Rapid Syphilis Testing Is Cost-Effective Even in Low-Prevalence Settings: The CISNE-PERU Experience

Studies have addressed cost-effectiveness of syphilis testing of pregnant women in high-prevalence settings. This study compares costs of rapid syphilis testing (RST) with laboratory-based rapid plasma reagin (RPR) tests in low-prevalence settings in Peru. The RST was introduced in a tertiary-level maternity hospital and in the Ventanilla Network of primary health centers, where syphilis prevalence is approximately 1%. The costs per woman tested and treated with RST at the hospital were $2.70 and $369 respectively compared with $3.60 and $740 for RPR. For the Ventanilla Network the costs per woman tested and treated with RST were $3.19 and $295 respectively compared with $5.55 and $1454 for RPR. The cost per DALY averted using RST was $46 vs. $109 for RPR. RST showed lower costs compared to the WHO standard costs per DALY ($64). Findings suggest syphilis screening with RST is cost-effective in low-prevalence settings.

Below:  RST and RPR cost components

Below:  Costs per woman screened and treated, by service comparing RST vs RPR at INMP and Ventanilla Network

Full article at:   http://goo.gl/mVWfxq

By:  Mallma P1, Garcia P1, Carcamo C1, Torres-Rueda S2, Peeling R2, Mabey D2, Terris-Prestholt F2.

• 1Epidemiology, STD/HIV Unit, School of Public Health, Universidad Peruana Cayetano Heredia, Lima, Peru.
• 2London School of Hygiene and Tropical Medicine, London, United Kingdom. 
• PLoS One. 2016 Mar 7;11(3):e0149568. doi: 10.1371/journal.pone.0149568. eCollection 2016.

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Anonymous Partnerships among MSM & Transgender Women (TW) Recently Diagnosed with HIV & Other STIs in Lima, Peru: An Individual-Level & Dyad-Level Analysis

OBJECTIVES:

Partner notification (PN) following sexually transmitted disease (STI) diagnosis is a key strategy for controlling HIV/STI transmission. Anonymous partnerships are an important barrier to PN and often associated with high-risk sexual behaviour. Limited research has examined the profile of men who have sex with men (MSM) and transgender women (TW) who engage in anonymous sex. To better understand anonymous partnership practices in Lima, Peru, we assessed participant-level and partnership-level characteristics associated with anonymous sex among a sample of MSM and TW recently diagnosed with HIV/STI.

METHODS:

MSM and TW diagnosed with HIV/STI within the past month completed a cross-sectional survey regarding anticipated PN practices. Participants reported sexual partnership types and characteristics of up to three of their most recent partners. Using a Poisson generalised estimating equation model, we assessed participant-level and partnership-level characteristics associated with anonymous partnerships.

RESULTS:

Among 395 MSM and TW with HIV/STI, 36.0% reported at least one anonymous sexual partner in the past 3 months (mean of 8.6 anonymous partners per participant; SD 17.0). Of the 971 partnerships reported, 118 (12.2%) were anonymous and the majority (84.8%) were with male partners, followed by 11.0% with female partners and 4.2% with transgender/travesti partners. Partner-level characteristics associated with increased likelihood of having an anonymous partner included female (adjusted prevalence ratio (aPR) 2.28, 95% CI 1.05 to 4.95, p=0.04) or transgender/travesti (aPR 4.03, 95% CI 1.51 to 10.78, p=0.006) partner gender.

CONCLUSIONS:

By assessing both individual-level and dyadic-level factors, these results represent an important step in understanding the complexity of partnership interactions and developing alternative PN strategies for Latin America.

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By:  Perez-Brumer AG1, Oldenburg CE2, Segura ER3, Sanchez J4, Lama JR4, Clark JL3.

• 1Department of Sociomedical Sciences, Columbia Mailman School of Public Health, New York, USA Department of Medicine and Program in Global Health, David Geffen School of Medicine at UCLA, Los Angeles, USA.
• 2Department of Epidemiology, Harvard School of Public Health, Boston, USA.
• 3Department of Medicine and Program in Global Health, David Geffen School of Medicine at UCLA, Los Angeles, USA.
• 4Asociación Civil Impacta Salud y Educación, Lima, Peru Department of Global Health, University of Washington, Seattle, USA. 
• Sex Transm Infect. 2016 Feb 24. pii: sextrans-2015-052310. doi: 10.1136/sextrans-2015-052310.

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Impact of Alcohol Use on Sexual Behavior among Men Who Have Sex with Men & Transgender Women in Lima, Peru

BACKGROUND:

Alcohol use disorders (AUDs) may enhance the likelihood of risky sexual behaviors and the acquisition of sexually transmitted infections (STIs). Associations between AUDs with condomless anal intercourse (CAI) and STI/HIV prevalence were assessed among men who have sex with men (MSM) and transgender women (TW) in Lima, Peru.

METHODS:

MSM and TW were eligible to participate based on a set of inclusion criteria which characterized them as high-risk. Participants completed a bio-behavioral survey. An AUDIT score ≥8 determined AUD presence. Recent STI diagnosis included rectal gonorrhea/chlamydia, syphilis, and/or new HIV infection within 6 months. Prevalence ratios (PR) were calculated using Poisson regression.

RESULTS:

Among 312 MSM and 89 TW, 45% (181/401) had an AUD. Among those with an AUD, 164 (91%) were hazardous/harmful drinkers, and 17 (9%) had alcohol dependence. Higher CAI was reported by participants with an AUD vs. without, (82% vs. 72% albeit not significant). Reporting anal sex in two or more risky venues was associated with screening AUD positive vs. not (24% vs. 15%, p=0.001). There was no difference in recent STI/HIV prevalence by AUD status (32% overall). In multivariable analysis, screening AUD positive was not associated with CAI or recent STI/HIV infection.

CONCLUSIONS:

In our sample AUDs were not associated with CAI or new HIV infection/recent STI. However higher prevalence of CAI, alcohol use at last sex, and anal sex in risky venues among those with AUDs suggests that interventions to reduce the harms of alcohol should be aimed toward specific contexts.

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By:  Herrera MC1, Konda KA2, Leon SR3, Deiss R4, Brown B5, Calvo GM6, Salvatierra HJ7, Caceres CF6, Klausner JD1.

• 1Division of Infectious Diseases, UCLA David Geffen School of Medicine, Los Angeles, CA, USA.
• 2Division of Infectious Diseases, UCLA David Geffen School of Medicine, Los Angeles, CA, USA. Electronic address: kkonda@mednet.ucla.edu.
• 3Partners in Health, Director of Research, Lima, Peru.
• 4Division of Infectious Diseases, Naval Medical Center San Diego, CA, USA.
• 5Division of Clinical Sciences, Center for Healthy Communities, University of California, Riverside, CA, USA.
• 6Unit of Health, Sexuality and Human Development, School of Public Health, Universidad Peruana Cayetano Heredia, Lima, Peru.
• 7Alberto Barton Health Center, Health Directorate of Callao, Lima, Peru. 
• Drug Alcohol Depend. 2016 Feb 16. pii: S0376-8716(16)00060-0. doi: 10.1016/j.drugalcdep.2016.01.030.

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Is Intimate Partner and Client Violence Associated with Condomless Anal Intercourse and HIV among Male Sex Workers in Lima, Peru?

Violence experience can increase HIV risk behaviors; however, literature is scarce on violence among male sex workers (MSWs) globally. 

In 2014, 210 Peruvian MSWs (median age 24.9) were interviewed about their experience of physical, emotional, and sexual violence and condom use with non-paying intimate partners and clients and were tested for HIV. 

Multivariable models examined relationships between violence in the past 6 months, condomless anal intercourse (CLAI) in the past 3 months and HIV infection. HIV infection (24 %), CLAI (43 %), being a violence victim (42 %) and perpetrator (39 %) were common. 

In separate multivariable models, being a violence victim and perpetrator were associated with CLAI. Further, being a victim was associated with HIV infection. 

Violence, which was significantly associated with CLAI and HIV infection, is common among Peruvian MSWs, reinforcing the importance of violence awareness and prevention as HIV risk-reduction strategies.

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By:  George PE1,2, Bayer AM3,4, Garcia PJ4,5, Perez-Lu JE4, Burke JG6, Coates TJ3, Gorbach PM3,7.

• 1Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, 10833 LeConte Ave., CHS 12-105, Los Angeles, CA, 90095, USA. george.paul.e@gmail.com.
• 2Washington University in St. Louis School of Medicine, St. Louis, MO, USA. george.paul.e@gmail.com.
• 3Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, 10833 LeConte Ave., CHS 12-105, Los Angeles, CA, 90095, USA.
• 4Epidemiology, STD, and HIV Unit, School of Public Health and Administration, Universidad Peruana Cayetano Heredia, Lima, Peru.
• 5Department of Global Health, University of Washington, Seattle, WA, USA.
• 6Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA.
• 7Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, USA. 
• AIDS Behav. 2016 Feb 15.

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HIV Self-Testing in Peru: Questionable Availability, High Acceptability But Potential Low Linkage to Care among Men Who Have Sex with Men & Transgender Women

HIV status awareness is key to prevention, linkage-to-care and treatment. Our study evaluated the accessibility and potential willingness of HIV self-testing among men who have sex with men (MSM) and transgender women in Peru. 

We surveyed four pharmacy chains in Peru to ascertain the commercial availability of the oral HIV self-test. The pharmacies surveyed confirmed that HIV self-test kits were available; however, those available were not intended for individual use, but for clinician use. 

We interviewed 147 MSM and 45 transgender women; nearly all (82%) reported willingness to perform the oral HIV self-test. However, only 55% of participants would definitely seek a confirmatory test in a clinic after an HIV-positive test result. Further, price may be a barrier, as HIV self-test kits were available for 18 USD, and MSM and transgender women were only willing to pay an average of 5 USD. 

HIV self-testing may facilitate increased access to HIV testing among some MSM/transgender women in Peru. However, price may prevent use, and poor uptake of confirmatory testing may limit linkage to HIV treatment and care.

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By:  Bustamante MJ1, Konda KA2, Joseph Davey D3, León SR1, Calvo GM4, Salvatierra J5, Brown B6, Caceres CF1, Klausner JD7.

• 1Unit of Health, Sexuality and Human Development, and Laboratory of Sexual Health, Universidad Peruana Cayetano Heredia, Lima, Peru.
• 2Unit of Health, Sexuality and Human Development, and Laboratory of Sexual Health, Universidad Peruana Cayetano Heredia, Lima, Peru Division of Infectious Diseases, Department of Medicine, University of California Los Angeles, Los Angeles CA, USA.
• 3Department of Epidemiology, University of California, Los Angeles, Los Angeles, CA, USA dvoradavey@ucla.edu.
• 4Unit of Health, Sexuality and Human Development, and Laboratory of Sexual Health, Universidad Peruana Cayetano Heredia, Lima, Peru Epicentro Salud, Lima, Peru.
• 5Barton Health Center, Health Directorate of Callao, Lima, Peru.
• 6Center for Healthy Communities, Division of Clinical Sciences, UCR School of Medicine, Riverside, CA USA.
• 7Division of Infectious Diseases, Department of Medicine, University of California Los Angeles, Los Angeles CA, USA Department of Epidemiology, University of California, Los Angeles, Los Angeles, CA, USA. 
• Int J STD AIDS. 2016 Jan 29. pii: 0956462416630674.

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Sexual Orientation, Gender Identity and Perceived Source of Infection among Men Who Have Sex with Men and Transgender Women (TW) Recently Diagnosed with HIV and/or STI in Lima, Peru

Risk perception and health behaviors result from individual-level factors influenced by specific partnership contexts. 

We explored individual- and partner-level factors associated with partner-specific perceptions of HIV/STI risk among 372 HIV/STI-positive MSM and transgender women (TW) in Lima, Peru. 

Generalized estimating equations explored participants' perception of their three most recent partner(s) as a likely source of their HIV/STI diagnosis. Homosexual/gay (PR = 2.07; 95 % CI 1.19-3.61) or transgender (PR = 2.84; 95 % CI 1.48-5.44) partners were more likely to be considered a source of infection than heterosexual partners. 

Compared to heterosexual respondents, gay and TW respondents were less likely to associate their partner with HIV/STI infection, suggesting a cultural link between gay or TW identity and perceived HIV/STI risk. 

Our findings demonstrate a need for health promotion messages tailored to high-risk MSM partnerships addressing how perceived HIV/STI risk aligns or conflicts with actual transmission risks in sexual partnerships and networks.

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By:  Blair CS1, Segura ER2, Perez-Brumer AG2,3, Sanchez J4, Lama JR4, Clark JL2.

• 1Division of Infectious Diseases and Program in Global Health, Department of Medicine, David Geffen School of Medicine at UCLA, 10833 Leconte Avenue, CHS 37-121, Los Angeles, CA, 90095, USA. cherieblair@mednet.ucla.edu.
• 2Division of Infectious Diseases and Program in Global Health, Department of Medicine, David Geffen School of Medicine at UCLA, 10833 Leconte Avenue, CHS 37-121, Los Angeles, CA, 90095, USA.
• 3Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, USA.
• 4Asociación Civil Impacta Salud y Educación, Lima, Peru. 
• AIDS Behav. 2016 Jan 14.

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High Prevalence of Chlamydia Trachomatis & Neisseria Gonorrhoeae Infections in Anal & Pharyngeal Sites among Men Who Have Sex with Men & Transgender Women in Lima, Peru

OBJECTIVES:

This study aimed to characterise the epidemiology of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections among men who have sex with men (MSM) and transgender women (TW) in Lima, Peru.

PARTICIPANTS:

We recruited a group of 510 MSM and 208 TW for a subsequent community-based randomised controlled trial. The presence of CT and NG were evaluated using Aptima Combo2 in pharyngeal and anal swabs. We also explored correlates of these infections.

PRIMARY AND SECONDARY OUTCOME MEASURES:

Study end points included overall prevalence of C. trachomatis and N. gonorrhoeae in anal and pharyngeal sites.

RESULTS:

Overall prevalence of CT was 19% (95% CI 16.1% to 22.1%) and 4.8% (95% CI 3.3% to 6.6%) in anal and pharyngeal sites, respectively, while prevalence of NG was 9.6% (95% CI 7.5% to 12.0%) and 6.5% (95% CI 4.8% to 8.5%) in anal and pharyngeal sites, respectively.

CONCLUSIONS:

The prevalence of each infection declined significantly among participants older than 34 years (p<0.05). Efforts towards prevention and treatment of extraurogenital chlamydial and gonococcal infections in high-risk populations like MSM and TW in Lima, Peru, are warranted.

Below:  Trends of prevalence of anal and pharyngeal infections over age group, satisfied by agent and sexual identity

Full article at:   http://goo.gl/fkxwMy

By:  Leon SR1, Segura ER2, Konda KA3, Flores JA4, Silva-Santisteban A4, Galea JT5, Coates TJ3, Klausner JD3, Caceres CF4.

• 1Laboratory of Sexual Health and Unit of Health, Sexuality and Human Development, Cayetano Heredia University, Lima, Peru Department of Global Health, University of Washington (http://globalhealth.washington.edu/), Seattle, Washington, USA Socios en Salud, Lima, Peru.
• 2Escuela de Medicina, Universidad Peruana de Ciencias Aplicadas, Lima, Peru.
• 3Division of Infectious Diseases, School of Medicine, University of California Los Angeles, Los Angeles, California, USA.
• 4Laboratory of Sexual Health and Unit of Health, Sexuality and Human Development, Cayetano Heredia University, Lima, Peru.
• 5Partners in Health, Boston, Massachusetts, USA. 
• BMJ Open. 2016 Jan 6;6(1):e008245. doi: 10.1136/bmjopen-2015-008245.

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Field Evaluation of a Dual Rapid Diagnostic Test for HIV Infection & Syphilis in Lima, Peru

OBJECTIVES:

Screening for HIV and syphilis in key populations is recommended by the WHO to reduce the morbidity, mortality and transmission associated with undiagnosed and untreated infections. Rapid point-of-care tests that can detect multiple infections with a single fingerprick whole blood specimen using a single device are gaining popularity. We evaluated the field performance of a rapid dual HIV and syphilis test in people at high risk of HIV and syphilis infections.

METHODS:

Participants included men who have sex with men and transgender women recruited in Lima, Peru. Reference standard testing for detection of HIV and syphilis infections, conducted using blood samples from venipuncture, included Treponema pallidum particle agglutination and fourth-generation HIV enzyme immunoassay for which positive results had a confirmation HIV Western blot test. For the evaluation test, SD BIOLINE HIV/Syphilis Duo test (Standard Diagnostics, Korea), a fingerprick blood specimen was used. Sensitivity and specificity were calculated and the exact binomial method was used to determine 95% CIs.

RESULTS:

A total of 415 participants were recruited for the study. The dual test sensitivity for detection of T. pallidum infection was 89.2% (95% CI 83.5% to 93.5%) and specificity 98.8% (95% CI 96.5% to 99.8%). For detection of HIV infection, the sensitivity of the dual test was 99.1% (95% CI 94.8% to 100%) and specificity 99.4% (95% CI 97.7% to 99.9%).

CONCLUSIONS:

This high performing dual test should be considered for the use in clinical settings to increase uptake of simultaneous testing of HIV and syphilis and accelerate time to treatment for those who need it.

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By:   Bristow CC1, Leon SR2, Huang E3, Brown BJ4, Ramos LB2, Vargas SK2, Flores JA2, Caceres CF2, Klausner JD3.

• 1Division of Global Public Health, Department of Medicine, University of California, San Diego, La Jolla, California, USA.
• 2Unit of Health, Sexuality and Human Development, and Laboratory of Sexual Health, Universidad Peruana Cayetano Heredia, Lima, Peru.
• 3Division of Infectious Diseases: Global Health, Department of Medicine, University of California, Los Angeles, Los Angeles, California, USA.
• 4Program in Public Health, University of California, Irvine, Irvine, California, USA.

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HIV & Sexually Transmitted Infection Incidence & Associated Risk Factors among High-Risk MSM & Male-To-Female Transgender Women in Lima, Peru

Men who have sex with men (MSM) and male-to-female transgender women (TW) are at increased risk of HIV and sexually transmitted infections (STIs). We evaluated factors associated with incidence of HIV, HSV-2, and chlamydia and gonorrhea (anal and pharyngeal).

We used data from the Comunidades Positivas trial with MSM/TW who have sex with men in Lima, Peru. Participants were asked about sexual risk behaviors and underwent HIV/STI testing at baseline and 9- and 18-month follow-ups. We used discrete time proportional hazards regression to calculate hazard ratios for variables associated with incidence of each STI.

• Among 718 MSM/TW, HIV incidence was 3.6 cases per 100 person-years. 
• HIV incidence was associated with having an incident STI adjusted hazard ratio (aHR) of 3.73. 
• Unprotected receptive anal intercourse was associated with incident anal chlamydia (aHR 2.20). 
• An increased number of sexual partners increased incident HSV-2 . 
• The risk of anal gonorrhea decreased with each sexually active year (aHR 0.94) and increased for unprotected compensated sex (aHR 2.36). 
• The risk of pharyngeal gonorrhea also decreased with each year since sexual debut (aHR 0.95). 
• The risk of anal chlamydia decreased with each sexually active year (aHR 0.96); the risk increased with reports of unprotected sex work (aHR 1.61) and unprotected receptive anal sex (aHR 2.63). 
• All aHRs have P values <0.05.

MSM/TW experience high incidence of HIV. Up-to-date prevalence and incidence information and identifying factors associated with infection can help develop a more effective combination prevention response.

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By: Castillo R1, Konda KA, Leon SR, Silva-Santisteban A, Salazar X, Klausner JD, Coates TJ, Cáceres CF.

• 1*School of Medicine, Stanford University, Stanford, CA; †Unit of Health, Sexuality and Human Development, Universidad Peruana Cayetano Heredia, Lima, Peru; and ‡Department of Medicine, Division of Infectious Diseases, University of California, Los Angeles, Los Angeles, CA. 

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The Syphilis Care Cascade: Tracking the Course of Care After Screening Positive among Men & Transgender Women Who Have Sex with Men In Lima, Peru

Syphilis is endemic among men who have sex with men (MSM) and transgender women in Latin America. The objective of this study was to assess if those who screen positive for syphilis are receiving appropriate care and treatment.

We use data from the 2011 Peruvian National HIV Sentinel Surveillance to describe the syphilis care cascade among high-risk MSM and transgender women. Medical records from participants who had a positive syphilis screening test at two of the enrolment sites in Lima were reviewed to determine their subsequent course of care.

We identified a cohort of 314 syphilis seropositive participants (median age: 30, 33.7% self-identified as transgender). Only 284/314 (90.4%) participants saw a physician for evaluation within 28 days of their positive test. Of these, 72/284 (25.4%) were asked to return for confirmatory results before deciding whether or not to start treatment; however, 45/72 (62.5%) of these participants did not follow up within 28 days. Of the people prescribed three weekly doses of penicillin, 34/63 (54%) received all three doses on time.

Many MSM and transgender women with a positive syphilis screening test are lost at various steps along the syphilis care cascade and may have persistent infection. Interventions in this population are needed to increase testing, link seropositive patients into care and ensure that they receive appropriate and timely treatment.

Below:  Course of care following positive syphilis screening test among 314 participants recruited at two non-governmental organization clinics in Lima, Peru through the 2011 HIV National Sentinel Surveillance. Rx=prescribed, PCN=penicillin, x1=one dose, x3=three weekly doses.

Read more at: http://ht.ly/SBVYK 

By: Tang EC1, Segura ER1, Clark JL1, Sanchez J2, Lama JR2.

• 1Department of Medicine/Division of Infectious Diseases, UCLA Geffen School of Medicine, Los Angeles, California, USA.
• 2Asociación Civil Impacta Salud y Educación, Lima, Peru Department of Global Health, University of Washington, Seattle, Washington, USA.