Ck Fairley

Increased Syphilis Testing of Men Who Have Sex With Men: Greater Detection of Asymptomatic Early Syphilis and Relative Reduction in Secondary Syphilis

Background Syphilis rates have increased markedly among men who have sex with men (MSM) internationally. We examined trends in syphilis testing and detection of early syphilis among MSM in Australia. Methods Serial cross-sectional analyses on syphilis testing and diagnoses among MSM attending a national sentinel network of 46 clinics in Australia between 2007 and 2014. Results 359313 clinic visits were included. The proportion of MSM serologically tested for syphilis annually increased in HIV-negative (48% to 91%; Ptrend < .0001) and HIV-positive MSM (42% to 77%; Ptrend < .0001). The mean number of tests per man per year increased from 1.3 to 1.6 in HIV-negative MSM (Ptrend < .0001) and from 1.6 to 2.3 in HIV-positive MSM (Ptrend < .0001). 2799 and 1032 syphilis cases were detected in HIV-negative and HIV-positive MSM, respectively. Among HIV-negative MSM, the proportion of infections that were early latent increased from 27% to 44% (Ptrend < .0001), while the proportion that were secondary decreased from 24% to 19% (Ptrend = .030). Among HIV-positive MSM, early latent infections increased from 23% to 45% (Ptrend < .0001), while secondary infections decreased from 45% to 26% (Ptrend = .0003). Among HIV-positive MSM, decreasing secondary syphilis correlated with increasing testing coverage (r = -0.87; P = .005) or frequency (r = -0.93; P = .001). Conclusions Increases in syphilis screening were associated with increased detection of asymptomatic infectious syphilis and relative falls in secondary syphilis for both HIV-positive and HIV-negative MSM nationally, suggesting interruption of syphilis progression.

Prospective Evaluation of ResistancePlus MG, a New Multiplex Quantitative PCR Assay for Detection of Mycoplasma genitalium and Macrolide Resistance

ABSTRACT Mycoplasma genitalium is a significant pathogen for which first-line treatment is becoming less effective due to increased resistance to macrolides. As conventional culture and antimicrobial susceptibility testing is not feasible for routine detection of this pathogen, molecular markers such as detection of mutations in the 23S rRNA gene have been described to predict resistance. Recently, a novel multiplex quantitative PCR (qPCR) assay, ResistancePlus MG, has been described for the simultaneous detection of Mycoplasma genitalium and macrolide resistance. In the current study, the clinical performance of the assay was evaluated on 1,089 consecutive urine and anogenital swab samples in symptomatic and asymptomatic male and female patients. Overall, 6.0% were positive for M. genitalium, with 63.1% having macrolide resistance-associated mutations. Compared to the laboratory-validated qPCR method targeting the 16S rRNA gene and Sanger sequencing to determine 23S rRNA mutations, the sensitivity and specificity of M. genitalium detection were 98.5% and 100% and for detection of macrolide resistance mutations were 100.0% and 96.2%, respectively. This assay offers a considerable advantage in clinical settings for M. genitalium testing by making the results of macrolide resistance and mutation analyses simultaneously available, which is increasingly important with escalating macrolide resistance.

A longitudinal cohort study of HIV ‘treatment as prevention’ in gay, bisexual and other men who have sex with men: the Treatment with Antiretrovirals and their Impact on Positive And Negative men (TAIPAN) study protocol

BackgroundAustralia has increased coverage of antiretroviral treatment (ART) over the past decade, reaching 73% uptake in 2014. While ART reduces AIDS-related deaths, accumulating evidence suggests that it could also bolster prevention efforts by reducing the risk of HIV transmission (‘treatment as prevention’). While promising, evidence of community-level impact of treatment as prevention on reducing HIV incidence among gay and bisexual men is limited. We describe a study protocol that aims to determine if scale up of testing and treatment for HIV leads to a reduction in community viraemia and, in turn, if this reduction is temporally associated with a reduction in HIV incidence among gay and bisexual men in Australia’s two most populous states.MethodsOver the period 2009 to 2017, we will establish two cohorts making use of clinical and laboratory data electronically extracted retrospectively and prospectively from 73 health services and laboratories in the states of New South Wales and Victoria. The ‘positive cohort’ will consist of approximately 13,000 gay and bisexual men (>90% of all people living with HIV). The ‘negative cohort’ will consist of at least 40,000 HIV-negative gay and bisexual men (approximately half of the total population). Within the negative cohort we will use standard repeat-testing methods to calculate annual HIV incidence. Community prevalence of viraemia will be defined as the proportion of men with a viral load ≥200RNA copies/mm3, which will combine viral load data from the positive cohort and viraemia estimates among those with an undiagnosed HIV infection. Using regression analyses and adjusting for behavioural and demographic factors associated with infection, we will assess the temporal association between the community prevalence of viraemia and the incidence of HIV infection. Further analyses will make use of these cohorts to assess incidence and predictors of treatment initiation, repeat HIV testing, and viral suppression.DiscussionThis study will provide important information on whether ‘treatment as prevention’ is associated with a reduction in HIV incidence at a community level among gay and bisexual men.

Clinical Characteristics of Herpes Simplex Virus Urethritis Compared With Chlamydial Urethritis Among Men

Background The aim of this study was to ascertain the clinical characteristics associated with herpes simplex virus (HSV) urethritis in men and to compare those with chlamydial urethritis. Methods We compared clinical and laboratory data from men diagnosed with polymerase chain reaction confirmed HSV urethritis with those of men with chlamydial urethritis presenting to Melbourne Sexual Health Centre between 2000 and 2015. Results Eighty HSV urethritis cases were identified: 55 (68%, 95% confidence interval, 58–78) were by HSV-1 and 25 (32%, 95% confidence interval, 22–42) by HSV-2. Compared with chlamydial urethritis, men with HSV urethritis were significantly more likely to report severe dysuria (20% vs 0%, P < 0.01) or constitutional symptoms (15% vs 0%, P < 0.01). Men with HSV urethritis were significantly more likely to have meatitis (62% vs 23%, P < 0.01), genital ulceration (37% vs 0%, P < 0.01), or inguinal lymphadenopathy (30% vs 0%, P < 0.01) but less likely to have urethral discharge (32% vs 69%, P < 0.01). There was no significant difference in the proportion of men who had raised (≥5) polymorphonuclear leukocytes per high-powered field between the two groups (P = 0.46). Conclusions The clinical presentation of HSV urethritis in men may differ from those of chlamydial urethritis and guide testing for HSV in men presenting with non-gonococcal urethritis.

P08.19 Risk of pelvic inflammatory disease from chlamydia and gonorrhoea among australian sexual health clinic attendees

Background Pelvic inflammatory disease (PID) is an important cause of infertility in women and can occur when micro-organisms such as chlamydia or gonorrhoea ascend to the upper genital tract. However few studies have quantified the contribution of these pathogens to PID. We estimated the burden of PID using the population attributable risk percent (PAR%) in an Australian urban sexual health clinic population that could potentially be avoided if chlamydia or gonorrhoea infection were prevented. Methods Data were extracted from the clinic’s electronic patient database for all females aged 16–49 at first visit to an urban sexual health clinic between Jan2006-Jun2013. Chlamydia and gonorrhoea tests were based on clinical and risk assessment. PID diagnosis was based on clinical examination findings. Two analyses were undertaken; one among chlamydia-tested women and one among a subset of the chlamydia-tested group who were also tested for gonorrhoea (chlamydia/gonorrhoea tested). Univariable and multivariable logistic regression was conducted to identify factors associated with PID. The PAR% for PID from a current chlamydia or gonorrhoea infection was calculated and adjusted for demographic and behavioural factors using multivariable logistic regression. Results Among 15690 chlamydia-tested women, 1279 (8.2%, 95% CI 7.7–8.6) tested chlamydia-positive, 436 (2.8%, 95% CI 2.5–3.0) had PID diagnosed. The PAR% for chlamydia was 14.1% (95% CI 9.9–18.1). Among 8839 chlamydia/gonorrhoea-tested women, 681 (7.7%, 95% CI 7.2–8.3) had chlamydia only, 30 (0.3%, 95% CI 0.2–0.5) gonorrhoea only, 22(0.2%, 95% CI 0.2–0.4) chlamydia and gonorrhoea; 419 (4.7%, 95% CI 4.3–5.2) had PID diagnosed. The PAR% was highest for chlamydia only (12.5%, 95% CI 8.5–16.3) compared with gonorrhoea only (0.9%, 95% CI-0.1–1.8) or concurrent infections (1.0%, 95% CI 0.0–1.9). Conclusion In this low gonorrhoea prevalence population, chlamydia control would have the greatest impact on reducing PID. Disclosure of interest statement The authors declare that they have no commercial or other association that might pose a conflict of interest.

S09.1 Molecular Detection of Antimicrobial Resistance in STI Pathogens

The emergence of antimicrobial resistance (AMR) among sexually transmitted infections (STI) is a cause for global concern, and is epitomised by the fact we are now running out of treatment options for gonorrhoea. The role of AMR surveillance is now more important than ever. Ideally, AMR surveillance should be fast, easy, inexpensive, accessible, reproducible across testing methods, and provide clinically meaningful information to inform treatment strategies. In reality this is not the case, with AMR surveillance activities for STIs typically weak or non-existent in many parts of the world. Molecular methods have the potential to enhance AMR surveillance, particularly for organisms that cannot easily or readily be characterised phenotypically; which is the case for most STIs. The challenges for molecular surveillance are however many and include factors such as; the mechanisms of resistance may be many or otherwise unknown, they may miss novel mutations, the technology can be expensive, they need specialised laboratories and trained staff, and that their specificity can be undermined where target sequences are shared across different species. Despite these challenges, such methods are being developed and are now finding their way into routine settings. Advances in molecular technology and expanding knowledge of resistance mechanisms continue to pave new directions in this important area.

O1-S05.01 The epidemiological associations of BV candidate bacteria in sexually experienced and inexperienced women with BV and normal vaginal flora

Background Several bacterial candidate organisms (COs) have recently been shown to be highly specific for BV. The epidemiological profiles for these COs are unknown and no studies have examined COs in young sexually-inexperienced women, whether these COs are sexually-transmitted, or how they relate to specific sexual activities. Methods This study incorporates two study populations: The Female University Student Study which recruited women aged 17–21 years attending the University of Melbourne, and a sexually-experienced clinic population from Melbourne Sexual Health Centre. Participants completed a questionnaire addressing demographics and detailed sexual practices. Gram-stained vaginal smears were scored by the Nugent method. Three-hundred-and-thirty-nine samples from women with normal flora and BV were selected for analysis using quantitative PCR assays (qPCR) targeting the specific 16S rRNA gene sequences of eight published COs (G vaginalis, A vaginae, Megasphaera spp., Sneathia spp., BVAB1, BVAB2, BVAB3, and Leptotrichia spp.) and L crispatus. Detection of COs and L crispatus and their total bacterial loads were compared between women with BV and normal flora. The associations between prevalence of COs and specific sexual behavioural practices were examined by univariate and multivariate analysis. Results Analysis found all COs were strongly associated with BV compared with normal flora and L crispatus was negatively associated. G vaginalis and A vaginae were relatively common in sexually inexperienced women: however other COs were absent in a truly virginal population. When women with normal flora and BV were analysed separately, Sneathia spp., BVAB1, BVAB2, BVAB3, Leptotrichia spp. and G vaginalis all demonstrated a progressive increase in prevalence with increasing sexual experienced and increasing numbers of vaginal sexual partners see Abstract O1-S05.01 table 1. Megasphaera spp. however differed from other COs, with a higher prevalence being strongly associated with increasing oral sex frequency and oral sex partner number. Abstract O1-S05.01 Table 1 Associations between prevalence of BV candidate organisms and lifetime sexual partners Candidate organism Megasphaera spp. detected (prevalence %) Sneathia spp. prevalence detected (prevalence %) Leptotrichia spp. detected (prevalence %) L crispatus prevalence detected (prevalence %) G vaginalis prevalence detected (prevalence %) BVAB1 prevalence detected (prevalence %) BVAB2 prevalence detected (prevalence %) BVAB3 prevalence detected (prevalence %) A vaginae prevalence detected (prevalence %) Women with normal flora Lifetime sexual partners  0 2/79 (3) 3/79 (4) 3/79 (4) 45/79 (57) 24/79 (30) 0/79 0/79 (0) 0/79 53/79 (67)  1–10 1/82 (1) 4/82 (5) 3/82 (4) 60/82 (73) 41/82 (50) 0/82 6/82 (7) 0/82 56/82 (68)  >10 6/72 (8) 10/72 (14) 12/72 (17) 59/72 (82) 49/72 (68) 0/72 6/72 (8) 2/72 (3) 34/72 (48) p for trend 0.1 0.03 0.006 0.001 <0.001 Undefined 0.2 0.2 0.02 Women with BV Lifetime sexual partners  0 1/3 (33) 1/3 (33) 1/3 (33) 1/3 (33) 3/3 (100) 0/3 (0) 0/3 (0) 0/3 (0) 2/3 (67)  1-10 12/33 (36) 17/33 (52) 16/33 (49) 11/33 (33) 31/33 (94) 1/33 (3) 18/33 (55) 4/33 (12) 33/33 (100)  >10 12/69 (17) 60/69 (87) 59/69 (86) 35/69 (51) 69/69 (100) 6/69 (9) 54/69 (78) 13/69 (19) 67/67 (100) p for trend 0.07 <0.001 <0.001 0.2 0.3 0.3 0.004 0.3 0.04 Conclusions These data provide compelling evidence for sexual transmission of several COs—with absence of COs in virginal women and increasing prevalence with increasing sexual exposure. Interestingly the COs Sneathia spp., BVAB1, BVAB2, BVAB3, Leptotrichia spp. and G vaginalis are significantly associated with vaginal sex while the epidemiological association of Megasphaera spp. differed from the other COs being significantly associated with oral sex.

P2-S6.02 Use of a computer alert increases detection of early, asymptomatic syphilis among higher risk men who have sex with men

Background More frequent screening of higher risk men who have sex with men (MSM) for syphilis could reduce the transmission and prevalence of syphilis. This study assessed the impact of a computer alert on the rate of syphilis testing and diagnoses among higher risk MSM. Methods In October 2008, a computer alert was introduced at the Melbourne Sexual Health Centre. This alert appeared during consultations for MSM who reported more than 10 male partners in the prior 12 months, reminding clinicians to test such higher risk men 3 monthly for syphilis. Syphilis testing rates and diagnoses among MSM were determined for the 12 months before and the 12 months after the introduction of the alert. Results The proportion of MSM who were identified as being higher risk who were tested for syphilis in the two time periods increased from 77 % (1559/2017) to 89% (1282/1445) (p<0.001). The proportion of higher risk men diagnosed with early syphilis and who were asymptomatic for syphilis was 16% (5/31) and 53% (31/58) respectively (p=0.001). By contrast, there was no significant increase in the proportion of MSM who were identified as being lower risk who were tested for syphilis: 65% (1228/1885) and 68% (1667/2448) (p=0.4). Nor was there a significant increase in the proportion of lower risk men diagnosed with early syphilis who were asymptomatic: 10% (1/10) and 19% (3/16) respectively (p=0.6). Conclusion The use of a computer alert was associated with increased syphilis testing of higher risk MSM attending a clinical service as well as increased detection of early, asymptomatic syphilis.