Prevention of STIs in Trans and Gender Diverse People

Over the last decade we have seen an exponential surge in research and peer reviewed publications about the sexual health of trans and gender diverse people. We now know that sexually transmitted infections are highly prevalent in this key population and there is an urgent need for concentrated efforts made by patient advocates, health care providers, public health policy developers and governments to improve health and prevent harm in this underserved population. Today we discuss with Prof Jade Ghosn, his team's latest publication in STI BMJ titled: "Pre-exposure prophylaxis (PrEP) uptake and retention in care in a group of transgender women at high risk of HIV: a French cohort of follow-up" and with Alisha Goburdhun, her team's work in supporting and advocating for trans clients at Accpetess-T.   Host: Ass Prof/Dr Fabiola Martin, Sexual health Specialist, Canberra Sexual Health Centre, Australian National University ‌ Guests: Alisha Goburdhun, Heath Mediator at Acceptess-T, Paris, France Prof Jade Ghosn, Infectious Diseases Specialist at the Sexual Health Clinic in Bichat University Hospital in Paris, France

Most people requiring HIV pre-exposure prophylaxis (PrEP) are offered a daily or event driven oral tablet which contains two HIV antiretroviral drugs combined. Oral medication, however, may not be a feasible and/or effective PrEP option for some. FDA has approved two long-acting injectable HIV anti-viral drugs: Cabotegravir, an HIV integrase inhibitor (2 monthly injections) and Lenacapavir an HIV capsid inhibitor (6 monthly injections) as safe and efficacious HIV PrEP. Today we will discuss the efficacy of and access to long-acting HIV PrEP with Prof Sinead Delany-Moretlwe and Dr Claire Dewsnap.   STI has published extensively on the topic, here are a few examples of recent articles: Pre-exposure prophylaxis (PrEP) uptake and retention in care in a group of transgender women at high risk of HIV: a French cohort of follow-up Association between HIV risk perception, knowledge of biomedical prevention and sexual behaviour among sub-Saharan African immigrants living in a precarious situation in France Preferences for pre-exposure prophylaxis service package among men who have sex with men in Australia: a discrete choice experiment Estimating the number of people who could benefit from HIV pre-exposure prophylaxis (PrEP) in England and the unmet need Regression-based risk scores using sociodemographic and sexual behaviour data do not predict asymptomatic sexually transmitted infections among HIV PrEP users   Host: Ass Prof/Dr Fabiola Martin, Sexual Health Specialist, Associate Professor at Australian National University Guests: Prof Sinead Delany-Moretlwe, Professor of Global Health and Infectious Diseases at the University of the Witwatersrand, Johannesburg Dr Claire Dewsnap, President of the British HIV Association for HIV & Sexual Health (BASHH) and Consultant in Genitourinary Medicine, Sheffield Teaching Hospital, Sheffield, UK

Worldwide the prevalence of sexually transmitted infections is increasing. Today we will discuss innovative ways of testing and treating large number of patients with STIs that are equitable, reliable and potentially cost-effective. We will discuss the eSexual Health Clinic (eSHC) research published in The Lancet Public Health in 2017 and NIHR funded  SEQUENCE Digital research program based in UK as well as the multi-site co-designed EmERGE research program based in UK, Croatia and Zambia. Host: Ass Prof/Dr Fabiola Martin, Sexual Health Specialist, Associate Professor at Australian National University Guests: Professor Claudia Estcourt, Professor of Sexual Health & HIV in Glasgow, Scotland and in London and a sexual health clinician Dr Mary Darking, Principal Lecturer in Social Policy and Innovation at Brighton University Lancet paper: https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(17)30034-8/fulltext 

Today we will discuss the evolution and efficacy of antenatal testing for blood borne pathogens as a strategy to improve pregnancy outcomes and prevent parent to child transmission. Over the last 40 years the number of infections tested for in the antenatal setting has expanded which has been followed closely by treatment guidelines for each infection. However, there are stark regional differences in the infections routinely tested for. Brazil has recently added Human T Leukaemia Virus (HTLV) to its antenatal testing and is planning to test 2.5 million pregnancies yearly. Pregnant people who test positive for HTLV are advised to avoid breast feeding and are provided with formula milk free of charge. Health care providers are being offered upskilling in HTLV care provision. This way Brazil aims to "Take HTLV out of Invisibility" and ultimately eliminate HTLV in Brazil. Host: Ass Prof/Dr Fabiola Martin, Sexual Health Specialist, Associate Professor at Australian National University Guests: Professor Graham Taylor, Head of Section of Virology at Imperial College London and a founder of the National Centre for Human Retrovirology at St. Mary’s Hospital – the UK’s clinical service for people living with Human T Leukaemia Virus (HTLV) infection. Dr Pâmela Cristina Gaspar, General Coordinator of Sexually Transmitted Infections Surveillance at Ministry of Health of Brazil, Brasilia, Brazil Host: Ass Prof/Dr Fabiola Martin, Sexual health, HIV and HTLV Specialist, Canberra, Australia and Australian National University   Brazil HTLV ANC testing: - National guide: https://www.gov.br/aids/pt-br/central-de-conteudo/publicacoes/2022/guia_htlv_internet_24-11-21-2_3.pdf/view   - Folder HTLV for general population: https://www.gov.br/aids/pt-br/assuntos/ist/materiais-informativos/folder-htlv-final-grafica.pdf  - Distance Learning Course for HTLV: https://campusvirtual.fiocruz.br/gestordecursos/hotsite/htlv    NACCHO-ASHM, Australia, HTLV testing guidelines: https://htlv1.guidelines.org.au/ 

Today we will discuss different types of HIV and Syphilis antibody testing performed at home by the patient or consumer. Home testing for HIV and Syphilis empower people, especially pregnant women who live in remote areas or are marginalised and hard to reach, to screen themselves for these two serious and communicable infections at home and seek additional confirmitory testing, treatment and support if their screening test is reactive. We will discuss what these tests are, how they can be used as well as review their merits and potential risks. Host: Dr Fabiola Martin, Sexual Health Specialist, Associate Professor at Australian National University Guest: Dr Bobbie Van Der Pol, Professor of Medicine and Public Health at the University of Alabama at Birmingham, the Director of the UAB STD Diagnostics Laboratory and President of the International Society for STD Research.

Today we will discuss if screening asymptomatic Men who have sex with Men, also referred to as MSM, who are receiving HIV pre-exposure anti-retroviral medication, called HIV PrEP, routinely for bacterial STIs, gonorrhoea and chlamydia through pharyngeal, urine and rectal PCR testing every three months- also referred to as 3x3 testing is indeed of benefit or may cause harm. This year, in Lancet HIV, the Gonoscreen trial, a randomised controlled trial, of 500 MSM on PrEP in each arm followed up for 12 months reported that 3x 3 testing does not reduce the incidence of gonorrhoea and chlamydia infections in this specific cohort. In Belgium, this trial has led to a change in clinic practice through the Belgium HIV PrEP guidelines where patients will be screened less frequently and intensely. Lancet ID on the other hand published an opinion piece by Raccagni et al where concerns about transmission and morbidity risk of untreated infection and implications of using poor quality screening tools are voiced. We will discuss today the merit of the Gonoscreen trial and other studies that support a decrease in screening & treating asymptomatic bacterial STIs and exercising stricter antimicrobial stewardship versus the risks associated with leaving asymptomatic infections untreated and risking morbidity and transmission. Relevant links: Effect of screening for Neisseria gonorrhoeae and Chlamydia trachomatis on incidence of these infections in men who have sex with men and transgender women taking HIV pre-exposure prophylaxis (the Gonoscreen study): results from a randomised, multicentre, controlled trial Primum non-nocere: Is it time to stop screening for Neisseria gonorrhoeae and Chlamydia trachomatis in men who have sex with men taking HIV pre-exposure prophylaxis? The arrested immunity hypothesis in an immunoepidemiological model of Chlamydia transmission Gonorrhoea and chlamydia screening for asymptomatic people with HIV and HIV PrEP users: open issues Host: Dr Fabiola Martin, Sexual Health Specialist and Associate Professor, Australian National University, Canberra, Australia Dr Thibaut Vanbaelen, physician and post-doctoral researcher at The Institute of Tropical Medicine in Antwerp, Belgium Dr Angelo Roberto Raccagni, physician at Vita-Salute San Raffaele University in Milan, Italy

Today we provide you with an update on the sexually transmitted infection: Trichomonas vaginalis, a protozoan which infects the vagina, urethra and paraurethral glands. It is an uncommon cause of vaginal discharge and penile urethritis and can persist for a long time if left untreated. Up to 50% of people with vaginal infections and especially people with urethral infections remain asymptomatic. Persistent trichomonas infection has been associated with facilitating the transmission of human immunodeficiency virus (HIV) and adverse poor reproductive health outcomes. Dr Christina Muzny, Professor in Infectious Diseases at University of Alabama, Birmingham, USA, will present on published clinical trial data on novel treatment against trichomoniasis. Relevant publications: Van Gerwen OT, Aaron KJ, Schroeder J, et al. Spontaneous resolution of Trichomonas vaginalis infection in men. Sexually Transmitted Infections. Published Online First: 27 June 2024. doi: 10.1136/sextrans-2024-056160. Muzny CA, Van Gerwen OT, Kaufman G, Chavoustie S. Efficacy of single-dose oral secnidazole for the treatment of trichomoniasis in women co-infected with trichomoniasis and bacterial vaginosis: a post hoc subgroup analysis of phase 3 clinical trial data. BMJ Open. 2023;13:e072071 Kissinger PJ, Gaydos CA, Seña AC, McClelland RS, Soper, Secor WE, Legendre D, Workowski KA, Muzny CA, Diagnosis and Management of Trichomonas vaginalis: Summary of Evidence Reviewed for the 2021 Centers for Disease Control and Prevention Sexually Transmitted Infections Treatment Guidelines, Clinical Infectious Diseases, Clinical Infectious Diseases, Volume 74, Issue Supplement_2, 15 April 2022 Howe K and Kissinger PJ. Single-dose compared with multidose metronidazole for the treatment of trichomoniasis in women: a meta-analysis. Sex Transm Dis 2017; 44: 29–34. Kissinger P, Muzny CA, Mena LA, et al. Single-dose versus 7- day-dose metronidazole for the treatment of trichomoniasis in women: an open-label, randomised controlled trial. Lancet Infect Dis 2018; 18: 1251–1259. Sherrard J, Pitt R, Hobbs KR, Maynard M, Cochrane E, Wilson J, Tipple C. British Association for Sexual Health and HIV (BASHH) United Kingdom national guideline on the management of Trichomonas vaginalis 2021. Int J STD AIDS. 2022 Jul;33(8):740-750. STI Guidelines Australia - Trichomoniasis Host: Dr Fabiola Martin, STI BMJ Podcast editor, a Sexual Health, HIV and HTLV Specialist, Canberra & University of Queensland, Brisbane, Australia Guest: Dr Christina Muzny, Professor in Infectious Diseases at University of Alabama, Birmingham, USA

You will recall a previous podcast about preventing Neisseria gonorrhoea through an effective vaccine. Neisseria gonorrhoeae is a ubiquitous sexually transmitted bacteria that can cause both localised and systemic disease if left untreated. It may be transmitted to neonates. We also reported on a rise of the gonorrhoea incidence, as well as increasing rates of antibiotic resistance. Today we will revisit the implementation of vaccinations against gonorrhoea in the UK. Here is an exciting up-date on the advice provided by UK's Joint Committee on Vaccination and Immunisation, JCVI, on using the vaccine 4CMebB OMV against Meningococcus used off-label for the prevention of gonorrhoea infection • in patients at significant risk of infection with bacterial STIs who • attend specialist sexual health services. Host: Dr. Fabiola Martin, Sexual Health HIV, HTLV Specialist, Canberra Sexual Health Services & University of Queensland, Australia Participants: Dr. Suneeta Soni, Consultant in Sexual Health and HIV, University Hospitals Sussex and Chair of the Bacterial special interest group for BASHH *British Association for Sexual health and HIV) Dr. Yen Bui, Consultant in Vaccination and Travel Health, Institut national de santé publique du Québec, Canada A/P. Dr. Kate Seib, NHMRC Leadership Fellow and Associate Director for Research, Institute for Glycomics, Griffith University, Australia

Today we will focus on the alternative treatments of early Syphilis. Worldwide many of us have experienced a shortage of gold standard treatment benzathine benzylpenicillin injections for syphilis. It is time we look for alternative antibiotic treatments and prevention strategies for syphilis. In conversation with Prof Jeffery Klausner, Professor of Medicine, Infectious Diseases and Public Health at the Keck School of Medicine of the University of Southern California, we will discuss a new study published in the Lancet in 2024. Mitja O. et al compared oral linezolid with benzathine penicillin G for treatment of early syphilis in adults (Trep-AB Study) in Spain, which is a prospective, open-label, non-inferiority, randomised controlled trial. Acknowledgement for his valuable contributions to the content of the podcast: Dr Oriol Mitjà, Skin Neglected Tropical Diseases and Sexually Transmitted Infections Section, Fundació Lluita Contra les Infeccions, Barcelona, Spain. Related link: https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(23)00683-7/fulltext 

In our final episode in honour of the World AIDS Day we have a conversation with Assistant Prof. Rajasuriar, who coordinates the translational research program in HIV immunology and Ageing at the Centre of Excellence for Research in AIDS (CERiA) in Kuala Lumpur, Malaysia. Today, thanks to effective HIV antiretroviral therapy, people living with HIV can live long and healthy lives. According to the latest data from the Centers for Disease Control and Prevention (CDC), in 2021, of the nearly 1.1 million people living with diagnosed HIV in the United States and dependent areas, over 53% were aged 50 or older. Hosted by: Dr Fabiola Martin, the BMJ STI Podcast editor and Sexual Health Specialist based in Australia and Senior Clinical Lecturer at School of Public Health at University of Queensland. Growing older with HIV in the Treat-All Era Reena Rajasuriar 1 , Heidi M Crane 2 , Aggrey S Semeere 3 PMID: 36176021 PMCID: PMC9522984 DOI: 10.1002/jia2.25997 https://onlinelibrary.wiley.com/doi/10.1002/jia2.25997  Integrated care for older people (‎ICOPE)‎: guidance for person-centred assessment and pathways in primary care https://www.who.int/publications-detail-redirect/WHO-FWC-ALC-19.1