Leandro Mena

A randomized comparison of azithromycin and doxycycline for the treatment of Mycoplasma genitalium-positive urethritis in men.

BACKGROUND Several uncontrolled observational studies have suggested that the tetracycline class of antibiotics may not be effective in treating Mycoplasma genitalium infection. The present study compared the efficacy of 1 g of azithromycin given as a single dose with that of 100 mg of doxycycline given twice a day for 7 days in eliminating M. genitalium infection. METHODS Men with signs or symptoms of urethral disease who were attending a New Orleans sexually transmitted disease clinic and who met clinical criteria for nongonococcal urethritis were enrolled in the study. They were randomized to receive either doxycycline (100 mg orally twice a day for 7 days) or azithromycin (1 g orally as a single dose). All participants were asked to return for a follow-up visit 10-17 days after enrollment. M. genitalium-positive men at enrollment were invited to return for a second follow-up visit between 31 and 41 days after enrollment. RESULTS Of the 398 men who enrolled, 197 were randomized to receive azithromycin, and 201 were randomized to receive doxycycline. Thirty-six (18%) and 42 (21%) men in these 2 groups, respectively, were infected with M. genitalium. At the early initial follow-up visit, 3 (13%) of 23 azithromycin-treated men were M. genitalium positive, compared with 17 (55%) of 31 doxycycline-treated men (P = .002). Of 15 persistently infected men who were clinically cured at the early initial follow-up visit, 7 (47%) experienced clinical relapse over the subsequent 2-6 weeks. CONCLUSIONS A single 1-g dose of azithromycin is more effective than multidose doxycycline for the treatment of M. genitalium-associated urethritis in men. M. genitalium may be an important cause of recurrent nongonococcal urethritis after administration of the treatment regimens currently recommended by the Centers for Disease Control and Prevention.

Missed Opportunities for HIV Testing in Health Care Settings Among Young African American Men Who Have Sex with Men: Implications for the HIV Epidemic

Limited health care access and missed opportunities for HIV and other sexually transmitted infection (STI) education and testing in health care settings may contribute to risk of HIV infection. In 2008, we conducted a case-control study of African American men who have sex with men (MSM) in a southeastern city (Jackson, Mississippi) with an increase in numbers of newly reported HIV cases. Our aims were to evaluate associations between health care and HIV infection and to identify missed opportunities for HIV/STI testing. We queried 40 potential HIV-infected cases and 936 potential HIV-uninfected controls for participation in this study. Study enrollees included HIV-infected cases (n=30) and HIV-uninfected controls (n=95) who consented to participate and responded to a self-administered computerized survey about sexual risk behaviors and health care utilization. We used bivariate analysis and logistic regression to test for associations between potential risk factors and HIV infection. Cases were more likely than controls to lack health insurance (odds ratio [OR]=2.5; 95% confidence interval [CI]=1.1-5.7), lack a primary care provider (OR=6.3; CI=2.3-16.8), and to not have received advice about HIV or STI testing or prevention (OR=5.4; CI=1.3-21.5) or disclose their sexual identity (OR=7.0; CI=1.6-29.2) to a health care provider. In multivariate analysis, lacking a primary health care provider (adjusted odds ratio [AOR]=4.5; CI=1.4-14.7) and not disclosing sexual identity to a health care provider (AOR=8.6; CI=1.8-40.0) were independent risk factors for HIV infection among African American MSM. HIV prevention interventions for African American MSM should address access to primary health care providers for HIV/STI prevention and testing services and the need for increased discussions about sexual health, sexual identity, and sexual behaviors between providers and patients in an effort to reduce HIV incidence and HIV-related health disparities.

A randomized treatment trial: single versus 7-day dose of metronidazole for the treatment of Trichomonas vaginalis among HIV-infected women.

Objective:To determine if the metronidazole (MTZ) 2-gm single dose (recommended) is as effective as the 7-day 500 mg twice a day dose (alternative) for treatment of Trichomonas vaginalis (TV) among HIV+ women. Methods:Phase IV randomized clinical trial; HIV+ women with culture confirmed TV were randomized to treatment arm: MTZ 2-gm single dose or MTZ 500 mg twice a day 7-day dose. All women were given 2-gm MTZ doses to deliver to their sex partners. Women were recultured for TV at a test-of-cure (TOC) visit occurring 6-12 days after treatment completion. TV-negative women at TOC were again recultured at a 3-month visit. Repeat TV infection rates were compared between arms. Results:Two hundred seventy HIV+/TV+ women were enrolled (mean age = 40 years, ±9.4; 92.2% African American). Treatment arms were similar with respect to age, race, CD4 count, viral load, antiretroviral therapy status, site, and loss-to-follow up. Women in the 7-day arm had lower repeat TV infection rates at TOC [8.5% (11 of 130) versus 16.8% (21 of 125) (relative risk: 0.50, 95% confidence interval = 0.25, 1.00; P < 0.05)] and at 3 months [11.0% (8 of 73) versus 24.1% (19 of 79) (relative risk: 0.46, 95% confidence interval = 0.21, 0.98; P = 0.03)] compared with the single-dose arm. Conclusions:The 7-day MTZ dose was more effective than the single dose for the treatment of TV among HIV+ women.

Sexually transmitted infections and risk behaviors among African American women who have sex with women: does sex with men make a difference?

Objective: We sought to determine the prevalence of infection with Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, Mycoplasma genitalium, syphilis, and HIV among African American women who have sex with women (AAWSW), and compare sociodemographics, sexual risk behavior characteristics, and STI diagnoses among women reporting sex exclusively with women (exclusive AAWSW) to women reporting sex with both women and men (AAWSWM) during the past 12 months. Methods: Eligible women presenting to the Mississippi State Department of Health STD Clinic between February 2009 and October 2010 were invited to participate. A survey on sociodemographics, sexual history, and sexual risk behavior characteristics was completed. Women were tested for the presence of C. trachomatis, N. gonorrhoeae, T. vaginalis, M. genitalium, syphilis, and HIV. Results: A total of 196 African American women were enrolled; 56.6% of all women reported engaging in sexual activity exclusively with women (AAWSW) during the past 12 months and 40.8% reported engaging in sexual activity with both men and women (AAWSWM). As compared with exclusive AAWSW, AAWSWM were significantly more likely to report prior infection with C. trachomatis (35.0% vs. 13.5%, P < 0.001), prior infection with N. gonorrhoeae (28.75% vs. 2.7%, P < 0.001), and transactional sex (18.8% vs. 2.7%, P = 0.001). Additionally, 13.8% of AAWSWM reported having sex with a homosexual or bisexual man during the past 12 months. Trichomoniasis was diagnosed in 18.3% of all women, C. trachomatis in 11.0%, M. genitalium in 7.6%, and N. gonorrhoeae in 3.7%. There were no cases of syphilis or HIV. AAWSWM were significantly more likely to be diagnosed with trichomoniasis (25.0% vs. 13.5%, P = 0.04), C. trachomatis (22.5% vs. 2.7%, P < 0.001), N. gonorrhoeae (7.5% vs. 0.9%, P = 0.01), or any STI (47.5% vs. 18.3%, P < 0.001) than exclusive AAWSW. Conclusions: AAWSW in this study were at high risk for STI. AAWSWM, as a subgroup, may demonstrate heightened sexual risk-taking behaviors and higher STI rates compared with exclusive AAWSW. Sexual health services provided to AAWSW should take into account partner gender heterogeneity when counseling and screening for STI.

Use of home-obtained vaginal swabs to facilitate rescreening for Chlamydia trachomatis infections: two randomized controlled trials.

OBJECTIVE: To determine whether the use of home-based, self-obtained vaginal swabs among women who were treated for Chlamydia infection can increase rescreening rates in comparison with clinic-based rescreening, and to identify subgroups in which rescreening could be enhanced using self-obtained vaginal swabs. METHODS: Two randomized trials were conducted: one with enrollment in sexually transmitted disease (STD) clinics and the other in family planning clinics. Study participants were recruited from STD (n=880) and family planning clinics (n=412) in three cities. Females aged 16 years or older who were treated for Chlamydia infection were randomly assigned to the home group (swab collection kits mailed to home) or the clinic group (made clinic appointments) for rescreening at 3 months after treatment, with reminder calls about 2 weeks before the scheduled rescreening date. RESULTS: Groups were similar with respect to age and other demographic characteristics. Women assigned to the home group had higher rescreening rates than those in the clinic group. In STD clinics, rescreening rates were 26.7% (home) compared with 19.1% (clinic) (P=.01). In family planning clinics, rescreening rates were 40.8% (home) compared with 20.7% (clinic) (P<.001). Among women reached by reminder calls, rescreening rates were also significantly higher in the home groups: 43.5% compared with 33.0% in STD clinic participants and 59.2% compared with 37.8% in family planning clinic participants (both P<.05). The rates of reinfection ranged from 12.9% to 19.4%, and the differences by group were not statistically significant (P≥.3). CONCLUSION: In STD and family planning clinics, use of home-based, self-obtained vaginal swabs resulted in significant increases in rescreening rates compared with rescreening in the clinic. Home-based specimen collection can be an alternative to clinic-based rescreening for Chlamydia infection in women. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov, www.clinicaltrials.gov, NCT 00132457. LEVEL OF EVIDENCE: I

HIV Risk Among Young African American Men Who Have Sex With Men: A Case–Control Study in Mississippi

OBJECTIVES We conducted a case-control study in the Jackson, Mississippi, area to identify factors associated with HIV infection among young African American men who have sex with men (MSM). METHODS During February to April 2008, we used surveillance records to identify young (16-25 years old) African American MSM diagnosed with HIV between 2006 and 2008 (case participants) and recruited young African American MSM who did not have HIV (controls). Logistic regression analysis was used to assess factors associated with HIV infection. RESULTS In a multivariable analysis of 25 case participants and 85 controls, having older male partners (adjusted odds ratio [OR] = 5.5; 95% confidence interval [CI] = 1.8, 17.3), engaging in unprotected anal intercourse with casual male partners (adjusted OR = 6.3; 95% CI = 1.8, 22.3), and being likely to give in to a partner who wanted to have unprotected sex (adjusted OR = 5.0; 95% CI = 1.2, 20.6) were associated with HIV infection. CONCLUSIONS Given the high prevalence of risk behaviors among the young African American MSM in our study, HIV prevention efforts must begin before or during early adolescence and need to focus on improving negotiation and communication regarding sex.

Demographic but not geographic insularity in HIV transmission among young black MSM

Objective:To understand patterns of HIV transmission among young black MSM and others in Mississippi. Design:Phylogenetic analysis of HIV-1 polymerase (pol) sequences from 799 antiretroviral-naive persons newly diagnosed with HIV infection in Mississippi during 2005–2008, 130 (16%) of whom were black MSM aged 16–25 years. Methods:We identified phylogenetic clusters and used surveillance data to evaluate demographic attributes and risk factors of all persons in clusters that included black MSM aged 16–25 years. Results:We identified 82 phylogenetic clusters, 21 (26%) of which included HIV strains from at least one young black MSM. Of the 69 persons in these clusters, 59 were black MSM and seven were black men with unknown transmission category; the remaining three were MSM of white or Hispanic race/ethnicity. Of these 21 clusters, 10 included residents of one geographic region of Mississippi, whereas 11 included residents of multiple regions or outside of the state. Conclusion:Phylogenetic clusters involving HIV-infected young black MSM were homogeneous with respect to demographic and risk characteristics, suggesting insularity of this population with respect to HIV transmission, but were geographically heterogeneous. Reducing HIV transmission among young black MSM in Mississippi may require prevention strategies that are tailored to young black MSM and those in their sexual networks, and prevention interventions should be delivered in a manner to reach young black MSM throughout the state. Phylogenetic analysis can be a tool for local jurisdictions to understand the transmission dynamics in their areas.

Clinical Evaluation of the BD ProbeTec™ Chlamydia trachomatis Qx Amplified DNA Assay on the BD Viper™ System With XTR™ Technology

Background: This study evaluated the performance of the BD ProbeTec Chlamydia trachomatis Qx (CTQ) Amplified DNA Assay on the BD Viper System with XTR Technology in a multicenter study. Methods: Specimens were collected at 7 geographically diverse clinical sites from 1538 women and men attending sexually transmitted disease, family planning, and obstetrics and gynecology clinics. There were 1465 evaluable participants, 993 women and 472 men. CTQ assay results from female endocervical, self-collected vaginal, male urethral swab specimens, and male and female neat (unpreserved) urine specimens as well as those obtained using the Urine Preservative Transport (UPT) tube for the CTQ assay were compared with patient-infected status (PIS). PIS was determined based on the combined results from Aptima Combo 2 and BD ProbeTec ET CT Amplified DNA Assay. Results: The sensitivity versus PIS for endocervical, vaginal, and both female urine samples was 91.3%, 96.5%, and 93.0%, respectively. The specificity for the same specimen types was 98.3%, 99.2%, and 99.4% (urine neat) and 99.2% (UPT), respectively. The sensitivity versus PIS for male urethral swabs and both male neat and UPT urine were 92.1% and 98%, respectively, with specificities of 98.4%, 99.2%, and 98.1%, respectively. Conclusions: The CTQ assay demonstrated performance characteristics comparable with other commercially available nucleic acid-based tests such as Aptima Combo 2 and BD ProbeTec ET CT-Amplified DNA assay. Vaginal swabs and male urine specimens, the sample types recommended by the Centers for Disease Control for chlamydia screening, both performed at least as well as other sample types evaluated.

Retention in care outcomes for HIV pre-exposure prophylaxis implementation programmes among men who have sex with men in three US cities.

Despite the efficacy of pre‐exposure prophylaxis (PrEP) in preventing HIV transmission, few studies have evaluated PrEP use and retention in care outcomes in real‐world settings outside of clinical trials.

Network analysis among HIV-infected young black men who have sex with men demonstrates high connectedness around few venues.

Background Network analysis is useful for understanding sexual transmission of HIV and other sexually transmitted infections. We conducted egocentric and affiliation network analysis among HIV-infected young black men who have sex with men (MSM) in the Jackson, Mississippi, area to understand networks and connectedness of this population. Methods We interviewed 22 black MSM aged 17 to 25 years diagnosed as having HIV in 2006 to 2008. Participants provided demographic and geographic information about each sex partner during the 12 months before diagnosis and identified venues where they met these partners. We created affiliation network diagrams to understand connectedness of this population and identify venues that linked participants. Results The median number of partners reported was 4 (range, 1–16); a total of 97 partners (88 of whom were male) were reported. All but 1 participant were connected through a network of venues where they had met partners during the 12 months before diagnosis. Three venues were named as places for meeting partners by 13 of 22 participants. Participants reported having partners from all regions of Mississippi and 5 other states. Conclusions HIV-infected young black MSM in this analysis were linked by a small number of venues. These venues should be targeted for testing and prevention interventions. The pattern of meeting sex partners in a small number of venues suggests densely connected networks that propagate infection. This pattern, in combination with sexual partnerships with persons from outside Jackson, may contribute to spread of HIV and other sexually transmitted infections into or out the Jackson area.