BACKGROUND: The 2022 mpox outbreak disproportionately affected gay, bisexual, and other men who have sex with men (GBMSM). Mpox cases continue to be reported nationally. Vaccination is a tool to prevent the spread of and serious disease from mpox. To understand mpox vaccine uptake and hesitancy, a virtual focus group with unvaccinated GBMSM was conducted. METHODS: In November 2022, a 60-minute, virtual focus group was conducted within an artificial intelligence (AI) platform that engages participants in chat-based conversation. The AI system uses machine learning and natural language processing to analyze and provide results immediately to the moderator. Descriptive frequencies, cross-tabulations and qualitative themes were analyzed. RESULTS: Fifty-one GBMSM ages 18-55 participated, of whom 12 had attempted to get the mpox vaccine. The top barriers in accessing the vaccine included challenges in scheduling appointments (4/12), available vaccine locations (3/12), and transportation (2/12). Nine participants reported not wanting the vaccine and 22 were undecided; Of these, 15 (4/9 and 11/22, respectively) said they did not think they needed the vaccine due to low perceived risk or monogamy.. Among the undecided, after receiving health messaging about mpox, 12/22 said the messaging made them reconsider getting the vaccine. CONCLUSION: During an outbreak, many unvaccinated GBMSM who may be at increased risk for mpox either wanted the vaccine or, with appropriate health messaging, may be open to getting the vaccine. Messaging about mpox vaccine efficacy, potential side effects, and how to access the vaccine may improve vaccine uptake especially as cases continue to occur.

Pre-exposure prophylaxis (PrEP) is an effective tool for human immunodeficiency virus (HIV) prevention. The purpose of this study is to identify correlates of PrEP retention using patient data from an urban, publicly funded safety-net clinic in Washington, DC. Cox proportional hazards regression, logistical regression, and survival curves were used to assess the association of age, gender, race/ethnicity, insurance, number of partners, and sexually transmitted infection (STI) diagnosis at PrEP initiation with time on PrEP. From August 2016-December 2020, 1,126 people were prescribed PrEP - patients were mostly Black (44.8%) or Latinx (30.4%) and identified as cisgender men (84.6%). Half had no insurance (49.1%), with the remaining patients reporting private (28.9%) or public (21.5%) insurance. Age at PrEP prescription ranged from 15 to 66 with 80% being 20 to 39 years. For the 87.7% (n = 987) of patients who discontinued PrEP, mean PrEP time was 158 days and median was 28 days. The highest rates of discontinuation were observed within the first month with 44.3% discontinuing by day 30, 52.3% by 3 months, and 73.2% by 1 year. Cisgender women, transgender persons, and those younger than 30 years were more likely to discontinue PrEP. Latinx and patients with less than 3 male partners in the last 90 days were less likely to discontinue PrEP. We demonstrated a high level of PrEP uptake among populations disproportionally affected by HIV. Future analyses are needed to examine ways of reducing barriers to PrEP initiation and improving PrEP adherence.

District of Columbia (DC) has high rates of HIV infection and human papillomavirus (HPV)-associated cancers. People living with HIV (PLWH) are at risk for developing HPV-associated cancers. Previous studies identified factors that may further increase the risk of HPV-associated cancer among PLWH such as age, race/ethnicity, sex, risk factor for HIV transmission, stage of HIV infection, and age at HIV diagnosis. The extent to which PLWH in DC are affected by HPV-associated cancers has not previously been well described, and to our knowledge, the relationship between bacterial sexually transmitted infections (STIs) and subsequent development of HPV-associated cancer among PLWH in DC has not been explored. This was a retrospective case-control analysis of surveillance data on cancer, STIs, and HIV in Washington, DC from 1996 to 2015. There were 20,744 PLWH included in this study, of whom 335 (1.6%) had been diagnosed with an HPV-associated cancer. Among males living with HIV (MLWH), for every additional STI per 10 person-years, risk of developing an HPV-associated cancer increased by 11%. Exposure to STIs was not a significant risk factor for HPV-associated cancer among females. Ever being diagnosed with stage three HIV infection increased risk of HPV-associated cancers among males by 109% and females living with HIV by 111%. STI exposures were associated with HPV-associated cancers among MLWH in DC and ever being diagnosed with advanced HIV infection was associated with HPV-associated cancers among all PLWH. Clinicians treating MLWH should ensure their patients receive primary HPV infection prevention and HPV-associated cancer screenings.

BACKGROUND: The Centers for Disease Control and Prevention recommends that men who have sex with men (MSM) get tested annually for urethral and rectal chlamydia (CT) and gonorrhea (NG), and pharyngeal NG. There are no national recommendations to screen women and heterosexual men at extragenital sites. We assessed extragenital CT/NG screening among men and women at Louisiana's Parish Health Units (PHU). METHODS: The Louisiana STD/HIV/Hepatitis Program piloted extragenital screening at four PHUs in February 2016 and expanded to eleven PHUs in 2017. Sexual histories were used to identify gender of sex partners and exposed sites. Due to billing restrictions, up to two anatomical sites were tested for CT/NG. RESULTS: From February 2016-June 2019, 70,895 urogenital and extragenital specimens (56,086 urogenital, 13,797 pharyngeal and 1,012 rectal) were collected from 56,086 patients. Pharyngeal CT positivity was 160/7,868 (2.0%) among women, 54/4,838 (1.1%) among MSW (men who have sex with women) and 33/1,091 (3.0%) among MSM. Rectal CT positivity was 51/439 (11.6%) among women and 95/573 (16.6%) among MSM. Pharyngeal NG positivity was 299/7,868 (3.8%) among women, 222/4,838 (4.6%) among MSW and 97/1,091 (8.9%) among MSM. Rectal NG positivity was 20/439 (4.6%) among women and 134/573 (23.4%) among MSM.Urogenital-only screening would have missed: among women,173/3,923 (4.4%) CT and 227/1,480 (15.3%) NG infections; among MSW, 26/2,667 (1%) CT and 149/1,709 (8.7%) NG infections; and among MSM, 116/336 (34.5%) CT and 127/413 (42.1%) NG infections. CONCLUSIONS: Many CT/NG infections would have been missed with urogenital-only screening. MSM had much higher extragenital infection rates than women and MSW.

As of October 11, 2022, a total of 26,577 monkeypox cases had been reported in the United States.* Although most cases of monkeypox are self-limited, lesions that involve anatomically vulnerable sites can cause complications. Ocular monkeypox can occur when Monkeypox virus (MPXV) is introduced into the eye (e.g., from autoinoculation), potentially causing conjunctivitis, blepharitis, keratitis, and loss of vision (1). This report describes five patients who acquired ocular monkeypox during July-September 2022. All patients received treatment with tecovirimat (Tpoxx)(†); four also received topical trifluridine (Viroptic).(§) Two patients had HIV-associated immunocompromise and experienced delays between clinical presentation with monkeypox and initiation of monkeypox-directed treatment. Four patients were hospitalized, and one experienced marked vision impairment. To decrease the risk for autoinoculation, persons with monkeypox should be advised to practice hand hygiene and to avoid touching their eyes, which includes refraining from using contact lenses (2). Health care providers and public health practitioners should be aware that ocular monkeypox, although rare, is a sight-threatening condition. Patients with signs and symptoms compatible with ocular monkeypox should be considered for urgent ophthalmologic evaluation and initiation of monkeypox-directed treatment. Public health officials should be promptly notified of cases of ocular monkeypox. Increased clinician awareness of ocular monkeypox and of approaches to prevention, diagnosis, and treatment might reduce associated morbidity.

BACKGROUND: Associations between online sex seeking and increased risk for STIs and HIV among men who have sex with men (MSM) typically rely on convenience samples. We examined internet and mobile app use for finding sex partners among a nationally representative sample of MSM. METHODS: We analyzed 2011-2017 data from the National Survey of Family Growth (NSFG), a nationally representative sample of the civilian, non-institutionalized US population (15-44 years). The analytic sample was comprised of males who reported one or more same-sex partners in the past year. We also assessed associations between online sex-seeking and STI risk, sexual health care behaviors, and condom use. RESULTS: Of 13,320 male respondents, 442 (3.0%) reported sex with a man in the past year, of whom 215 (46.3%) had met a partner online. Between MSM who met partners online and those who did not, we found no differences by age, education, race/ethnicity or socioeconomic status. MSM with online partners were more likely to identify as gay (68.4% vs 49.5%, p=0.0124). They also reported more sex partners overall (M = 3.04 versus 1.60, p <0.0001), and multiple insertive (46.3% versus 8.5%, p <0.0001) and receptive (33.2% versus 15.4%, p=0.0055) anal sex partners, in the past year. They were also more likely to receive sexual risk assessments (56.0% versus 40.4%, p=0.0129), STI testing (57.4% versus 35.3%, p =0.0002) and STI treatment (17.8% versus 8.7%, p=0.0152) in the past year. We found no differences in condom use. CONCLUSION: MSM who report using online sources to find sex partners are more likely than other MSM to report behaviors that increase risk for STI/HIV but are also more likely to engage in behaviors that may mitigate further transmission, such as STI testing.

BACKGROUND: Lesbian, gay, bisexual, transgender, and queer (LGBTQ) populations have an increased risk of multiple adverse health outcomes. Capturing patient data on sexual orientation and gender identity (SOGI) in the electronic health record (EHR) can enable healthcare organizations to identify inequities in the provision of preventive health screenings and other quality of care services to their LGBTQ patients. However, organizations may not be familiar with methods for analyzing and interpreting SOGI data to detect health disparities. PURPOSE: To assess an approach for using SOGI EHR data to identify potential screening disparities of LGBTQ patients within distinct healthcare organizations. METHODS: Five US federally qualified health centers (FQHCs) retrospectively extracted three consecutive months of EHR patient data on SOGI and routine screening for cervical cancer, tobacco use, and clinical depression. The screening data were stratified across SOGI categories. Chi-Square and Fisher's Exact test were used to identify statistically significant differences in screening compliance across SOGI categories within each FQHC. RESULTS: In all FQHCs, cervical cancer screening percentages were lower among lesbian/gay patients than among bisexual and straight/heterosexual patients. In three FQHCs, cervical cancer screening percentages were lower for transgender men than for cisgender (i.e., not transgender) women. Within each FQHC, we observed statistically significant associations (P < 0.05) between SOGI categories and at least one screening measure. The small number of transgender patients, and limitations in EHR functionality, created challenges in interpretation of SOGI data. CONCLUSIONS: To our knowledge, this is the first published report of using SOGI data from EHRs to detect potential disparities in healthcare services to LGBTQ patients. Our finding that lesbian/gay and transgender male patients had lower cervical cancer screening rates compared to heterosexual, bisexual, and cisgender women, is consistent with the research literature and suggests that using SOGI EHR data to detect preventive screening disparities has value. EHR functionality should allow for cross-checking gender identity with sex assigned at birth to reduce errors in data interpretation. Additional functionality, like clinical decision support based on anatomical inventories rather than gender identity, is needed to more accurately identify services that transgender patients need.

PURPOSE: Lesbian, gay, bisexual, and transgender (LGBT) people experience multiple disparities in access to care and health outcomes. We developed a quality improvement initiative, Transforming Primary Care for LGBT People, to enhance the capacity of federally qualified health centers (FQHCs) to provide culturally affirming care for this population. METHODS: The 1-year intervention blended the models of Practice Improvement Collaboratives and Project ECHO (Extension for Community Health Outcomes) to facilitate learning and translate knowledge into action. FQHC teams received coaching in creating LGBT-inclusive environments, collecting sexual orientation and gender identity (SOGI) data, taking risk-based sexual histories, and screening LGBT people for syphilis, chlamydia and gonorrhea, and HIV. We used a preintervention-postintervention evaluation design. RESULTS: We selected 10 FQHCs serving 441,387 patients in 123 clinical sites in 9 states. The intervention spread from 10 clinicians in 10 clinical sites to 431 clinicians in 79 clinical sites. FQHCs reported increases in culturally affirming practices, including collecting patient pronoun information (42.9% increase) and identifying LGBT patient liaisons (300.0% increase). Postintervention, among 9 FQHCs reporting SOGI data from electronic health records, SOGI documentation increased from 13.5% to 50.8% of patients (276.3% increase). Among 8 FQHCs reporting number of LGBT patients, screening of LGBT patients increased from 22.3% (95% CI, 4.9%-40.0%) to 34.6% (95% CI, 19.4%-48.6%) for syphilis (86.5% increase); from 25.3% (95% CI, 7.6%-43.1%) to 44.1% (95% CI, 30.2%-58.1%) for chlamydia and gonorrhea (109.0% increase); and from 14.8% (95% CI, 3.2%-26.5%) to 30.5% (95% CI, 26.7%-34.3%) for HIV (132.4% increase). CONCLUSIONS: FQHCs participating in this initiative reported improved capacity to provide culturally affirming care and targeted screening for LGBT patients.

BACKGROUND: Health departments prioritize investigations of reported reactive serologic tests based on age, gender, and titer using reactor grids. We wondered how reactor grids are used in different programs, and if administratively closing investigations of low-titer tests could lead to missed primary syphilis cases. METHODS: We obtained a convenience sample of reactor grids from 13 health departments. Interviews with staff from several jurisdictions described the role of grids in surveillance and intervention. From 5 jurisdictions, trends in reactive nontreponemal tests and syphilis cases over time (2006-2015) were assessed by gender, age, and titer. In addition, nationally-reported primary syphilis cases (2013-2015) were analyzed to determine what proportion had low titers (</=1:4) that might be administratively closed by grids without further investigation. RESULTS: Grids and follow-up approaches varied widely. Health departments in the study received a total of 48,573 to 496,503 reactive serologies over a 10-year period (3044-57,242 per year). In 2006 to 2015, the number of reactive serologies increased 37% to 169%. Increases were largely driven by tests for men although the ratios of tests per reported case remained stable over time. Almost one quarter of reported primary syphilis had low titers that would be excluded by most grids. The number of potentially missed primary syphilis cases varied by gender and age with 41- to 54-year-old men accounting for most. CONCLUSIONS: Reactor grids that close tests with low titers or from older individuals may miss some primary syphilis cases. Automatic, computerized record searches of all reactive serologic tests could help improve prioritization.

Syphilis control strategies are old, but interventions have changed and there is now a more scientific approach to evidence of effectiveness. We searched PubMed using 'syphilis control' to identify papers that measured the effectiveness of interventions. We also included novel approaches and comprehensive responses to outbreaks. Few papers used high-quality research methodology and fewer evaluated impact on prevalence or incidence; most assessed intermediate outcomes. Syphilis can often be controlled by a combination of case finding, treatment and education. However, outbreaks are unique and ongoing evaluation is needed to see if interventions are producing intended intermediate outcomes at reasonable costs.

Persons living with HIV/AIDS who acquire new sexually transmitted diseases (STDs) pose a risk for enhanced transmission of both HIV and STDs. To describe the frequency of HIV coinfection among gonorrhea cases (GC), HIV and GC surveillance databases (2000-2008) were cross-matched in New York City (NYC), Washington, DC (DC), Miami/Dade County (MDC), and Arizona (AZ). During 2000-2008, 4.6% (9471/205,689) of reported GCs occurred among persons with previously diagnosed HIV: NYC (5.5%), DC (7.3%), MDC (4%), and AZ (2%). The overall HIV-GC coinfection rates increased over the study period in all 4 sites. Real-time data integration could allow for enhanced prevention among persons with HIV infection and acute STDs.

To increase self-examination for syphilis among men who have sex with men (MSM), we developed educational materials to increase knowledge of primary and secondary syphilis manifestations. Materials were piloted in five cities' infectious disease or MSM clinics. Self- and partner-examination behaviour was assessed with an anonymous questionnaire. Of 1459 participants, 914 men had had sex with a man in the previous three months; the 171 MSM who reported having read the materials were significantly more likely to examine themselves (anus, adjusted prevalence ratio [aPR] 1.3, 95% confidence interval [CI] 1.15-1.52), mouth, penis and skin, and their partners' anus (aPR 1.3, 95% CI 1.03-1.73) and mouth (aPR 1.6, 95% CI 1.1-2.26). Further research is needed to determine whether educational materials affect early detection and treatment of primary and secondary syphilis and reduce transmission.

BACKGROUND: Screening for syphilis has been performed for decades, but it is unclear if the practice yields many cases at acceptable cost, and if so, at which venues. We attempted a retrospective study to determine the costs, yield, and feasibility of analyzing health department-funded syphilis outreach screening in 5 diverse US sites with significant disease burdens. METHODS: Data (venue, costs, number of tests, reactive tests, new diagnoses) from 2000 to 2007 were collected for screening efforts funded by public health departments from Philadelphia; New York City; Washington, District of Columbia; Maricopa County, Arizona (Phoenix); and the state of Florida. Crude cost per new case was calculated. RESULTS: Screening was conducted in multiple venues including jails, shelters, clubs, bars, and mobile vans. Over the study period, approximately 926,258 tests were performed and 4,671 new syphilis cases were confirmed, of which 225 were primary and secondary, and 688 were early latent or high-titer late latent. Jail intake screening consistently identified the largest numbers of new cases (including 67.6% of early and high-titer late-latent cases) at a cost per case ranging from $144 to $3,454. Data quality from other venues varied greatly between sites and was often poor. CONCLUSIONS: Though the yield of jail intake screening was good, poor data quality, particularly cost data, precluded accurate cost/yield comparisons at other venues. Few cases of infectious syphilis were identified through outreach screening at any venue. Health departments should routinely collect all cost and testing data for screening efforts so that their yield can be evaluated.

BACKGROUND: The Internet has become a common venue for meeting sex partners and planning participation in risky sexual behavior. In this article, we evaluate the first 18 months of the Washington, DC, Department of Health Internet-based Partner Notification (IPN) program for early syphilis infections, using the standard Centers for Disease Control and Prevention (CDC) Disease Investigation Specialist (DIS) disposition codes, as well as Washington, DC, Department of Health's IPN-specific outcomes for pseudonymous partners. METHODS: We analyzed DIS disposition codes and IPN-specific outcomes from all early syphilis investigations initiated January 2007-June 2008. Internet partners were defined as sex partners for whom syphilis exposure notification was initiated by e-mail because no other locating information existed. If the e-mails resulted in additional locating information, we used the standard CDC disposition codes. Alternatively, the following IPN-specific outcomes were used: Informed of Syphilis Exposure, Informed of General STD Exposure, Not Informed or Unable to Confirm Receipt of General STD Exposure. RESULTS: From the 361 early syphilis patients, a total of 888 sex partners were investigated, of which 381 (43%) were via IPN. IPN led to an 8% increase in the overall number of syphilis patients with at least one treated sex partner, 26% more sex partners being medically examined and treated if necessary, and 83% more sex partners notified of their STD exposure. CONCLUSIONS: IPN augmented traditional syphilis case management and aided in the location, notification, testing, and treatment of partners. Conversely, without IPN, these 381 partners would not have been investigated.