RM, of which one component focused on rectal douching. Focus groups and interviews were recorded, transcribed verbatim and coded; text relating to rectal douching was extracted and analysed. Sociodemographic information was collected using a self-administered questionnaire.
Support for a douche-formulated RM centred on the possibility of combined pre-coital hygiene and HIV protection, and it was believed that a deeply-penetrating liquid douche would confer greater HIV protection than a gel. Drawbacks included rectal dryness; impracticality and portability issues; and, potential side effects. Non-commercial douching apparatus use was common and liquids used included detergents, vinegar, bleach, lemon juice and alcohol.
A douche-formulated RM while desirable and perceived as more effective than a gel-formulated RM also generated questions regarding practicality and side-effects. Of immediate concern were the non-commercial liquids already being used which likely damage rectal epithelia, potentially increasing HIV infection risk. Pre-coital rectal douching is common and a RM formulated as such is desirable, but education on rectal douching practices is needed now.
PMCID: PMC4035233  PMID: 23966338
rectal douching; microbicides; HIV prevention; MSM; transgender women; South America
14.  Enrollment of young adolescents in a microbicide acceptability study 
Clinical trials of microbicides should include adolescent participants. There may be unique challenges including obtaining informed consent, meeting eligibility criteria and adherence to study demands. We report on our experience enrolling young adolescents in a microbicide surrogate acceptability study and the implication of our experience for other types of clinical trials.
Adolescent females were enrolled in a microbicide surrogate acceptability study for 6 months which required parental consent. They were asked to use the product every time they had coitus. They had face-to- face interviews at intake, 3 and 6 months, and completed weekly phone diaries.
Of the 208 enrolled, 95 participants were between 14 and 17 years. Ten were pregnant at intake, and 15 did not have sex during the study. Of the remaining 70 adolescents, 46 (66%) used the product at least once during the 6-month period, and all but seven attended a face-to-face interview after intake.
It will be possible to include young adolescents in clinical studies, even if parental consent is required. However, there will be challenges, and researchers need to anticipate those challenges and reduce barriers to enrolling young adolescents.
PMCID: PMC4118769  PMID: 19965801
15.  The role of physical examination in diagnosing common causes of vaginitis: a prospective study 
Sexually transmitted infections  2012;89(3):185-190.
We evaluated agreement in diagnoses for bacterial vaginosis (BV), Trichomonas vaginalis (TV) and vulvovaginal candidiasis (VVC) between clinicians examining the patient and performing diagnostic tests versus a clinician with access only to the patient’s history and diagnostic findings from self-obtained vaginal swabs (SOVS).
Women presenting with vaginal discharge to a sexually transmitted infections clinic provided SOVS for evaluation and completed the study and qualitative questionnaires. A clinician then obtained a history and performed speculum and bimanual examinations. Participants’ history and diagnostic test results from SOVS were provided to a masked non-examining clinician who rendered independent diagnoses. Overall agreement in diagnoses and κ statistics was calculated.
The prevalence of infections among the 197 participants was 63.4% (BV), 19% (TV) and 14% (VVC). The per cent agreement between the examining and non-examining clinician for the diagnoses of BV was 68.5%, 90.9% for TV and 91.9% for VVC. Of the 105 women diagnosed with BV by the examining clinician, 34 (32%) were missed by the non-examining clinician. The non-examining clinician missed 13 (48%) of 27 women and 12 (34%) of 35 women treated for VVC and TV, respectively. Four women who all presented with abdominal pain were diagnosed with pelvic inflammatory disease.
Tests from SOVS and history alone cannot be used to adequately diagnose BV, TV and VVC in women presenting with symptomatic vaginal discharge. Cost benefits from eliminating the speculum examination and using only tests from SOVS may be negated by long-term costs of mistreatment.
PMCID: PMC4104961  PMID: 23019659
16.  “Just getting by”: A cross-sectional study of male sex workers as a most-at-risk population for HIV/STIs among men who have sex with men in Peru 
Sexually transmitted infections  2014;90(3):223-229.
To describe the socio-demographic and sex work characteristics, recent sexual practices, HIV risk perception and testing history, and HIV and syphilis prevalences of Cercado (downtown) and non-Cercado (close urban) male sex workers (MSWs) in Lima, Peru.
Eighty-nine MSWs completed a self-administered survey and participated in HIV and syphilis testing.
Cercado MSWs had significantly lower median weekly earnings than non-Cercado MSWs (US $43 versus $72, p=0.04). Most non-Cercado MSWs (81%) reported only insertive anal intercourse with male/transgender partners, while Cercado MSWs primarily reported only insertive (52%) or both insertive and receptive (45%) anal intercourse (p=0.03). Consistent condom use was low with insertive and receptive anal intercourse in both sub-groups. Among MSWs with recent female partners, condom use with the last partner was lower among Cercado versus non-Cercado MSWs for vaginal sex (37% versus 65%, p=0.04) and anal sex (27% versus 80%, p=0.01). More Cercado than non-Cercado MSWs (57% versus 42%) perceived high HIV risk (p=0.05) and Cercado MSWs had a much higher prevalence than non-Cercado MSWs of HIV [23% versus 4% (p = 0.04)] and syphilis [22% versus 0% (p = 0.02)] infections.
MSWs in Lima are diverse and Cercado MSWs are “just getting by,” engaging in more risk behaviors, and more likely to have HIV/STIs. Future research should identify, describe and HIV/STI test broader groups of MSWs and their client and non-client partners. Prevention efforts should provide HIV/STI risk reduction education for MSWs and related sub-groups who are currently not targeted such as female partners.
PMCID: PMC4096958  PMID: 24391061
17.  Sub-optimal adherence to doxycycline and treatment outcomes among men with non-gonococcal urethritis: a prospective cohort study 
Doxycycline, one of two recommended therapies for non-gonococcal urethritis (NGU), consists of a seven-day course of therapy (100mg BID). Since suboptimal adherence may contribute to poor treatment outcomes, we examined the association between self-reported imperfect adherence to doxycycline and clinical and microbiologic failure among men with NGU.
Men aged ≥16 years with NGU attending a Seattle, WA sexually transmitted diseases clinic were enrolled in a double-blind, parallel-group superiority trial from January 2007 to July 2011. Men were randomized to active doxycycline/placebo azithromycin or placebo doxycycline/active azithromycin. Imperfect adherence was defined as missing ≥1 dose in 7 days. Urine was tested for Chlamydia trachomatis (CT), Mycoplasma genitalium (MG), and Ureaplasma urealyticum-biovar2 (UU-2) using nucleic acid amplification tests. Clinical failure (symptoms and ≥5 PMNs/HPF or discharge) and microbiologic failure (positive tests for CT, MG, and/or UU-2) were determined after 3-weeks.
184 men with NGU were randomized to active doxycycline and provided data on adherence. Baseline prevalence of CT, MG, and UU-2 was 26%, 13%, and 27%, respectively. 28% of men reported imperfect adherence and this was associated with microbiologic failure among men with CT (aRR=9.33; 95% CI=1.00–89.2) and UU-2 (aRR=3.08; 95% CI=1.31–7.26) but not MG. Imperfect adherence was not significantly associated with clinical failure overall or for any specific pathogens, but it was more common among imperfectly adherent men with CT (aRR=2.63; 0.93–7.41, p=0.07).
Adherence may be important for microbiologic cure of select pathogens. Factors other than adherence should be considered for CT-negative men with persistent NGU.
PMCID: PMC4057099  PMID: 24106340
Chlamydia infection; adherence; doxycycline; Ureaplasma urealyticum-biovar2; urethritis
18.  Concurrent sexual partnerships among female sex workers and their non-commercial male partners in Tijuana and Ciudad Juárez, Mexico 
Sexually transmitted infections  2012;89(4):330-332.
To investigate the prevalence and correlates of concurrent (overlapping) sexual partnerships among female sex workers (FSWs) and their non-commercial male partners in two Mexico-U.S. border cities.
A cross-sectional survey of FSWs and their non-commercial male partners was conducted in Tijuana and Ciudad Juárez, Mexico (2010–2011). Eligible FSWs and verified non-commercial partners were aged ≥18 years; FSWs had ever used hard drugs (lifetime) and recently exchanged sex for money, drugs, or other goods (past month). Participants underwent baseline questionnaires obtaining dates of sex and condom use with ≤5 other recurring partners, including FSWs’ regular clients. These dates were compared to dates of sex with enrolled study partners to determine overlap (i.e., “recurring” concurrency). Bivariate probit regression identified recurring concurrency correlates.
Among 428 individuals (214 couples), past-year recurring concurrency prevalence was 16% and was higher among women than their non-commercial male partners (26% vs. 6%). In 10 couples (5%), both partners reported recurring concurrency. The majority of couples (64%) always had unprotected sex, and most of the individuals (70%) with recurring concurrency “sometimes” or “never” used condoms with their concurrent partners. Recurring concurrency was positively associated with FSWs’ income, men’s caballerismo (a form of traditional masculinity), and men’s belief that their FSW-partners had STIs.
Recurring concurrency, representing sustained periods of overlapping partnerships in which unprotected sex was common, should be addressed by couple-based STI prevention interventions.
PMCID: PMC3638049  PMID: 23172036
Sexual behavior; concurrent sexual partners; sexually transmitted diseases/*transmission; epidemiology; cross-sectional study
19.  High risk human papillomavirus viral load and persistence among heterosexual HIV-negative and HIV-positive men 
Sexually transmitted infections  2014;90(4):337-343.
High-risk human papillomavirus (HR-HPV) viral load is associated with HR-HPV transmission and HR-HPV persistence in women. It is unknown whether HR-HPV viral load is associated with persistence in HIV-negative or HIV-positive men.
HR-HPV viral load and persistence were evaluated among 703 HIV-negative and 233 HIV-positive heterosexual men who participated in a male circumcision trial in Rakai, Uganda. Penile swabs were tested at baseline and 6, 12 and 24 months for HR-HPV using the Roche HPV Linear Array, which provides a semi-quantitative measure of HPV shedding by hybridization band intensity (graded:1–4). Prevalence risk ratios (PRR) were used to estimate the association between HR-HPV viral load and persistent detection of HR-HPV.
HR-HPV genotypes with high viral load (grade:3–4) at baseline were more likely to persist than HR-HPV genotypes with low viral load (grade:1–2) among HIV-negative men (month 6: adjPRR=1.83, 95%CI:1.32–2.52; month 12: adjPRR=2.01, 95%CI:1.42–3.11), and HIV-positive men (month 6: adjPRR=1.33, 95%CI:1.06–1.67; month 12: adjPRR=1.73, 95%CI:1.18–2.54). Long-term persistence of HR-HPV was more frequent among HIV-positive men compared to HIV-negative men (month 24: adjPRR=2.27, 95%CI: 1.47–3.51). Persistence of newly detected HR-HPV at the 6 and 12 month visits with high viral load were also more likely to persist to 24 months than HR-HPV with low viral load among HIV-negative men (adjPRR=1.67, 95%CI 0.88–3.16).
HR-HPV genotypes with high viral load are more likely to persist among HIV-negative and HIV-positive men, though persistence was more common among HIV-positive men overall. The results may explain the association between high HR-HPV viral load and HR-HPV transmission.
PMCID: PMC4030299  PMID: 24482488
Human papillomavirus (HPV); human immunodeficiency virus (HIV); male circumcision; Uganda; penile cancer; sexually transmitted infections; viral shedding; viral load; linear array band intensity
20.  DNA Detection and Seroprevalence of Human Papillomavirus in a Cohort of Adolescent Women 
Human papillomavirus (HPV infections are common in adolescent females, while the rare cancerous sequelae of HPV infections do not generally occur until the 4th or 5th decades of life. This prospective study of a cohort of adolescent women was performed to further our knowledge of the natural history of incident and prevalent HPV infections.
Self-vaginal swabs collected from high-risk, unvaccinated adolescent women in a longitudinal study were analyzed for HPV DNA. Sera collected at enrollment and later were tested for HPV antibodies. Statistical analysis was performed to determine the HPV genotype distribution and duration of detection, and to determine rates of seropositivity and seroconversion for HPV types represented in the assays.
146 subjects (mean age = 15.4 years at enrollment; mean duration of follow-up = 5.8 years) had samples adequate for analysis of HPV detection, and 95 of these subjects had paired sera available. The cumulative prevalence for high-risk and low-risk HPV types was 95.9% and 91.1%, respectively. HPV types 6, 11, 16, and 18 (HPV types represented in the quadrivalent vaccine) were found at some point in 40.4%, 6.2%, 48%, and 24% of participants, respectively. Serologic data confirmed exposure to these vaccine-covered types, as well as to other high-risk HPV types.
In this cohort of adolescent women, high-risk and low-risk HPV types were frequently detected, and serologic data confirmed exposure in most subjects. The high prevalence HPV types represented in the quadrivalent HPV vaccine further supports vaccination of women at an age well before sexual debut.
PMCID: PMC4034260  PMID: 24031030
Human Papillomavirus; adolescents; antibodies; seroprevalence
21.  Human papillomavirus knowledge and vaccine acceptability among a national sample of heterosexual men 
Sexually transmitted infections  2009;86(3):241-246.
If approved for use in young males in the United States, prophylactic human papillomavirus (HPV) vaccine may reduce the incidence of HPV-related disease in vaccinated males and their sexual partners. We aimed to characterise heterosexual men’s willingness to get HPV vaccine and identify correlates of vaccine acceptability.
Participants were from a national sample of heterosexual men (n=297) aged 18–59 y from the United States who were interviewed in January 2009. We analysed data using multivariate logistic regression.
Most men had not heard of HPV prior to the study or had low HPV knowledge (81%; 239/296). Most men had heard of HPV vaccine prior to the study (63%; 186/296) and 37% (109/296) were willing to get HPV vaccine. Men were more willing to get vaccinated if they reported higher perceived likelihood of getting HPV-related disease (OR 1.80, 95% CI 1.02 to 3.17), perceived HPV vaccine effectiveness (OR 1.86, 95% CI 1.22 to 2.83) or anticipated regret if they did not get vaccinated and an HPV infection later developed (OR 2.01, 95% CI 1.40 to 2.89). Acceptability was also higher among men who thought (OR 9.02, 95% CI 3.45 to 23.60) or who were unsure (OR 2.67, 95% CI 1.30 to 5.47) if their doctor would recommend they get HPV vaccine if licenced for males.
Men had low HPV knowledge and were moderately willing to get HPV vaccine. These findings underscore the need for HPV educational efforts for men and provide insight into some of the factors that may affect the HPV vaccination decision making process among men.
PMCID: PMC4028225  PMID: 19951936
22.  HIV shedding in the oral cavity: an assessment of HIV type, immunovirologic, demographic and oral factors 
To quantify the prevalence and burden of HIV type 2 (HIV-2) and HIV-1 RNA in the oral cavity of antiretroviral therapy-naive HIV-infected Senegalese individuals and to identify correlates of oral HIV viral loads.
A cross-sectional study of 163 HIV-1 and 27 HIV-2-infected antiretroviral therapy-naive Senegalese adults.
Participants received clinical and oral exams and provided blood and oral wash samples for viral load and plasma CD4 count ascertainment. Logistic and interval regression models were used to identify univariate and multivariable associations between presence and level of oral HIV RNA and various immunovirologic, local and demographic factors.
Presence of detectable oral HIV RNA was less common in HIV-2-infected compared with HIV-1-infected study participants (33% vs 67%, OR 0.25, 95% CI 0.11 to 0.59). HIV type was no longer associated with oral shedding of HIV when plasma viral load was considered. Detection of oral HIV RNA was associated with increased plasma viral load in both HIV-1-infected and HIV-2-infected individuals (HIV-1, OR 1.89, 95% CI 1.24 to 2.61; HIV-2, OR 1.93, 95% CI 1.1 to 3.39). Oral HIV-1 detection was also associated with periodontal disease (OR 3.02, 95% CI 1.16 to 7.87).
Oral shedding of HIV-2 RNA is less common than HIV-1 RNA, a likely consequence of lower overall viral burden. Both systemic and local factors may contribute to shedding of HIV in the oral cavity.
PMCID: PMC4028315  PMID: 22250179
23.  Male Circumcision and Mycoplasma genitalium Infection in Female Partners: a Randomized Trial in Rakai, Uganda 
Sexually transmitted infections  2013;90(2):150-154.
Previous randomized trial data have demonstrated that male circumcision reduces Mycoplasma genitalium prevalence in men. We assessed whether male circumcision also reduces M. genitalium infection in female partners of circumcised men.
HIV-negative men were enrolled and randomized to either male circumcision or control. Female partners of male trial participants from the intervention (n=437) and control (n=394) arms provided interview information and self-collected vaginal swabs that were tested for M. genitalium by APTIMA transcription-mediated-amplification-based assay. Prevalence risk ratios (PRR) and 95% confidence intervals (95%CI) of M. genitalium prevalence in intervention versus control group were estimated using Poisson regression. Analysis was by intention-to-treat. An as-treated analysis was conducted to account for study-group crossovers.
Male and female partner enrollment sociodemographic characteristics, sexual behaviors, and symptoms of STIs were similar between study arms. Female M. genitalium prevalence at year-two was 3.2% (14/437) in intervention arm and 3.6% (14/394) in control arm (PRR=0.90, 95%CI 0.43–1.89, p=0.78). In an as-treated analysis, the prevalence of M. genitalium was 3.4% in female partners of circumcised men and 3.3% in female partners of uncircumcised men (PRR= 1.01, 95%CI 0.48–2.12, p=0.97).
Contrary to findings in men, male circumcision did not affect Mycoplasma genitalium infection in female partners.
PMCID: PMC4018720  PMID: 24259189
Male circumcision; mycoplasma genitalium; HIV; Uganda; sexually transmitted infections; transmission
24.  Male circumcision reduces penile high-risk human papillomavirus viral load in a randomised clinical trial in Rakai, Uganda 
Sexually transmitted infections  2012;89(3):262-266.
Male circumcision reduces penile high-risk human papillomavirus (HR-HPV) prevalence in randomised trials. The goal of this study was to examine the effect of circumcision on HPV viral load among HPV-infected men in a randomised trial of male circumcision.
In a randomised trial to assess the efficacy of circumcision on HIV acquisition in Rakai, Uganda, HIV-negative men were randomised to immediate (intervention) or delayed (control) circumcision and followed over 24 months. We performed quantitative-PCR HPV viral load assays on penile swabs which tested positive by Linear Array (LA) for six HR-HPV genotypes and estimated viral load in the remaining types by LA signal strength.
At 24 months, circumcision intervention arm men infected with one of the six selected HR-HPV genotypes had a lower viral load and significantly reduced HR-HPV high LA band intensity (PRR=0.61, 95% CI 0.43 to 0.86) compared to infected men in the control arm of the trial. The decreased viral load associated with circumcision was seen among HPV infections acquired after enrolment but not among infections that persisted from trial enrolment to 24 months (p=0.80).
The decreased penile HR-HPV shedding observed among HPV-infected circumcised men may help to explain the protective association observed between circumcision and reduced acquisition of HR-HPV in female partners.
PMCID: PMC3706631  PMID: 23112341
25.  Awareness of human papillomavirus among women attending a well woman clinic 
Sexually Transmitted Infections  2003;79(4):320-322.
Objectives: To assess the level and accuracy of public understanding of human papillomavirus (HPV) in the United Kingdom.
Methods: Women attending a well woman clinic were asked to complete a questionnaire assessing HPV awareness and specific knowledge about the virus.
Results: Questionnaires were completed by 1032 women, of whom 30% had heard of HPV. Older women, non-smokers, and those with a history of candida, genital warts, or an abnormal smear result were more likely to have heard of HPV. Even among those who had heard of HPV, knowledge was generally poor, and fewer than half were aware of the link with cervical cancer. There was also confusion about whether condoms or oral contraceptives could protect against HPV infection.
Conclusions: In this relatively well educated sample, awareness and knowledge of HPV were poor. Public education is urgently needed so that women participating in cervical cancer screening are fully informed about the meaning of their results, especially if HPV testing is soon to be introduced.
PMCID: PMC1744711  PMID: 12902585
human papillomavirus; public understanding; cervical screening

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