STI Testing among Medicaid Enrollees Initiating PrEP for HIV Prevention in Six Southern States.

BackgroundRegular HIV and sexually transmitted infection (STI) testing for men who have sex with men (MSM) is an important means of infection prevention, the adoption of which remains suboptimal in the community.ObjectiveOn the hypothesis that engagement plays an important role in sexual health monitoring, this study aimed to pilot-test internet-based HIV and STI testing with self-sampling to enhance engagement of MSM with regular testing.MethodsThis 1-year cohort study was conducted on HIV-negative MSM aged 18 years or older. A designated website was set up to enable participants to make appointments for baseline and follow-up visits at 3-monthly intervals. On-site blood sampling was performed for HIV and syphilis tests, along with self-collection of pharyngeal swabs, rectal swabs, and urine samples for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) testing. Full engagement, as defined by having made at least 3 visits over a 6-12 months’ follow-up period, was compared with partial engagement in the bivariable logistic regression model.ResultsBetween August 2019 and October 2020, 204 MSM were recruited, after the exclusion of 2 baseline HIV-positive MSM. The majority (189/204, 92.7%) were Chinese, the median age was 31 (IQR 26-39) years, and 58.0% (116/200) had experience with pre-exposure prophylaxis (PrEP) at baseline. Full engagement (146/204, 71.6%) was associated with incident STI during the follow-ups (odds ratio [OR] 4.23, 95% CI 1.63-10.94), seeking a medical referral after STI detection (OR 10.25, 95% CI 3.25-29.79), and a synchronized schedule of HIV and STI testing with PrEP visits (OR 51.85, 95% CI 19.30-139.34). No incident HIV was detected in the follow-up period. At baseline, the overall STI (CT, NG, or syphilis) prevalence was 30%, with CT at 18%, NG at 13%, and syphilis at 5%. During follow-up, the incidences were 59.08/100 person-years (py) for any STI, 33.05/100 py for CT, 29.86/100 py for NG, and 10.4/100 py for syphilis. The detection rates of CT and NG in urine samples were lower than with pharyngeal swabs and rectal swabs. The scores for convenience, confidence of correct sampling, and accuracy of self-sampling were high (7 to 8 out of 10).ConclusionsBoth baseline prevalence and incidence of STI were high among MSM engaged in regular testing. A high degree of engagement in regular STI and HIV testing was positively associated with incident STI, history of health-seeking behaviors, and perceived convenience of self-sampling. Self-sampling could be introduced as a means of enhancing engagement in regular HIV and STI testing.

ObjectivePregnant and postpartum women (PPW) in Southern Africa are at increased risk of acquiring HIV and curable sexually transmitted infections (STIs). Oral pre-exposure prophylaxis (PrEP) is safe and effective to...

Laboratory Industry Perspectives on the Role of Self-Collection and Self-Testing in Remote Care for Sexually Transmitted Infections: How Do We Bring These Services to Scale?

Initial and follow-up sexually transmitted infection (STI) and human immunodeficiency virus (HIV) testing are recommended when taking HIV preexposure prophylaxis (PrEP). We assessed STI services before and after PrEP initiation among persons 18 years or older. We conducted this retrospective cohort study at a US integrated healthcare delivery system. We measured HIV/STI testing rates, STI prevalence and treatment at 3 time points: (1) at PrEP initiation, (2) at 120 days, and (3) at 210 days. Of 685 PrEP initiators, 67.2% continued PrEP use at 120 days and 49.5% at 210 days. Of PrEP users, HIV and STI testing were greater than 85% and greater than 80%, respectively, at all 3 time points. Prevalence for any chlamydia, rectal chlamydia, and any gonorrhea, rectal gonorrhea, or pharyngeal gonorrhea was always high at the 120 days and 210 days (eg, 6.9%, 10.5%, 6.7%, 5.0%, and 5.2%, respectively, at the 120 days for continuous PrEP users). Over 90% of all individuals who tested positive for chlamydia and gonorrhea received antibiotic pharmacy fills within 7 days at 120 and 210 days. Monthly PrEP-related pharmacy cost was about $2259 to $2659. The proportion of the total medical cost that was PrEP-related pharmacy was about 82% for PrEP continuous users. Although HIV/STI testing rates were high, they can still be improved during HIV PrEP management. High STI prevalence after PrEP initiation in this study suggests that patients taking PrEP are at risk of acquiring an STI. Interventions to improve STI services during PrEP management are continuously needed.

BackgroundThe correlation between human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) usage and sexually transmitted infections (STIs) remains equivocal. Limited studies have investigated national STI trends after introducing PrEP. We aimed to examine STI incidence before and after PrEP introduction and explore correlations with PrEP use in the United States.MethodsPrEP usage data (2012–2022) were obtained from AIDSVu, and STI data (2001–2022) from the Centers for Disease Control and Prevention's STI Statistics Archive. We used the coefficient of determination to estimate variance in STI rates explained by PrEP usage. We used cross-correlation to identify lagged correlations and segmented linear regression to examine STI trends by demographics before and after PrEP initiation.ResultsSyphilis rates increased by 0.2/100 000 people annually before 2012 and by 1.4/100 000 persons after PrEP introduction. Gonorrhea rates dropped by 2.9/100 000 people before 2012 but rose by 14/100 000 afterward. The slope for chlamydia dropped from 20.9 to 6.6. The coefficients of determination for syphilis, gonorrhea, and chlamydia attributable to PrEP usage were 0.98, 0.88, and 0.2, respectively. Lagged correlations were significant for chlamydia, but not for syphilis and gonorrhea. Overall, STI rates were more strongly correlated with PrEP usage among males than females.ConclusionsWe found significant changes in the rate of incident STIs from 2012 to 2022 and a high correlation between PrEP usage and reported cases of syphilis and gonorrhea. Given the role of PrEP in comprehensive HIV prevention in the United States, its impact on rates of STI infection should be further studied.

BackgroundHIV prevention is a public health priority. Despite progress in recent years, pre-exposure prophylaxis (PrEP) use remains suboptimal especially among groups disproportionately impacted by new HIV diagnoses such as gender and sexual minorities of color. Multiple barriers including a lack of PrEP providers and challenges with attending quarterly monitoring visits contribute to low PrEP uptake and retention. Home-based PrEP (HB-PrEP) services could reduce stigma, increase convenience, expand health system capacity for PrEP care, and improve PrEP retention.ObjectiveHome Option Testing for PrEP (HOT4PrEP) is a hybrid randomized controlled trial (RCT) that aims to examine whether HB-PrEP care is acceptable to PrEP users, feasible to implement in a sexual health clinic setting, and impacts PrEP retention.MethodsThe RCT will recruit 458 persons currently taking or soon to initiate PrEP at a sexual health clinic in Seattle, Washington, and randomize them to continue the standard of care or have the option to use HB-PrEP for 2 of 3 triannual PrEP follow-up visits. Participants in the intervention arm will be sent home kits containing gonorrhea and chlamydia swabs and Tasso devices for blood self-collection. The primary outcome is PrEP retention between groups at 20 months; secondary outcomes include user satisfaction and acceptability, feasibility, self-reported PrEP adherence, and sexually transmitted infection (STI) incidence. Interviews with PrEP users and clinic staff will elucidate barriers and facilitators of implementation.ResultsThe HOT4PrEP RCT began enrolling in March 2022, was on hold during the height of the US mpox epidemic, then resumed enrollment in December 2022. Of the first 100 enrollees, the median age is 34 years, and most are cisgender gay men (89/100, 89%) with at least some college education (91/100, 91%). Among the 49 participants randomized to the HB-PrEP option, 33 (67%) chose to self-collect samples at home at least once, of whom 27 (82%) successfully returned test kits for HIV and STI testing. Primary PrEP retention and qualitative analyses are ongoing.ConclusionsImplementation of HB-PrEP into a high-volume sexual health clinic seems to be feasible and acceptable to early RCT enrollees. This strategy has the potential to address individual and systemic barriers associated with initiating and persisting on PrEP, such as increasing sexual health agency and expanding clinical capacity to serve greater numbers of PrEP users.Trial RegistrationClinicalTrials.gov NCT05856942; https://clinicaltrials.gov/study/NCT05856942International Registered Report Identifier (IRRID)DERR1-10.2196/56587

Uptake of PrEP for HIV slow among MSM

BackgroundCamellia is a single-arm longitudinal cohort study. We engaged a Community Advisory Board to support refinement of an existing mHealth app platform for use among cis- and transwomen in Alabama, one of seven states prioritized in the federal Ending the HIV Epidemic (EHE) strategy. We partnered with the Alabama Department of Public Health to recruit from a database of women recently diagnosed with gonorrhea or syphilis, aged 18–50, across Alabama. Potential participants are recruited by telephone. A home-based HIV and sexually transmitted infection (STI) testing program allows the study to offer tailored sexual health information, testing, linkage to care and support while assessing STI and HIV incidence and associated predictors.MethodsStudy participants are enrolled into the digital Camellia Cohort in which they complete home-based HIV and STI testing and online surveys every 6 months. Participants are followed for at least 24 months or until study completion (up to 42 months). Primary outcomes include predictors, mediators and moderators for HIV and STI incidence and pre-exposure prophylaxis (PrEP) use via self-report, medical record review, and dried blood spots.ConclusionThe Camellia Cohort integrates epidemiologic methods, mHealth technology, and data science to better characterize HIV transmission dynamics and engagement in the prevention care cascade among women in an EHE focus state. This study will provide critical insights into the feasibility and acceptability of a remote, light-touch cohort design, while also providing data on STI and HIV incidence, PrEP use, and key mediators and moderators influencing prevention behaviors among women with indications for PrEP in this high-priority region.

Introduction: The coronavirus disease 2019 (COVID-19) pandemic resulted in acute decreases in human immunodeficiency virus (HIV) preexposure prophylaxis (PrEP) prescribing and access to sexual health care in the US, but less is known about sustained changes as the COVID-19 pandemic continued. We explored patterns of PrEP prescribing and STI testing for lesbian, gay, bi, transgender, and queer (LGBTQ) populations from 2019–2022 at Fenway Health—one of the largest prescribers of PrEP (N=5,832) in the Northeastern US. Methods: After the Fenway Institute was granted institutional review board (IRB) approval in 2022, quarterly numbers of (1) total PrEP prescriptions, (2) new PrEP prescriptions, and (3) patients undergoing bacterial sexually transmitted infection (STI) screening were procured from January 1, 2019, to June 30, 2022, as well as the average number of days between prescriptions per quarter. We calculated incidence rate ratios (IRRs) which compared average quarterly numbers of prescriptions from 2020–2022 to 2019 (baseline), overall and disaggregated by race, age, and insurance status. Rates of new PrEP prescriptions and STI screening were used to contextualize the observed decline in number of PrEP prescriptions. Results: By the second quarter of 2022 (Q2 2022), PrEP prescriptions remain lower than before the COVID-19 pandemic for the study population (IRR 0.70, 95% CI 0.67–0.73, p<.001). Individuals under 30 years had a larger relative decline compared to their baseline (IRR 0.58, 95% CI 0.53–0.63, p<.001) than did older patients. Uninsured individuals had larger relative declines (IRR 0.42, 95% CI 0.30–0.58, p<.001) than those enrolled in coverage. Between 2019 and Q1-2020 the monthly average number of individuals testing for at least one bacterial STI decreased by 64%; however, by Q4-2021 rates had rebounded. Discussion: Being younger than 30 years or being uninsured was more associated with decreasing rates of PrEP prescriptions than was race. Rates of new PrEP prescriptions and testing for bacterial STIs decreased immediately after the onset of the pandemic and did not recover to pre-pandemic levels, though STI testing rates rebounded to a greater extent than new or total PrEP prescriptions. Conclusions: PrEP prescriptions remain lower than pre-pandemic levels. Decreasing numbers of prescriptions may be linked to on demand PrEP use, abstinence, disengagement from care, or receipt of PrEP elsewhere. Interviews with patients are needed to optimize PrEP engagement.

Gay, bisexual, and other men who have sex with men (GBM) are overrepresented in diagnoses of sexually transmitted infections (STIs) relative to their population size. This study assessed trends in STI testing and diagnoses among GBM in Australia. The Gay Community Periodic Surveys are repeated cross-sectional behavioral surveillance surveys of GBM. Participants reported the number of anal swabs, throat swabs, urine samples, and blood tests for syphilis they undertook in the last year. "Frequent comprehensive testing" was defined as ≥3 of each test in the previous year. Participants reported STI diagnoses of chlamydia, gonorrhea, syphilis, and other STIs in the last year. Trends in testing and diagnoses from 2017 to 2020 and 2020 to 2021 were assessed with logistic regression models. We analyzed 24,488 survey responses from participants reporting casual sex in the last 6 months. Between 2017 and 2020, frequent comprehensive STI testing decreased among HIV-negative GBM on preexposure prophylaxis (PrEP) from 71.7% to 68.9% and declined further to 58.6% in 2021. Frequent comprehensive STI testing was stable during 2017-2020 among HIV-negative/untested GBM not on PrEP (17.4%-14.6%) and HIV-positive GBM (30.4%-35.1%) but declined in 2021 to 7.5% among non-PrEP-users and 25.7% among HIV-positive participants. There were minimal changes in STI diagnoses during 2017-2020, but diagnoses declined in 2021. Many GBM do not meet Australian STI testing guidelines that recommend quarterly testing. Further evaluation of whether this recommendation is realistic or necessary to reduce STIs among GBM is recommended.

BackgroundPersons with opioid use disorders who inject drugs (PWID) in the United States (US) face multiple and intertwining health risks. These include interference with consistent access, linkage, and retention to health care including medication for opioid use disorder (MOUD), HIV prevention using pre-exposure prophylaxis (PrEP), and testing and treatment for sexually transmitted infections (STIs). Most services, when available, including those that address substance misuse, HIV prevention, and STIs, are often provided in multiple locations that may be difficult to access, which further challenges sustained health for PWID. HPTN 094 (INTEGRA) is a study designed to test the efficacy of an integrated, “whole-person” strategy that provides integrated HIV prevention including antiretroviral therapy (ART), PrEP, MOUD, and STI testing and treatment from a mobile health delivery unit (“mobile unit”) with peer navigation compared to peer navigation alone to access these services at brick and mortar locations.MethodsHPTN 094 (INTEGRA) is a two-arm, randomized controlled trial in 5 US cities where approximately 400 PWID without HIV are assigned either to an experimental condition that delivers 26 weeks of “one-stop” integrated health services combined with peer navigation and delivered in a mobile unit or to an active control condition using peer navigation only for 26 weeks to the same set of services delivered in community settings. The primary outcomes include being alive and retained in MOUD and PrEP at 26 weeks post-randomization. Secondary outcomes measure the durability of intervention effects at 52 weeks following randomization.DiscussionThis trial responds to a need for evidence on using a “whole-person” strategy for delivering integrated HIV prevention and substance use treatment, while testing the use of a mobile unit that meets out-of-treatment PWID wherever they might be and links them to care systems and/or harm reduction services. Findings will be important in guiding policy for engaging PWID in HIV prevention or care, substance use treatment, and STI testing and treatment by addressing the intertwined epidemics of addiction and HIV among those who have many physical and geographic barriers to access care.Trial registrationClinicalTrials.gov NCT04804072. Registered on 18 March 2021.

BackgroundRising rates of sexually transmitted infections (STIs) among adolescents and young adults are concerning. Emergency department (ED) visits offer a unique opportunity to increase STI testing. However, providers in the ED may not have the time or self-efficacy to screen patients, and patients may be unable to initiate discussion on their STI care needs. A patient decision aid may improve the effectiveness and efficiency of the ED encounter for STI testing.ObjectiveThis study aims to pilot STI Check in the Emergency Room (STIckER) app, a shared decision-making aid for urinary, oral, and rectal gonorrhea and chlamydia testing among adolescents and young adults, and assess STIckER’s efficacy and implementation outcomes in an adult and pediatric ED.MethodsWe are conducting a parallel-group, two-arm provider-randomized controlled pilot trial in the adult and pediatric EDs at an urban academic medical center. Fifty providers were randomized 1:1 to intervention (trained on STIckER) or control (standard of care). Adolescents and young adults aged 14‐24 years, English-speaking, and sexually active within the past 6 months are recruited during eligible shifts and assigned to the study arm of their provider. The standard of care comparator consists of usual provider-initiated STI discussions and testing without access to the decision aid; control participants receive a QR code directing them to a simple landing page encouraging them to ask their provider about STI testing. The planned enrollment target was 44 providers and 140 adolescent and young adult participants. Primary outcome is preliminary efficacy, defined as the proportion of adolescents and young adults receiving gonorrhea and chlamydia testing based on electronic medical record (EMR) review. Secondary outcomes include extragenital testing uptake, STI positivity rates, decisional conflict, and perceived level of shared decision-making. Implementation outcomes include feasibility, acceptability, appropriateness (using acceptability of intervention measure, intervention appropriateness measure, and feasibility of intervention measure), and provider self-efficacy. Data will be analyzed using descriptive statistics and regression models, with mixed-effects models applied if clustering by provider is detected. Exploratory analyses will examine differences by patient age, gender, and sexual identity, and provider characteristics.ResultsBetween September 2023 and July 2025, we completed recruitment of 44 providers and 139 adolescent and young adult participants across both adult and pediatric EDs. Enrollment targets were met, with high fidelity to intervention delivery and strong rates of survey completion by both patients and providers. Final data cleaning and analyses are underway, and primary results are expected to be available in late 2025.ConclusionsThis pilot trial will provide critical data on the feasibility, acceptability, and preliminary efficacy of a digital SDM tool to increase STI testing in the ED. Findings will inform the design of a future multisite trial and the potential for scaling STIckER to support equitable, patient-centered STI screening across diverse clinical settings.

Current guidelines recommend that sexually active men who have sex with men (MSM) be screened at least annually for bacterial sexually transmitted infections (STIs) at sites of sexual contact regardless of condom use. Extragenital (rectal and pharyngeal) STI are common in MSM and associated with an increased risk of human immunodeficiency virus. We describe the prevalence of MSM who reported any STI test and an extragenital STI test in the past 12 months (p12m) in the United States. Data were obtained from the 2017 American Men's Internet Survey, an annual cross-sectional behavioral internet survey of MSM in the United States. We examined the prevalence of MSM who reported any STI test and an extragenital STI test in the p12m and compared the prevalence across demographic, clinical, and behavioral factors. Of 10,049 sexually active MSM who participated in American Men's Internet Survey 2017, 42% reported any STI test in the p12m and 16% reported an extragenital (rectal or pharyngeal) STI test in the p12m. Among those who reported getting an extragenital STI test in the p12m, 19% reported providing a throat swab only, 14% reported providing a rectal swab only, and 68% reported providing both a rectal and throat swab for STI testing. In a large sample of internet-using MSM in the United States, levels of STI screening were suboptimal, with fewer than half (42%) of MSM reporting any STI test and even fewer reporting an extragenital STI test in the p12m. Increased efforts are needed to ensure annual STI screening guidelines among MSM are implemented.

BackgroundTo explore university students’ Sexually Transmitted Infection (STI) testing knowledge, psychosocial and demographic predictors of past STI testing behaviour, intentions to have an STI test, and high risk sexual behaviour, to inform interventions promoting STI testing in this population.MethodsA cross-sectional, quantitative online survey was conducted in March 2016, recruiting university students from North East Scotland via an all-student email. The anonymous questionnaire assessed student demographics (e.g. sex, ethnicity, age), STI testing behaviours, sexual risk behaviours, knowledge and five psychological constructs thought to be predictive of STI testing from theory and past research: attitudes, perceived susceptibility to STIs, social norms, social fear and self-efficacy.ResultsThe sample contained 1294 sexually active students (response rate 10%) aged 18–63, mean age = 23.61 (SD 6.39), 888 (69%) were female. Amongst participants, knowledge of STIs and testing was relatively high, and students held generally favourable attitudes. 52% reported ever having an STI test, 13% intended to have one in the next month; 16% reported unprotected sex with more than one ‘casual’ partner in the last six months. Being female, older, a postgraduate, longer UK residence, STI knowledge, perceived susceptibility, subjective norms, attitudes and self-efficacy all positively predicted past STI testing behaviour (p < 0.01). Perceived susceptibility to STIs and social norms positively predicted intentions to have an STI test in the next month (p < 0.05); perceived susceptibility also predicted past high-risk sexual behaviour (p < 0.01).ConclusionsSeveral psychosocial predictors of past STI testing, of high-risk sexual behaviour and future STI intentions were identified. Health promotion STI testing interventions could focus on male students and target knowledge, attitude change, and increasing perceived susceptibility to STIs, social norms and self-efficacy towards STI-testing.

Preexposure prophylaxis (PrEP) stigma (ie, negative attitudes toward PrEP users) has been widely documented and is considered a significant barrier to implementation. However, few studies have examined PrEP stigma using implicit measures designed to reduce demand characteristics in responding. This study examined implicit PrEP- and HIV-related stigma among gay and bisexual men using geospatial social networking applications (ie, "hookup apps"). Participants were presented with 4 simulated online profiles (pretested for comparability) paired with each of the following characteristics: HIV negative, HIV positive, on PrEP, or substance user. Participants rated the profiles on attractiveness, desirability, trustworthiness, likelihood of condom use, and riskiness of sex. There was no evidence of PrEP-related stigma, ie, participants did not rate profiles of PrEP users more negatively than profiles of HIV-negative individuals not disclosing PrEP use. However, profiles of HIV-positive individuals were rated significantly less attractive and desirable than HIV-negative or PrEP profiles. When the sample was split by history of PrEP use, negative ratings of HIV-positive profiles remained only among participants who had never taken PrEP. Participants with any history of PrEP use demonstrated no difference in ratings by HIV status. These data provide the first empirical evidence for lower HIV stigma among PrEP users. Individuals who have used PrEP may "see" HIV-positive individuals differently than those without a history of PrEP use. The lack of evidence for PrEP-related stigma is encouraging and suggests that negative stereotypes about PrEP users may not extend to negative implicit judgments about them on social networking sites.