Madeline C. Montgomery

Extragenital Infections Caused by Chlamydia trachomatis and Neisseria gonorrhoeae: A Review of the Literature

In the United States, sexually transmitted diseases due to Chlamydia trachomatis and Neisseria gonorrhoeae continue to be a major public health burden. Screening of extragenital sites including the oropharynx and rectum is an emerging practice based on recent studies highlighting the prevalence of infection at these sites. We reviewed studies reporting the prevalence of extragenital infections in women, men who have sex with men (MSM), and men who have sex only with women (MSW), including distribution by anatomical site. Among women, prevalence was found to be 0.6–35.8% for rectal gonorrhea (median reported prevalence 1.9%), 0–29.6% for pharyngeal gonorrhea (median 2.1%), 2.0–77.3% for rectal chlamydia (median 8.7%), and 0.2–3.2% for pharyngeal chlamydia (median 1.7%). Among MSM, prevalence was found to be 0.2–24.0% for rectal gonorrhea (median 5.9%), 0.5–16.5% for pharyngeal gonorrhea (median 4.6%), 2.1–23.0% for rectal chlamydia (median 8.9%), and 0–3.6% for pharyngeal chlamydia (median 1.7%). Among MSW, the prevalence was found to be 0–5.7% for rectal gonorrhea (median 3.4%), 0.4–15.5% for pharyngeal gonorrhea (median 2.2%), 0–11.8% for rectal chlamydia (median 7.7%), and 0–22.0% for pharyngeal chlamydia (median 1.6%). Extragenital infections are often asymptomatic and found in the absence of reported risk behaviors, such as receptive anal and oral intercourse. We discuss current clinical recommendations and future directions for research.

Implementation of Preexposure Prophylaxis for Human Immunodeficiency Virus Prevention Among Men Who Have Sex With Men at a New England Sexually Transmitted Diseases Clinic.

Background Preexposure prophylaxis (PrEP) is efficacious in preventing human immunodeficiency virus (HIV) among men who have sex with men (MSM). We assessed PrEP uptake among MSM presenting for services at a sexually transmitted diseases (STD) clinic. Methods Men who have sex with men presenting to the Rhode Island STD Clinic between October 2013 and November 2014 were educated about, and offered, PrEP. We categorized PrEP engagement using an implementation cascade to describe gaps in uptake which described MSM who: (1) were educated about PrEP, (2) indicated interest, (3) successfully received follow-up contact, (4) scheduled an appointment, (5) attended an appointment, and (6) initiated PrEP (ie, received a prescription). Bivariate and multivariable logistic regression models were used to examine predictors of PrEP initiation. Results A total of 234 MSM were educated about PrEP; of these, 56% expressed interest. Common reasons for lack of interest were low HIV risk perception (37%), wanting more time to consider (10%), concern about side effects (7%), and financial barriers (3%). Among those interested, 53% followed up. Of those, 51% scheduled an appointment. The most common reason patients did not schedule an appointment was low HIV risk perception (38%). Seventy-seven percent of those with an appointment attended the appointment; of those, 93% initiated PrEP. Patients with higher HIV-risk perception (adjusted odds ratios, 2.17; 95% confidence interval, 1.29–3.64) and a history of sex with an HIV-positive partner (adjusted odds ratios, 7.08; 95% confidence interval, 2.35–21.34) had significantly higher odds of initiating PrEP. Conclusions Low HIV-risk perception was the most significant barrier to PrEP uptake among MSM attending a public STD clinic.

Adherence to Pre-Exposure Prophylaxis for HIV Prevention in a Clinical Setting

Background The HIV epidemic in the United States (US) disproportionately affects gay, bisexual, and other men who have sex with men (MSM). Pre-exposure prophylaxis (PrEP) using co-formulated tenofovir disoproxil fumarate (TDF) and emtricitabine (FTC) has demonstrated high efficacy in reducing HIV incidence among MSM. However, low adherence was reported in major efficacy trials and may present a substantial barrier to successful PrEP implementation. Rates of adherence to PrEP in “real-world” clinical settings in the US remain largely unknown. Methods We reviewed demographic and clinical data for the first 50 patients to enroll in a clinical PrEP program in Providence, Rhode Island. We analyzed self-reported drug adherence as well as drug concentrations in dried blood spots (DBS) from patients who attended either a three- or six-month follow-up appointment. We further assessed drug concentrations and the resistance profile of a single patient who seroconverted while taking PrEP. Results Of the first 50 patients to be prescribed PrEP, 62% attended a follow-up appointment at three months and 38% at six months. Of those who attended an appointment at either time point (70%, n = 35), 92% and 95% reported taking ±4 doses/week at three and six months, respectively. Drug concentrations were performed on a random sample of 20 of the 35 patients who attended a follow-up appointment. TDF levels consistent with ±4 doses/week were found in 90% of these patients. There was a significant correlation between self-reported adherence and drug concentrations (r = 0.49, p = 0.02). One patient who had been prescribed PrEP seroconverted at his three-month follow-up visit. The patient’s drug concentrations were consistent with daily dosing. Population sequencing and ultrasensitive allele-specific PCR detected the M184V mutation, but no other TDF- or FTC-associated mutations, including those present as minor variants. Conclusion In this clinical PrEP program, adherence was high, and self-reported drug adherence accurately reflected drug concentrations as measured by DBS.

Insurance Coverage and Utilization at a Sexually Transmitted Disease Clinic in a Medicaid Expansion State

Background In Rhode Island, the Patient Protection and Affordable Care Act has led to over 95% of the states population being insured. We evaluated insurance coverage and barriers to insurance use among patients presenting for services at the Rhode Island sexually transmitted disease (STD) clinic. Methods We analyzed factors associated with insurance coverage and utilization among patients presenting for STD services between July and December 2015. Results A total of 692 patients had insurance information available; of those, 40% were uninsured. Patients without insurance were more likely than those with insurance to be nonwhite (50% among uninsured, compared with 40% among insured; P = 0.014) and Hispanic or Latino/a (25%, compared with 16%; P = 0.006), and less likely to be men who have sex with men (27%, compared with 39%; P = 0.001). Of those with health insurance, 26% obtained coverage as a result of the Affordable Care Act, and 56% of those were previously uninsured. Among uninsured individuals, barriers to obtaining health insurance included cost and unemployment. Among those with insurance, 43% reported willingness to use insurance for STD services. Barriers to insurance use included concerns about anonymity and out-of-pocket costs. Conclusions Despite expanded insurance access, many individuals presenting to the Rhode Island STD Clinic were uninsured. Among those who were insured, significant barriers still existed to using insurance. STD clinics continue to play an important role in providing safety-net STD services in states with low uninsured rates. Both public and private insurers are needed to address financial barriers and optimize payment structures for services.

Statewide Evaluation of New HIV Diagnoses in Rhode Island: Implications for Prevention

Objectives: Patterns of HIV transmission vary widely across demographic groups. Identifying and engaging these groups are necessary to prevent new infections and diagnose disease among people who are unaware of their infection. The objective of this study was to determine characteristics of newly diagnosed individuals across an entire state to determine patterns of HIV transmission. Methods: We evaluated data on people with new HIV diagnoses in Rhode Island from 2013 through 2015. We performed a latent class analysis (LCA) to identify underlying demographic and behavioral characteristics of people with newly diagnosed HIV. Results: Of 167 people with new HIV diagnoses interviewed in Rhode Island from 2013 through 2015, 132 (79%) were male, 84 (50%) were nonwhite, 112 (67%) were men who have sex with men (MSM), 112 (67%) were born in the United States, and 61 (37%) were born in Rhode Island. LCA revealed 2 major classes. Of the 98 people in class 1, 96% were male, 85% were MSM, 80% were white, 94% were born in the United States, and 80% believed they acquired HIV in Rhode Island. Class 2 was 63% male and 69% Hispanic/Latino; 29% were born in the United States, and 61% believed they acquired HIV in Rhode Island. Conclusions: Most new HIV diagnoses in Rhode Island were among MSM born in the United States, and a substantial number were likely infected in-state. People with newly diagnosed HIV who were foreign-born, including Hispanic/Latino and heterosexual groups, were less likely to have acquired HIV in Rhode Island than were MSM. HIV prevention approaches, including pre-exposure prophylaxis, should be adapted to the needs of specific groups. Rhode Island offers lessons for other states focused on eliminating HIV transmission.

Improving the impact of HIV pre-exposure prophylaxis implementation in small urban centers among men who have sex with men: An agent-based modelling study

Objectives Identifying prescribing strategies that improve the efficiency of PrEP should increase its impact at the population level. This study identifies PrEP allocation criteria that most effectively reduce 10-year HIV incidence by 25%, in accordance with the US National HIV/AIDS Strategy’s goal for the proportionate reduction in new diagnoses. Methods We used a discrete-time stochastic agent-based model to simulate several PrEP engagement strategies. The model represented MSM aged 15–74 in Rhode Island and was calibrated to statewide prevalence from 2009–2014. We simulated HIV transmission in the absence of PrEP and compared the following PrEP engagement scenarios: 1) allocation to the current patient population; 2) random allocation; 3) allocation to MSM with greater than 5 sexual partners in one year; 4) allocation to MSM with greater than 10 sexual partners in one year. For each scenario and coverage level we estimated the number and proportion of infections averted and the person-years on PrEP per averted infection. Results In 2014, HIV prevalence before PrEP implementation was between 4% and 5%. In the No PrEP scenario 826 new infections (95% simulation limits [SL]: 711, 955) occurred over 10 years, with an incidence rate of 3.51 per 1000 person-years (95% SL: 3.00, 4.08). Prevalence rose to 7.4% (95% SL: 6.7, 8.1). None of the PrEP scenarios reduced new HIV infections by 25% while covering less than 15% of the HIV-uninfected population. At 15% coverage, allocating PrEP to the current patient population, MSM with greater than 5 sexual partners in a year, and MSM with greater than 10 partners reduced new infections by at least 25%, requiring 161 (95% SL: 115, 289), 150 (95% SL: 107, 252), and 128 (95% SL: 100, 184) person-years on PrEP per averted infection, respectively. Conclusions Engaging MSM with high numbers of sexual partners would improve the population-level impact and efficiency of PrEP in settings where PrEP coverage remains low. However, the sustained population-level PrEP coverage needed to reduce new infections by 25% is substantially higher than current levels of PrEP uptake.

Partner notification outcomes after integration of an on-site disease intervention specialist at a sexually transmitted disease clinic

Background Partner notification services (PNS) are highly effective in reducing transmission of sexually transmitted diseases (STDs). We assessed outcomes of PNS before and after integration of an on-site disease intervention specialist (DIS) at a publicly-funded STD clinic. Methods From August 2014 to December 2015, patients testing positive for infectious syphilis or gonorrhea at the Rhode Island STD Clinic were referred to on-site DIS for partner notification. Data on PNS outcomes were reviewed for eight months before integration of DIS at the clinic and compared to eight months after. Results Of the 145 index patients referred for PNS during the study period (n = 58 before DIS integration, n = 87 after), 86% were interviewed. DIS integration resulted in a significantly greater proportion of index patients interviewed overall (92% versus 76%, p<0.01), on the day of diagnosis (85% versus 61%; p<0.01), and in person at the STD clinic (64% versus 11%; p<0.01). However, there was no significant difference in number of sexual partners named or treated. Conclusions Integrating DIS at a publicly-funded STD clinic resulted in a greater number of index cases interviewed, a greater number interviewed in person, and a greater number interviewed on the day of diagnosis. Challenges remain in identifying and engaging partners for treatment.

Public health opportunities and challenges in the provision of partner notification services: the New England experience

BackgroundPartner notification services (PNS) are recommended by the Centers for Disease Control and Prevention as a public health intervention for addressing the spread of HIV and other sexually transmitted diseases (STDs). Barriers and facilitators to the partner notification process from a public health perspective have not been well described.MethodsIn 2015, a coalition of New England public health STD directors and investigators formed to address the increasing STD prevalence across the region (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont) and to promote communication between state STD programs. To evaluate barriers and facilitators of PNS programs, a survey was administered to representatives from each state to describe PNS processes and approaches.ResultsOf the six PNS programs, Connecticut, Maine, Massachusetts, Vermont, and New Hampshire had combined HIV and STD PNS programs; Rhode Island’s programs were integrated but employed separate disease intervention specialists (DIS). All states performed PNS for HIV and syphilis. Maine, New Hampshire and Vermont performed services for all gonorrhea cases. Rhode Island, Connecticut, and Massachusetts performed limited partner notification for gonorrhea due to lack of resources. None of the six states routinely provided services for chlamydia, though Maine and Vermont did so for high-priority populations such as HIV co-infected or pregnant individuals. Across all programs, clients received risk reduction counseling and general STD education as a component of PNS, in addition to referrals for HIV/STD care at locations ranging from Planned Parenthood to community- or hospital-based clinics. Notable barriers to successful partner notification across all states included anonymous partners and index cases who did not feel comfortable sharing partners’ names with DIS. Other common barriers included insufficient staff, inability of DIS to identify and contact partners, and index cases declining to speak with DIS staff.ConclusionsIn New England, state health departments use different strategies to implement PNS programs and referral to STD care. Despite this, similar challenges exist across settings, including difficulty with anonymous partners and limited state resources.

Risk Perception and Interest in HIV Pre-exposure Prophylaxis Among Men Who Have Sex with Men with Rectal Gonorrhea and Chlamydia Infection

Rectal gonorrhea and chlamydia infections are associated with significantly increased risk of HIV transmission among gay, bisexual, and other men who have sex with men (MSM). MSM diagnosed with rectal gonorrhea or chlamydia may benefit from pre-exposure prophylaxis (PrEP) for HIV prevention. We analyzed HIV risk perception, PrEP interest, and sexually transmitted infection (STI) test results among MSM presenting to a publicly funded STI clinic from 2014 to 2016. A total of 401 MSM were tested for rectal STIs during the study period: 18% were diagnosed with rectal gonorrhea or chlamydia infection. Patients who perceived themselves to be at medium or high risk for HIV were significantly more likely to express interest in PrEP compared to those who reported low or no perceived risk (OR 1.88, 95% CI 1.13–3.11; p = .014). However, there was no significant difference in perceived HIV risk between those who were diagnosed with a rectal STI and those who were not. Although rectal STIs are a significant risk factor for HIV infection, MSM diagnosed with a rectal STI did not perceive themselves to be at increased risk for HIV infection, indicating a potential barrier to successful PrEP implementation in this population.

Improving insurance and healthcare systems to ensure better access to sexually transmitted disease testing and prevention

Despite ongoing national efforts and advances in testing and treatment, sexually transmitted diseases (STDs) including human immunodeficiency virus (HIV), chlamydia, gonorrhea, and syphilis remain a significant public health challenge in the United States.1 Approximately 20 million cases of STDs and 40,000 cases of HIV are diagnosed annually,2,3 contributing an estimated