bluuebunny/crossref_metadata_2025 huggingface dataset:
PL03.2 Control of Syphilis in the World’s Most Populous Country: Opportunities and Challenges
Authors: Chen X
Published: July 2013

As one of the major sexually transmitted infections (STIs), syphilis has made a strong resurgence in China at a rate faster than any other country since 1980s. Epidemic of the infection has focused on the groups most at risk, such as men who have sex with men (MSM), female sex workers (FSWs), particularly those women working in the service venues or on the streets, and migrants. In recent years, the Chinese government has increased its efforts to respond the epidemic. Specifically, the Ministry of Health’s recently launched 10-year national syphilis control and prevention plan includes the national milestone of achieving an explicit decline in the reported syphilis incidence and the elimination of congenital syphilis by 2020, indicating specific targets for percentages of target populations educated about syphilis, tested and treated for syphilis. Increasing political commitment, innovative screening technologies, and functional health systems have provide opportunities for China to develop the comprehensive intervention package consisting of “One integration of behavioural prevention, Two systems to be strengthened, and Three active screening accesses to high-risk groups to link One standardised treatment at clinic” to highlight the combination of behavioural and biomedical interventions for achieving the goals of the national plan. However, many significant challenges at programing and implementation levels, such as capacity of health system, affordability to STI care, trust between public health providers and clients, access to hidden populations, social stigma, confidentiality, and micro-environment to support delivery of intervention and care, still remain.
PL03.3 Syphilis: From Pathogenesis to Control
Authors: Lukehart S A
Published: July 2013

Syphilis is one of the most fascinating of all infections. Although its origin is still debated, the history of syphilis includes many famous (and infamous) persons, and the disease is featured in art and literature. Syphilis is caused by a corkscrew-shaped bacterium,Treponema pallidum, that was first identified over 100 years ago. It has a miniscule genome, and it lacks many of the common metabolic pathways. It is so fragile that it dies within hours outside of the host, yet it is capable of evading host defences to persist for decades within the host.

Syphilis is known as “the great imitator” because its clinical manifestations, which can range from an ulcer or rash to blindness and insanity, can be mistaken for many other clinical conditions. In contrast, the infection can lie smouldering for many years, without any clinical evidence. After 70 years of use, penicillin continues to be an effective treatment, yet resistance to macrolide antibiotics like azithromycin has erupted inT. pallidumin many regions of the world. Physicians recognise that some persons who are treated for syphilis can be reinfected, sometimes multiple times. At the population level, the incidence of syphilis can wax and wane, often shifting from one population group to another.

How doesT. pallidumcause the many manifestations of syphilis and still evade immune clearance? How does macrolide resistance develop and spread? Is there a biological basis for determining which patients can be reinfected or when the incidence of syphilis will decline in a given population? Molecular studies involving the laboratory and the clinic have shed insights into pathogenic mechanisms involved in invasion and dissemination, induction of host responses, and immune evasion byT. pallidum. Molecular epidemiology studies have begun to unravel the movement ofT. pallidumstrains throughout communities, and to shed light on the appearance of macrolide resistance. Our evolving knowledge about these issues will be discussed in the context of the natural history of syphilis.
PL04.1 Sexual Behaviour and STIs in Men Who Have Sex with Men: A Global Perspective
Authors: Mayer K H
Published: July 2013

Sexual and gender minorities have been present throughout human history, but recently there has been increased public awareness of their prevalence, because of human rights activism and the recognition of the increased STI and HIV burden among some subpopulations, particularly men who have sex with men (MSM) and transgender women. Behavioral and biological factors explain some of the disparities noted in their higher rates of STI and HIV. The colorectal mucosa has the greatest concentration of cells that can bind HIV in the body, and single layer columnar epithelial cells may be readily traumatised and inflamed during anal intercourse. MSM who are versatile in their sex roles may efficiently acquire HIV/STI by being the receptive partner, and then can readily transmit infections to new partners if they are insertive. STI and HIV potentiate the transmission of each other, and certain venues that enable MSM to meet partners readily, such as saunas and specific internet sites, have been associated with rapid expansion of micro-epidemics. MSM in many parts of the world have been found to have higher rates of many bacterial and viral STIs than demographically matched peers, and may have unique STIs based on specific behaviours (e.g. association of faecal contact and enteric pathogens) and the concentration of new infections within subpopulations (e.g. recent outbreaks of MRSA and LGV). The stigmatisation of homosexuality and gender nonconformity create barriers to effective STI and HIV control, since many MSM may defer seeking health care because of the expectation of receiving insensitive care, and concerns about confidentiality, as well as liability, in many jurisdictions. In order to mitigate the disproportionate rates of STI and HIV among MSM, public health officials and clinicians need to become culturally competent, to develop services that conduct appropriate screening (e.g. rectal NAAT) in a sensitive manner.
PL04.2 Sex Hormones, HIV Infection and Unintended Pregnancy: Ever Since Adam and Eve
Authors: Cates W
Published: July 2013

Regardless of the Genesis interpretation, human sexual behaviour is necessary for species survival. Biologically, steroidal sex hormones affect sexual function, reproductive capacity, and possibly infection risk. Women have 2 main sex hormones - oestrogen and progestin. These hormones function in two ways - endogenously to regulate the reproductive cycle and exogenously to control fertility.

In the highest HIV prevalence regions, women wishing not to conceive have limited contraceptive choices - typically injectable progestins, oral oestrogen/progestin combinations or male condoms. None of these are in the top tier of contraceptive effectiveness.

For nearly a quarter century, the hypothesis that women using hormonal contraceptives may be at increased risk of HIV acquisition has persevered. However, the results across multiple human studies have been mixed - some demonstrate increased HIV risk, but others do not. The strongest evidence that use of hormonal contraception may increase HIV susceptibility is for injectable progestin-only contraceptives. Observational studies have estimated that this method may increase HIV acquisition risk 1.4–2-fold. Their limitations include few endpoints, measurement error in contraceptive use, and likely confounding by behavioural factors. Evidence on HIV acquisition risk is weaker for oral contraceptives, and few data are available for other hormonal formulations including progestin implants or IUDs.

In addition, trade offs between the alleged risks of hormonal contraception and those of an unintended pregnancy must be considered. Four mathematical models have addressed this question. Using different assumptions, analytic algorithms and levels of rigour, they all reached similar conclusions. Withdrawal of injectable progestins has adverse pregnancy consequences, switching to implants/IUDs has better outcomes than injectables, while switching to orals/condoms was worse. While the current situation creates a public health conundrum, it also presents an opportunity to expand contraceptive choice, and concomitant reproductive rights, for women exposed to HIV.
PL04.3 Protective and Non-Protective Immunity in STIs
Authors: Stingl G
Published: July 2013

Protective and non-protective immunity in STIs.

It is certainly remarkable that the causative agents of sexually transmitted infections (STIs) induce long-lasting protective immune responses only occasionally and insufficiently (T. pallidum, human papilloma viruses, herpes simplex virus, S. scabie) or not at all (C. trachomatis, N. gonorrhoeae”, C. albicans, human immunodeficiency virus, T. vaginalis).

The reasons for this phenomenon are often microbe-related, but may also be due to peculiarities of the mucosal immune system. Evidence exists, for instance, that density and function of epithelial dendritic cells in the mucosa are different from those in the epidermis and, perhaps as a consequence of this, mucosal sensitization more often results in T cell non-responsiveness or anergy than epicutaneous sensitization.

The relatively poor functionality of the adaptive immune response in the defence against the various STI-causing microorganisms can sometimes by compensated by cells and molecules of the innate immune system. Good examples of this are the overexpression of certain anti-microbial peptides in the vaginal epithelium and the imiquimod-induced cytotoxic response of plasmacytoid dendritic cells against HPV-infected targets.

At a time where we are challenged with increased anti-microbial resistance to anti-microbial chemotherapy, research efforts are needed to better understand the mechanisms of microbe - host cell interactions and to use this knowledge for the development of better therapeutic strategies.
PL05.1 PrEP & Treatment as Prevention For HIV: Finding the Balance
Authors: Baeten J
Published: July 2013

Antiretroviral-based HIV-1 prevention strategies - including antiretroviral treatment (ART) to reduce the infectiousness of HIV-1 infected persons and antiretroviral pre-exposure prophylaxis (PrEP) for uninfected persons to prevent HIV-1 acquisition - are promising new approaches for decreasing HIV-1 spread. The past two years have seen significant new advances in knowledge regarding ART and PrEP for HIV-1 prevention, including definitive demonstration in randomised trials that both ART and PrEP reduce HIV-1 risk and the development of normative guidance for prescribing these HIV-1 prevention strategies. Adherence is key to efficacy of antiretrovirals for HIV-1 prevention, both as ART and PrEP. There are numerous parallels in the challenges and opportunities ahead for ART and PrEP, including how to target to realise maximum population benefits, whether HIV-1 infected persons at earlier stages of infection would accept ART to reduce their risk for transmitting HIV-1 and highest-risk HIV-1 negative persons would use PrEP, whether high adherence could be sustained to achieve high effectiveness, and how to integrate these strategies into HIV-1 prevention programmes. Delivering these strategies in order to achieve population-level benefits is the next step, balancing costs, optimism, and realistic appreciation of the challenges ahead.
PL05.2 New Technologies in STI Diagnosis and Control: Promising Future
Authors: Gaydos C A
Published: July 2013

Background

Over 350 million (M) prevalent cases of curable STIs are estimated worldwide: 100 M chlamydia (CT), 36M gonorrhoea (NG), 187 M trichomonas, and 36 M cases of syphilis. 34 M HIV infections are estimated worldwide. Human papillomavirus infections (HPV) and herpes viruses (HSV) are highly prevalent, yet are not often diagnosed. Technology has led to sensitive nucleic acid amplification tests (NAATs), allowing use of non-invasive specimens, like vaginal swabs and urine. NAATs are widely available, and novel approaches include point-of-care (POC) tests, internet availability, and self-testing. New serological tests have advanced diagnoses of HIV, HPV, and HSV. Yet, challenges to diagnosing STIs continue.

Methods

To discern where we are heading in the field of HIV/STI diagnostics research, new assays and new approaches to enhance care were reviewed.

Results

There are commercial NAATs for CT/NG by 4–5 companies. Some are available on expensive robotic platforms, limiting their use in resource-constrained settings. Additionally, a new CT/NG NAAT that can return results in 90 minutes is available. Other rapid NAAT and hybridization POC assays are in the pipeline.

There are two NAATs and a POC test for trichomonas. POC syphilis serology tests have proliferated, which is important to syphilis elimination. Several platforms offer NAAT tests for HPV and there is a NAAT for HSV ulcers. Rapid HIV POC and 4thgeneration tests have advanced earlier detection of HIV. A home oral-fluid HIV test can be purchased in the US. Patients perform their own HIV tests in Emergency Departments with excellent accuracy. Internet availability of select STI tests for home collection/outreach programmes offer novel approaches to increasing options offered to individuals at risk.

Conclusions

Learning how to wisely and effectively use these tools can improve the detection of STIs and provide cost-effective ways to increase the number of patients being treated.
S01.3 Making Anal Sex Safe: Current Status of Products For Rectal Use
Authors: Cranston R
Published: July 2013

There are no products available that make anal sex completely safe from the point of view of HIV acquisition, and the likelihood of this happening in the future is slim. However, in terms of risk reduction, there are practical interventions to implement, the possibility of new concepts to explore, and the promise in the future of an effective rectal microbicide.

The individual risks of anal intercourse (apart from those posed by the insertive partner) are multifactorial and may be broadly broken down to three main areas: trauma, co-infection, and products that may all facilitate inflammation and so increase HIV acquisition risk.

Trauma: The anal canal is a high pressure environment due to the combined effects of both internal and external anal sphincters and requires preparation prior to anal intercourse that may be usefully discussed in directed sex education to reduce traumatic injury.

Co-infection: Human papillomavirus is an almost ubiquitous infection in sexually active adults and is an independent risk factor for HIV acquisition by both vaginal and anal intercourse. The vaccination of both boys and girls prior to sexual debut may have the potential to reduce HIV acquisition risk.

Products: These may potentially harm and also protect. Many unregulated off the shelf sexual lubricant products have high osmolality and may contain Nononxynol 9 that can both injure and induce inflammation in rectal epithelium and so provide an environment conducive to HIV infection. However, the gel formulation of tenofovir has shown efficacy in reducing both HIV and herpes simplex virus acquisition (a cofactor for HIV infection) following vaginal application. The reduced glycerin rectal formulation of this product has been shown to be safe in a short Phase 1 study and is currently entering an extended safety Phase 2 study.

These elements will be explored during this presentation.
S02.1 The Public Health Need For Diagnostics and the Differing Pathways to Approval and Use Around the World
Authors: Deal C
Published: July 2013

The global impact of STIs is difficult to understand due to the lack of systematic, coordinated, and standardised surveillance of disease prevalence and incidence. A barrier to these efforts is the lack of easy to use, rapid, diagnostic tests in all regions of the world. Regulatory evaluation and approval of diagnostics varies by country. Common to most approval processes is the need for the diagnostic test to be evaluated for the performance characteristics in an appropriate clinical setting. Parameters that need to be understood are the sensitivity and specificity of the test, as well as practical considerations such as stability and ease of use. The degree of clinical validation and the various ways to design the studies are some of the areas that are approached differently by the various regulatory authorities. Understanding of the various regulatory pathways is important to understanding the scientific considerations necessary to map out a product development plan as diagnostic developers embark on product development in this arena.
S02.2 Overview of Rapid/Point of Care Diagnostic Tests For HIV and Current Challenges Associated with HIV Testing
Authors: Singh A E
Published: July 2013

Advances in rapid/point of care testing (RPOCT) for HIV have transformed global capacity to reach individuals who might not otherwise have been tested for HIV, particularly in non-traditional health care settings. In addition to reducing patient anxiety associated with awaiting the results of standard laboratory tests, a positive HIV RPOCT may allow for urgent medical interventions which could in turn reduce the risk of transmission of HIV, e.g. in the mother to child setting and in blood and body fluid exposures. The availability of a rapid test result also has the potential to allow immediate linkage to care and to modify behaviour which might result in reduced transmission of infection.

Despite these benefits, RPOCT has also resulted in new challenges to health systems. For example, false positive results create unnecessary anxiety and occasionally, unnecessary medical interventions.

The majority of currently available HIV RPOCT detect HIV-1 and sometimes HIV-2 antibody. Some newer test kits include the detection of p24 antigen with the potential to enhance diagnostic sensitivity in early infections. Future research should focus on better combination antigen/antibody rapid assays or rapid tests to detect nucleic acid to improve the diagnosis of early HIV seroconversion and for early infant diagnosis. Another area of unmet need is the accurate detection of infection in individuals who have received HIV vaccine who may screen positive on rapid tests making distinguishing vaccination and disease difficult. Finally, future directions should combine testing for multiple infections (e.g. HIV, HBV, HCV and syphilis) in a single test kit.
S02.3 Extra-Genital CT/GC Testing by NAATS: Use in Screening and Prevalence of Infection in MSM, Issues in Validation
Authors: Schachter J
Published: July 2013

MostChlamydia trachomatis(CT) andNeisseria gonorrhoeae(GC) infections in men who have sex with men (MSM) are not in the urethra. This has been confirmed often since it was shown by Kent and colleagues, in 2 clinics in San Francisco, (J. Infect. Dis.2003). All of these studies have been made possible by the use of highly sensitive and specific nucleic acid amplification tests (NAATs) that are currently recommended for routine diagnosis of CT/GC infections. The increment in sensitivity for NAATs compared to culture is greater with pharyngeal and rectal specimens than with cervical and urethral specimens; doubling the number of rectal or pharyngeal infections detected.

In MSM attending STD clinics the prevalence of rectal or urethral CT and GC is often in the 7–10% range. GC is found in the oropharynx at about the same level, but CT is less common there, typically 1–2%. Most STD clinics’ routine has been to test urethral specimens when evaluating males, with rectal or oropharyngeal specimens tested in symptomatic MSM. We need a paradigm shift: in MSM routine testing of oropharyngeal and rectal sites, as well as urethra, must become the norm. Whether testing should be based on a history of sex practises needs more research.

Unfortunately, no NAATs have received FDA clearance for pharyngeal or rectal specimens. But CDC, recognising the superior performance of NAATs with these specimens, took an unusual step recommending NAATs for diagnosing CT/GC in oropharynx and rectum, despite absence of FDA clearance.

It is possible to use tests that have not received FDA clearance for patient management. Large laboratories can verify use of NAATs for rectal and pharyngeal specimens by following Clinical Laboratory Improvement Act (CLIA) guidelines. We need NAATs with FDA clearance for use on oropharyngeal and rectal specimens to further expand clinical access to these tests.
S02.4 What Are the Most Efficient Ways to Communicate Research Derived Information to Clinical Practise: The Role of Diagnostic and Treatment Guidelines, Packet Inserts, Clinicians’ Perspective
Authors: White J
Published: July 2013

When implementing innovative diagnostics or novel therapeutics in medicine, the modern process of knowledge transfer can be described in a stepwise progression from (1) knowledge creation, to (2) diffusion and dissemination, and finally (3) organisational adoption and implementation. We can observe how such processes have contributed to the STI testing and treatment guidelines that we use currently.

As clinicians we strive to keep abreast of developments in our field that enable us to deliver the best quality management to our patients. The experience and intuition of an individual clinician is valuable, but all our practises should be subject to rigorous evaluation to ensure they are safe and effective. Without such processes, different and conflicting practises can persist, examples of which will be discussed. The need to implement evidence-based best practise has become widely accepted; however, this can still be hampered by financial constraints as well as the unavailability of specific resources locally. In addition, there is often a lag time in our ability to adopt new tests or treatments due to the need to adhere to local or national guidelines or a lack of evidence such as randomised controlled trials that drive changes in practise.

This symposium allows us to examine the most effective ways of getting research into practise and this session will focus on the clinician’s viewpoint. Many knowledge gaps remain where further work is needed to better guide STI testing and treatment. More consideration is needed as to how new information is best disseminated to enable our patients to benefit most promptly from implementation of new information.
S03.1 Sexual Health: Conceptual Framework and Recommendations For Indicators
Authors: Toskin I A , Hawkes S , Moreno C Garcia , Caceres C F , Zohrabyan L
Published: July 2013

Background

In 2010 WHO convened an expert consultation to formulate recommendations and strategic directions for sexual health. Two specific recommendations, derived from the consultation were: (a) to develop a conceptual framework on sexual health that clearly outlines the elements of sexual health and how it overlaps and differs from reproductive health and the role of sexuality; (b) to develop, operationalize and promote sexual health indicators.

Method

The WHO Department of Reproductive Health and Research established consultative processes, including a review of the existing evidence, conducted interviews with key informants and held expert consultations to address the aforementioned recommendations.

Results

Two documents;Towards a conceptual framework for sexual health: understanding and improving sexual health for allandCore Set of Sexual HealthIndicatorswere developed during 2011–2013.

The conceptual framework outlines the central role that key sexual health concepts of autonomy, individual choice and protection of human rights play in achieving health and development outcomes. The document proposes new ways of ‘framing’ sexual health in order to reach the widest audience, which in turn can influence and deliver positive approaches for ensuring sexual health for all.

The proposed indicators cover the following areas of sexual health: adolescent sexual health, family planning, harmful practises, healthy sexuality, sexual dysfunctions and concerns, STI/HIV, and sexual violence. Indicators range from policy, to services (access) to outcome/impact. Most of the proposed indicators have previously been validated, however some new population-based survey indicators have been submitted for validation through special surveys among men who have sex with men and people who inject drugs, to be conducted throughout 2012/2013 in the WHO European region. Preliminary validation results are available.

Conclusion

Both documents are concrete steps towards promoting sexual health as a public health concept at international and national levels.
S03.2 Sexual Health Promotion Interventions: Results of a Systematic Review
Authors: Hogben M S , Ford J V , Becasen J
Published: July 2013

Background

Population-level rates of sexual health indicators such as STI rates have stimulated interest in a public health approach to improving sexual health in the United States. We used several existing definitions (World Health Organization, U.S Surgeon-General’s office, CDC/HRSA Advisory Committee) to derive sexual health principles: recognition of sexuality as intrinsic to individual healthandrelationships should have positive outcomes for all partners involved.

Methods

Studies for a systematic review of intervention literature were drawn from Medline and PsycInfo databases (English language, adult populations, published between 1996–2011, country with developed public health infrastructure). They addressed outcomes in one or more domains: knowledge, attitudes, communication, healthcare use, sexual behaviours or adverse events. Data were summarised in a narrative review organised by population (adults, parents, sexual minorities, vulnerable populations) across domains. Selected data from knowledge, attitudes and behaviours were summarised in meta-analyses.

Results

From 9064 studies, 58 were retained in the narrative review. Studies employed qualitative, experimental, pre-post and matched comparison group designs; the number of studies published was correlated with publication year (r = 0.77, p < 0.001). Interventions were predominantly individual and small-group in-person designs that addressed sexual behaviours (42 studies, 72%) and attitudes/norms (32, 55%). Studies with parents covered communication. All but one study reported at least one positive finding, but many (29 studies, 50%) also reported null findings. The most consistent positive effects on behaviours and adverse events were found for sexual minorities and vulnerable populations; interventions with parents uniformly increased attitudes and communication skills.

Conclusions

Sexual health-framed interventions generate positive effects across adult populations, as well as mental and behavioural domains and adverse outcomes. Interventions may be especially effective among vulnerable populations and in improving parent communication. Where scalable, incorporating aspects of existing sexual health definitions into public health may contribute to improving sexual health.
S03.4 Sexual Health in the European Union: An Inventory of Data, Programmes, Initiatives, and Policies
Authors: Laar M Van de
Published: July 2013

Background

Sexually transmitted infections and HIV represent a major public health challenge in European Union/European Economic Area. In 2011, 346911 chlamydia, 39179 gonorrhoea, 28038 HIV and 19798 syphilis cases were reported to the European Centre for Disease Prevention and Control (ECDC). Improving prevention efforts is therefore a priority, especially among populations groups that are most vulnerable to infection, including young people, MSM, migrants and people living with HIV/AIDS.

Methods

A mapping exercise of European sexual health data, programmes, initiatives and policies was conducted aiming to increase the understanding of how HIV/STI can be prevented in the general population and among vulnerable population groups.

Results

Synergies and gaps in the availability of data and in policies and programming were identified across EU/EEA. Eleven countries ever adopted a national sexual health strategy and 24 implemented a national HIV/STI prevention strategy. Specific HIV/STI prevention strategies targeting vulnerable groups were identified for: young people (24 countries), MSM (22 countries), sex workers (19 countries), migrants (20 countries) and injecting drug users (24 countries). National surveys on sexual knowledge, attitude and practise were conducted in general population by 19 countries. Eighteen countries collect data on sexual health in MSM, 9 in PLHIV and 6 in migrants. Sexuality education is mandatory in 20 countries. In the last 5 years, 24 Member States conducted HIV/AIDS awareness campaigns.

Conclusions

The following mechanisms are considered to support Member States and to promote a comprehensive approach for HIV/STI prevention in the context of sexual health: endorse synergy between European bodies and NGOs in regards to data collection, reporting and publication; development of a standardised set of indicators for collecting comparable data; development of an evidence-based framework to allow countries to evaluate their sexual health interventions; facilitate communication among (inter)national experts through a dedicated sexual health platform.
S03.5 Advancing Sexual Health in the US: from Theory to Action
Authors: Douglas J M
Published: July 2013

Background

The United States faces a variety of public health issues related to sexual behaviour including HIV, STD, unintended pregnancy, and sexual violence. A 2010 CDC consultation onA Public Health Approach for Advancing Sexual Health in the United States(http://www.cdc.gov/sexualhealth/docs/SexualHealthReport-2011–508.pdf) provided recommendations on how CDC could enhance prevention programme impact by comprehensively addressing sexual health.

Methods

Since the consultation, CDC has worked across its divisions and with external partners to translate the theoretical concept of sexual health into public health action through national leadership, partnership development, and scientific and programme efforts.

Results

Initially, we developed a sexual health framework emphasising the importance of using sexual health promotion to complement and enhance core disease control and prevention activities based on five key principles: acknowledgment of the impact of sexual health on overall health, consideration of underlying social issues, an emphasis on wellness, a focus on relationships, and integrated prevention approaches. Subsequently, we reviewed U.S. national data systems to identify existing measures of key domains of sexual health and conducted health communications research assessing optimal frameworks and messages for communicating with audiences with varied perspectives. Partnership development was accelerated by forming a National Sexual Health Coalition, with a spectrum of non-governmental partners addressing sexual health among the general population, adolescents, and MSM. Public health implementation of sexual health promotion has focused on supporting development of sexual health plans by U.S. states and sexual health training for providers in public health and primary care settings.

Conclusions

Implementing actions to address sexual health in a society with diverse values is a challenging and evolving process, but has great potential to improve prevention efforts by engaging a spectrum of partners, facilitating societal dialogue around sexuality and sexual behaviour, reducing stigma and fear, and enhancing efficiency and effectiveness of prevention messages and services.
S04.1 Scaling Up of HIV Treatment Programmes Among the Most At-Risk Populations in Low- and Middle-Income Countries - Introduction
Authors: Alary M
Published: July 2013

Although access to antiretroviral therapy (ART) for HIV infection in low- and middle-income countries has tremendously improved over the last decade, it remains far from optimal in most settings when it comes to the treatment of marginalised populations, such as sex workers, injection drug users and men who have sex with men. Small-scale demonstration projects indicate that ART can be successfully implemented among sex workers, with satisfactory immunological and virological responses, good treatment compliance levels, and maintenance or even improvement of safe sex behaviour. Some of the studies carried out so far underline the importance of strongly linking prevention with care through the integration of HIV/STI care services and community-based prevention packages. Scaling-up treatment programmes for marginalised, hard-to-reach populations, will undoubtedly be challenging. Nevertheless, in addition to the health equity issues related to access to ART for such populations, the application of targeted “test and treat” strategies could substantially impact HIV prevention at the general population level, given recent trial data showing that the implementation of this strategy among sero-discordant couples led to a 96% reduction in HIV transmission. Such a strategy should however be carefully evaluated in the target population before implementation and scale-up, and would require specific adherence support and community involvement.

It is in this context that this symposium will present practical experiences in implementing ART programmes among female sex workers in the context of generalised, concentrated and mixed epidemics. Modelling studies of the preventive impact of such programmes across different epidemic contexts, and with different criteria for ART initiation (including “test and treat”), will also be presented. A similar study about injection drug users in the context of a concentrated epidemic will complete the presentations in this symposium that should stimulate a fruitful discussion period between the participants and the speakers.
S04.2 Modelling the Impact of Early Anti-Retroviral Treatment Amongst People Who Inject Drugs in a High Prevalence Setting
Authors: Vickerman P
Published: July 2013

Background

HIV transmission in many settings is concentrated amongst people who inject drugs (PWID), and can reach high HIV prevalence. Early anti-retroviral treatment (ART) for PWID could be important for reducing HIV transmission in these settings. This modelling analysis projects the impact of such a strategy in a high HIV prevalence (30%) setting, and explores how behavioural and epidemiological factors affect the projections.

Methods

A deterministic,model of HIV transmission amongst PWID is calibrated to HIV prevalence data from Manipur, India. The model is used to assess the 20 year impact (on HIV incidence/prevalence) of scaling up early ART to PWID, compared to a baseline of current ART access (20% of HIV+ individuals with CD4 < 350 cells/µL are recruited onto ART annually). An uncertainty analysis was undertaken using posterior model fits to consider which PWID behavioural/epidemiological factors affect impact.

Results

Only small reductions in PWID HIV incidence/prevalence (< 10% over 20 years) will occur with current ART provision in Manipur. If current ART recruitment rates are maintained, but all HIV+ PWID become eligible for ART, then a median 12%/11% relative decrease in HIV incidence/prevalence occurs over 20 years compared to baseline. This increases to 22%/20% or 33%/28% if 40% or 80% of HIV+ PWID are recruited per year, respectively. If the ART LTFU amongst PWID is halved to 7.5% per year then impact increases by half. Uncertainty analyses suggest the impact achieved through scaling-up ART is highly dependent on baseline HIV prevalence and the cofactor increase in HIV infectivity during early infection, with less impact occurring for higher HIV prevalences and cofactors. The injecting cessation rate and level of mixing between risk groups are also important.

Discussion

HIV treatment could result in large reductions in PWID HIV incidence, but is unlikely to result in local elimination except in low HIV prevalence settings.
S04.3 Antiretroviral Therapy Among Female Sex Workers in Burkina Faso: Current Situation
Authors: Konate I , Ouédraogo A , Bazié W W , Traoré I T , Sanon A , Huet C , Méda N , Mayaud P , Perre P Van De , Nagot N
Published: July 2013

Background

In Burkina Faso, female sex workers (FSW) are a core group in HIV transmission with 16.5% cases of HIV-infection, vs. 1.0% in the general population. Provision of ART to this core group may be key to controlling the HIV epidemic. We aimed at documenting the current situation regarding ART provision to FSW in Burkina Faso.

Methods

We reviewed the interventions of the national HIV/AIDS control programme (NACP) regarding ART provision to FSW, using grey literature and interviews of stakeholders. In addition, we reviewed the findings of the local research on this topic.

Results

Before 2010, programmes targeting FSW in Burkina Faso focused only on prevention, mainly through local NGOs. From 2010, in each of the 13 regions, the NACP designated one primary health centre to care for FSW. No statistics are available yet from these centres, but NACP/MOH stakeholders admitted that few FSW adhere to it, mainly because of a lack of strategy to reach and retain FSW, and lack of health care workers training. The ANRS 1222 “Yerelon” research programme tested a FSW peer-led intervention integrating prevention and care activities within one dedicated centre in Bobo-Dioulasso. Beside care providers, peers and a psychologist much contributed to support ART adherence before and after initiation. Preliminary data among the 47 FSW treated with ART showed high adherence to ART (> 95%) at 12 months (92%) and 36 months (100%). At 36 months, plasma viral load was undetectable in 82% of FSW, with a mean CD4 increase of 230 cells/µL (IQR: 90–400).

Conclusion

Despite a specific programme, ART provision to FSW remains limited in Burkina Faso. The ‘Yerelon’ model of prevention and care intervention can serve as a strategy for the NACP FSW programme, and the research sites be used as training centres to improve ART provision coverage and efficiency.
S04.4 ART Among FSW in South Africa
Authors: Venter F
Published: July 2013

Until recently South Africa has targeted its HIV interventions towards the general population, but the National Strategic Plan of 2012–2106 has expanded this focus to include key populations with high HIV prevalence and incidence. Foremost in this group are sex workers who are identified in the 2011 South African Know Your Epidemic (KYE) as contributing as much as 20% of the HIV transmission burden in the country. A model of health care delivery through an inner city sex worker programme has steadily expanded over a decade from special services delivered in a clinic, to clinical outreach services delivered within brothels and a mobile clinic, that now includes ART. The intervention includes behaviour change communication delivered through peer educators and outreach staff, programme-supported free clinical services to detect and treat STIs, HIV counselling and testing (HCT), TB detection, contraceptive provision, male and female condom provision. Referral linkages to relevant state services including HIV and TB treatment services and reproductive health services are in place with outreach workers tracing defaulting patients. We will discuss the outcomes of community based ART for sex workers, the challenges of provision, and present outcomes including virological suppression and loss to follow up data.
S04.5 ART Among FSW in India
Authors: Mishra S , Boily M
Published: July 2013

In India, the provision of antiretroviral treatment (ART) began in 2004. Around the same time, a large-scale, condom-based HIV prevention programme targeted to FSWs was implemented in several districts. In this talk, we present findings from a comprehensive review of available data exploring trends in the ART “care-cascade” among FSWs in India, with a focus on routine HIV testing, linkage to pre-ART care, ART uptake, and retention on ART. We then examine the association between local condom-based targeted HIV prevention programmes and HIV testing among FSWs, and identify key data gaps in the “care cascade” among FSWs. We conclude by exploring the interaction between turn-over in sex work and ART eligibility among FSWs, and discuss the potential implications for local ART programmes.
S04.6 Examining the Population-Level Impact of Scaling-Up ART For FSWs Across Epidemic Context
Authors: Boily M , Mishra S
Published: July 2013

In this presentation, we will summarise the results of a recent systematic review of the published literature on the key parameters of the treatment cascade among female sex workers. Using different examples from transmission dynamics modelling studies of HIV transmission and ART use, we will discuss the potential impact of scaling-up ART for FSWs in contrasting epidemiological settings. We will present results of the impact of ART programmes in settings with different HIV prevalence levels in the general population (very low, low/medium, high) and different history of condom use interventions and level of ART scale-up already achieved. For example, we will compare the impact of different ART scale-up scenarios and eligibility criteria in districts of India (low prevalence settings) where there has been and there has not been a large-scale condom use intervention implemented in recent years. Other settings with higher HIV prevalence such as Benin, Burkina Faso, Columbia or Kisumu will be considered. We will also contrast the impact of ART programme targeted to FSW on HIV transmission in the general population and assess the influence of key parameters of the treatment cascade on the impact of ART among FSWs.
S05.1 Antimicrobial Resistance in N. Gonorrhoeae: Update of the Situation
Authors: Wi T C
Published: July 2013

Background

The rapidly changing antimicrobial susceptibility ofN. gonorrhoeaesince the introduction of antibiotics has created challenges in gonorrhoea control. Antimicrobial resistance has regularly appeared and expanded with every release of new classes of antibiotics for gonorrhoea.

Methods

The Gonococcal Antimicrobial Surveillance Programme (GASP) has been documenting the emergence and spread of antimicrobial resistance in gonorrhoea since 1992 and has informed treatment guidelines.

Results

Sixty two countries participated in GASP in varying degrees including the extend of specific antimicrobials tested for resistance in 2010. There are high rates of resistance inN. gonorrhoeaeto penicillin and quinolones. There are 36 countries reporting increasing minimum inhibitory concentration (MIC) to Cefixime (≥ 0.25 μg/mL) or Ceftriaxone (≥ 0.125 μg/mL). Treatment failures to Ceftriaxone were reported in Japan, Austria, Australia, Canada, France, Norway, Slovenia, Sweden, UK and South Africa. Majority of reports is from developed countries. This is only the tip of the global health burden as surveillance data from resource-constrained settings are scarce.

Spectinomycin and azithromycin resistance are monitored in limited countries. Brunei, China, Mongolia and Russia reported decreased susceptibility to spectinomycin. Resistance to azithromycin has been identified in some European countries, US and Chile. Azithromycin resistance remains well below the 5% threshold in most countries.

Conclusions

Treatment options for gonorrhoeae is dwindling. In the short term, options for treatment will include increasing dosage, using intramuscular or intravenous route and multiple doses of Ceftriaxone; use of alternative medication (e.g. gentamycin), and combination therapies. In the long term there is a need to develop newer classes of antibiotic. There is a need to ensure rational drug use and strengthen antimicrobial resistance monitoring in gonorrhoea including detection and management of treatment failure.
S05.4 Integrating Antimicrobial Susceptibility Monitoring inNeisseria Gonorrhoeaeto Broader AMR Agenda
Authors: Ghidinelli M , Ramon-Pardo P , Dillon J A , Galarza P
Published: July 2013

Background

Based upon the strategies of the WHO “Global action plan to control the spread and impact of antimicrobial resistance inNeisseria gonorrhoeae”,a plan was developed and implemented to align GASP related activities within the broader agenda of the Antimicrobial Resistance Latin-America Network. Spite of the achievements of GASP in the last decades, there was a need to increase the number of countries and institutions collaborating inN. gonorrhoeaesusceptibility surveillance. In order to achieve this, a comprehensive plan to strengthen the capacity of the Latin-America National Reference Laboratories (NRL) to conduct AMR surveillance in a systematic and regular manner to ensure the early detection of resistantN. gonorroheaewas implemented.

Methods

After a number of communications and training activities with the NRL,N. gonorrhoeaesusceptibility 2010 data were collected through a questionnaire sent to the National Reference Laboratories in Latin America. Data included country, number of isolated tested, and percentage of resistance to cefixime, ceftriaxone, ciprofloxacin, spectinomycin, penicillin, and tetracycline.

Results

From 21 Latin American countries integrating the network, 8 (38%) provide data. None of them detected decreased susceptibility to ceftriaxone; resistance to ciproloxacine ranked from 0% to 83%; penicillin from 6 to 78%; no resistance to spectinomycin; resistance to tetracyline from 27 to 83%.

Conclusions

The NRL demonstrated certain capacity and commitment to collect, analyse, and report data on N. gonorrhoeae susceptibility, however, this should be strengthned and expanded to more countries in the Region.

Broad differences among countries were observed, specially on the susceptibility to ciprofloxacine and penicillin.

Some challenges were identified, such the lack of a system for referral of specimens at national and regional level.

This effort should be continued, emphasising the importance of periodicity on data collection, analysis and dissemination.
S06.1 Treating Contacts to Gonorrhoea and Chlamydia Without a Clinic Visit; The Efficacy and Effectiveness of Different Models
Authors: Schillinger J A
Published: July 2013

The sex partners of persons with Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) infection must be treated to prevent repeat infection of the index patient and to interrupt forward transmission of disease. Asking patients to refer sex partner(s) for evaluation and treatment (‘patient referral’) is an inadequate strategy, as many sex partners will not seek care, and the large burden of CT and GC infections makes it impractical and cost prohibitive to rely upon health care providers or public health field investigators to assure partner treatment. Although no single sex partner treatment approach will be a panacea, innovative strategies are clearly needed.

This session will focus on strategies that do not require sex partners to attend a clinic to obtain treatment for CT or GC. The presenter will describe two models: (1) Expedited Partner Therapy (EPT), used in many parts of the US, includes patient delivered partner therapy, wherein a patient is asked to deliver medication or a prescription to their sex partner; (2) Accelerated Partner Therapy (APT), studied in the UK, uses clinician-staffed hotlines or pharmacists to assess the health status of sex partners before arranging for treatment. APT is being evaluated in a community-based randomised controlled trial, and efficacy data are not yet available, however, EPT has been shown to reduce risk for repeat GC infection by 68% and repeat CT by 20%. In practise, uptake and effectiveness of EPT has been limited by a variety of implementation challenges. The session will describe and - where possible - quantify obstacles to EPT, including: legal issues (perceived and real), lack of provider and pharmacist knowledge, patient preference and acceptability (for example, as few as 50% of eligible patients accept EPT for CT), medication costs, use of prescriptions rather than dispensing medication, and the emergence of cephalosporin resistance among GC.