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An Exploration of Factors Impacting Preexposure Prophylaxis Eligibility and Access Among Syringe Exchange Users

imageBackground In 2015, approximately 50,000 new HIV infections occurred in the United States, 2,400 of which were attributable to injection drug use. Preexposure prophylaxis (PrEP) has the potential to curb HIV acquisition; however, uptake remains low among persons who inject drugs (PWID). The purpose of the study is to describe PrEP eligibility, willingness to use PrEP, and ability to access PrEP among PWID recruited from a pilot program that paired screening and treatment of sexually transmitted infections with mobile syringe exchange program (SEP) services. Methods Between 2015 and 2016, 138 PWID 18 years or older were recruited from a mobile SEP in Camden, New Jersey. Participants completed a survey assessing sociodemographics and HIV risk and underwent chlamydia and gonorrhea screening. Centers for Disease Control clinical guidelines were used to calculate PrEP eligibility. Differences by sex were examined using inferential statistics. Results Most women (95.4%) and men (84.5%) were considered PrEP eligible (P < 0.04). More women than men were willing to take PrEP (88.9% vs. 71.0%; P < 0.02). Participants reported substantial barriers to PrEP including feeling embarrassed (45.0%) or anxious (51.6%) about taking PrEP, nondisclosure to partners (51.4%), limited engagement with health care providers where PrEP might be provided (43.8%), and lacking health insurance (32.9%). Conclusions Despite reporting behavior that warrants the use of PrEP to prevent HIV and finding the concept acceptable, PWID face multiple barriers to PrEP access. Without tailored interventions to promote PrEP, uptake will likely remain suboptimal. Packaging PrEP with SEP services could provide a viable option for reaching eligible and interested PWID. 04/01/2018 01:00 AM

Integration of Contact Tracing and Phylogenetics in an Investigation of Acute HIV Infection

imageBackground The integration of traditional contact tracing with HIV sequence analyses offers opportunities to mitigate some of the barriers to effective network construction. We used combined analyses during an outbreak investigation of spatiotemporally clustered acute HIV infections to evaluate if the observed clustering was the product of a single outbreak. Methods We investigated acute and recent HIV index cases reported in North Carolina from 2013 to 2014 and their reported contacts. Contact tracing networks were constructed with surveillance data and compared with phylogenetic transmission clusters involving an index case using available HIV-1 pol sequences including 1672 references. Clusters were defined as clades of 2 or more sequences with a less than 1.5% genetic distance and a bootstrap of at least 98% on maximum-likelihood phylogenies. Results In total, 68 index cases and 210 contacts (71 HIV infected) were reported. The contact tracing network involved 58 components with low overall density (1.2% statewide); 33% of first-degree contacts could not be located. Among 38 (56%) of 68 index cases and 34 (48%) of 71 contacts with sequences, 13 phylogenetic clusters were identified (size 2–4 members). Four clusters connected network components that were not linked in contact tracing. The largest component (n = 28 cases) included 2 distinct phylogenetic clusters and spanned 2 regions. Conclusions We identified the concurrent expansion of multiple small transmission clusters rather than a single outbreak in a largely disconnected contact tracing network. Integration of phylogenetic analyses provided timely information on transmission networks during the investigation. Our findings highlight the potential of combined methods to better identify high-risk networks for intervention. 04/01/2018 01:00 AM

Integrated Hepatitis C Testing and Linkage to Care at a Local Health Department Sexually Transmitted Disease Clinic: Determining Essential Resources and Evaluating Outcomes

imageGuidance about integration of comprehensive hepatitis C virus (HCV)-related services in sexually transmitted disease (STD) clinics is limited. We evaluated a federally funded HCV testing and linkage-to-care program at an STD clinic in Durham County, North Carolina. During December 10, 2012, to March 31, 2015, the program tested 733 patients for HCV who reported 1 or more HCV risk factor; 81 (11%) were HCV-infected (ie, HCV antibody-positive and HCV ribonucleic acid-positive). Fifty-one infected patients (63%) were linked to care. We concluded that essential program resources include reflex HCV ribonucleic acid testing; a dedicated bridge counselor to provide test results, health education, and linkage-to-care assistance; and referral relationships for local HCV management and treatment. 04/01/2018 01:00 AM

Molecular Typing and Macrolide Resistance of Syphilis Cases in Manitoba, Canada, From 2012 to 2016

imageBackground The province of Manitoba, Canada, with a population of approximately 1.3 million, has been experiencing increased incidence of syphilis cases since 2015. In this study, we examined the detection of Treponema pallidum DNA in 354 clinical samples from 2012 to 2016, and determined molecular types and mutations conferring resistance to azithromycin in the polymerase chain reaction (PCR)–positive samples. Methods T. pallidum DNA detection was done by PCR amplification of tpp47, bmp, and polA genes. Syphilis serology results were reviewed for the PCR-positive cases. Molecular typing of syphilis strains was done by analysis of the T, pallidum arp, tpr, and tp0548 gene targets as well as partial sequencing of the 23S rRNA gene for azithromycin resistance. Results Of the 354 samples tested, 74 individual cases were PCR positive. A result from the treponemal antibody chemiluminescent microparticle immunoassay test was positive in 72 of these cases and that from the Venereal Disease Research Laboratory testing was positive in 66. Mutations conferring resistance to azithromycin were found in all 74 PCR-positive samples. Molecular typing was completed on 57 PCR-positive samples, and 12 molecular types were identified with 14d/g found in 63.2%. Increased strain diversity was observed with 8 molecular types detected in 2016, whereas only 2 to 3 types were found in 2012 to 2014. A patient with 2 episodes of infection 9 months apart caused by different molecular strain types was also identified. Conclusions The finding of an increase in genetic diversity in the strains in this study and an increase in macrolide resistance compared with previous Canadian reports highlighted the need for continued surveillance including strain characterization. 04/01/2018 01:00 AM

Enhanced Molecular Typing of Treponema pallidum subspecies pallidum Strains From 4 Italian Hospitals Shows Geographical Differences in Strain Type Heterogeneity, Widespread Resistance to Macrolides, and Lack of Mutations Associated With Doxycycline Resistance

imageBackground Although syphilis rates have been relatively high in Italy for more than 15 years, no data on the molecular types of Treponema pallidum subspecies pallidum circulating in this country are yet available. Likewise, no data on how widespread is resistance to macrolide or tetracycline antibiotics in these strains exist. Such data would, however, promote comprehensive studies on the molecular epidemiology of syphilis infections in Italy and inform future interventions aiming at syphilis control in this and other European countries. Goals and Study Design Swabs from oral, genital, cutaneous, or anal lesions were obtained from 60 syphilis patients attending dermatology clinics in Milan, Turin, Genoa, and Bologna. Molecular typing of T. pallidum DNA was performed to provide a snapshot of the genetic diversity of strains circulating in Northern Italy. Samples were also screened for mutations conferring resistance to macrolides and tetracyclines. Results T. pallidum DNA was detected in 88.3% (53/60) of the specimens analyzed. Complete and partial T. pallidum typing data were obtained for 77.3% (41/53) and 15.0% (8/53) of samples, respectively, whereas 4 samples could not be typed despite T. pallidum DNA being detected. The highest strain type heterogeneity was seen in samples from Bologna and Milan, followed by Genoa. Minimal diversity was detected in samples from Turin, despite the highest number of typeable samples collected there. Resistance to macrolides was detected in 94.3% (50/53) of the strains, but no known mutations associated with tetracycline resistance were found. Conclusions Genetic diversity among T. pallidum strains circulating in Northern Italy varies significantly among geographical areas regardless of physical distance. Resistance to macrolides is widespread. 04/01/2018 01:00 AM

Narrative Review: Assessment of Neisseria gonorrhoeae Infections Among Men Who Have Sex With Men in National and Sentinel Surveillance Systems in the United States

imageTo assess trends in Neisseria gonorrhoeae among gay, bisexual, and other men who have sex with men (MSM), we reviewed existing and published gonorrhea surveillance data in the United States. Data identified in this review include the following: national gonorrhea case report data and data from 3 other surveillance programs, the Gonococcal Isolate Surveillance Project (GISP), the STD Surveillance Network (SSuN), and National HIV Behavioral Surveillance. Rates of reported cases of gonorrhea among men increased 54.8% in 2006 to 2015 compared with a 2.6% increase among women. Since 2012, the rate of reported gonorrhea cases among men surpassed the rate among women; the male-to-female case rate ratio increased from 0.97 in 2012 to 1.31 in 2015. The proportion of gonococcal urethral isolates collected in the Gonococcal Isolate Surveillance Project that were collected from MSM increased from 21.5% to 38.1% in 2006 to 2015. In 2009 to 2015, the percent of MSM who tested positive for rectal and oropharyngeal gonorrhea in sexually transmitted disease (STD) clinics increased by 73.4% and 12.6%, respectively. Estimated rates of gonorrhea among MSM increased by 151% in 2010 to 2015 in jurisdictions participating in the STD Surveillance Network. Data from the National HIV Behavioral Surveillance demonstrate that testing for gonorrhea among MSM increased by 23.1% between 2011 and 2014. Together, surveillance data suggest a disproportionate burden of gonorrhea among MSM in the United States and suggest increases in both screening and disease in recent years. Because each data source has inherent limitations and biases, examining these data from different systems together strengthens this conclusion. 04/01/2018 01:00 AM

An Illustration of the Potential Health and Economic Benefits of Combating Antibiotic-Resistant Gonorrhea

imagePreventing the emergence of ceftriaxone-resistant Neisseria gonorrhoeae can potentially avert hundreds of millions of dollars in direct medical costs of gonorrhea and gonorrhea-attributable HIV infections. In the illustrative scenario we examined, emerging ceftriaxone resistance could lead to 1.2 million additional N. gonorrhoeae infections within 10 years, costing $378.2 million. 04/01/2018 01:00 AM

Early Evidence of the Effectiveness of the Human Papillomavirus Vaccination Program Against Anogenital Warts in Manitoba, Canada: A Registry Cohort Study

imageBackground We assessed the effectiveness of the quadrivalent human papillomavirus vaccine (qHPV) vaccination program in Manitoba, Canada, in reducing incident anogenital warts (AGWs) and to what extent effectiveness depends on age at vaccination and number of doses. Methods Female participants 9 years or older who received the qHPV in Manitoba between September 2006 and March 2013 (n = 31,464) through the publicly funded school-based program and a high-risk catch-up program were included. They were matched on age and area of residence to unvaccinated female participants. Information on incident AGWs was obtained from provincial administrative databases using validated algorithms. Using stratified Cox regression models, we estimate hazard ratios (HRs) for the association between qHPV and AGWs. Results For female participants vaccinated at age 18 years or younger, receipt of qHPV was associated with a 40% reduction in AGW risk (HR, 0.6; 95% confidence interval [CI], 0.4–0.8). Further adjustment for socioeconomic and medical history did not alter this estimate. For women vaccinated at age 19 years or older, we saw an increase in AGW incidence, especially among those who were sexually active (HR, 2.8; 95% CI, 2.1–3.7). Among female participants vaccinated at age 18 years or younger, risk of AGWs was lowest among those who received 3 doses, corresponding to a vaccine effectiveness of 56% (95% CI, 30%–70%). For women vaccinated at older age, risk of AGWs remained increased regardless of the number of doses. Conclusions Women vaccinated at an older (≥19 years) age may be less protected against AGWs, particularly if sexually active before vaccine administration. Further efforts should be targeted at increasing vaccine uptake among preadolescents before the initiation of sexual activity. 04/01/2018 01:00 AM