Sex, drugs and superbugs: The rise of drug resistant STIs

Antimicrobial resistance (AMR) presents a swiftly advancing challenge to a wide range of healthcare and health promotion practices. While rising rates of AMR share some dimensions across contexts, the specificities of field, practice, place and population shape – and at times hinder attempts to stem – the rising tide of this health threat. Sexually transmitted infections (STIs) are one area of healthcare where the threat of AMR has traditionally been met with lethargy. In this paper, we draw on a range of stakeholder perspectives across practice, innovation and regulatory systems in Australia, the US and the UK to understand and examine the evolving nexus of STIs and AMR, including the roles of cultural reception, professional practice and political traction. We argue for a critical sociology of the nexus of sexual health and evolving resistance, which will be instructive for comprehending inaction and informing future developments. We also note that part of this critical sociology must involve challenging stigma concerning sexual practices and people/groups, and recognising the role of communities in driving positive change

Modelling coseismic displacements during the 1997 Umbria-Marche earthquake (central Italy)

We propose a dislocation model for the two normal faulting earthquakes that struck the central Apennines (Umbria-Marche, Italy) on 1997 September 26 at 00:33 (Mw 5.7) and 09:40 GMT (Mw 6.0). We fit coseismic horizontal and vertical displacements resulting from GPS measurements at several monuments of the IGMI (Istituto Geografico Militare Italiano) by means of a dislocation model in an elastic, homogeneous, isotropic half-space. Our best-fitting model consists of two normal faults whose mechanisms and seismic moments have been taken from CMT solutions; it is consistent with other seismological and geophysical observations. The first fault, which is 6 km long and 7 km wide, ruptured during the 00:33 event with a unilateral rupture towards the SE and an average slip of 27 cm. The second fault is 12 km long and 10 km wide, and ruptured during the 09:40 event with a nearly unilateral rupture towards the NW. Slip distribution on this second fault is non-uniform and is concentrated in its SE portion (maximum slip is 65 cm), where rupture initiated. The 00:33 fault is deeper than the 09:40 one: the top of the first rupture is deeper than 1.7 km; the top of the second is 0.6 km deep. In order to interpret the observed epicentral subsidence we have also considered the contributions of two further moderate-magnitude earthquakes that occurred on 1997 October 3 (Mw 5.2) and 6 (Mw 5.4), immediately before the GPS survey, and were located very close to the 09:40 event of September 26. We compare the pattern of vertical displacements resulting from our forward modelling of GPS data with that derived from SAR interferograms: the fit to SAR data is very good, confirming the reliability of the proposed dislocation model

Loss to follow up of pregnant women with HIV and infant HIV outcomes in the prevention of maternal to child transmission of HIV programme in two high-burden provinces in Papua New Guinea: a retrospective clinical audit

Introduction Despite early adoption of the WHO guidelines to deliver lifelong antiretroviral (ARV) regimen to pregnant women on HIV diagnosis, the HIV prevention of mother to child transmission programme in Papua New Guinea remains suboptimal. An unacceptable number of babies are infected with HIV and mothers not retained in treatment. This study aimed to describe the characteristics of this programme and to investigate the factors associated with programme performance outcomes. Methods We conducted a retrospective analysis of clinical records of HIV-positive pregnant women at two hospitals providing prevention of mother to child transmission services. All women enrolled in the prevention of mother to child transmission programme during the study period (June 2012–June 2015) were eligible for inclusion. Using logistic regression, we examined the factors associated with maternal loss to follow-up (LTFU) before birth and before infant registration in a paediatric ARV programme. Results 763 of women had records eligible for inclusion. Demographic and clinical differences existed between women at the two sites. Almost half (45.1%) of the women knew their HIV-positive status prior to the current pregnancy. Multivariate analysis showed that women more likely to be LTFU by the time of birth were younger (adjusted OR (AOR)=2.92, 95% CI 1.16 to 7.63), were newly diagnosed with HIV in the current/most recent pregnancy (AOR=3.50, 95% CI 1.62 to 7.59) and were in an HIV serodiscordant relationship (AOR=2.94, 95% CI 1.11 to 7.84). Factors associated with maternal LTFU before infant registration included being primipara at the time of enrolment (AOR=3.13, 95% CI 1.44 to 6.80) and being newly diagnosed in that current/most recent pregnancy (AOR=2.49, 95% CI 1.31 to 4.73). 6.6% (50 of 763) of exposed infants had a positive HIV DNA test. Conclusions Our study highlighted predictors of LTFU among women. Understanding these correlates at different stages of the programme offers important insights for targets and timing of greater support for retention in care

Point-of-care testing and treatment of sexually transmitted infections to improve birth outcomes in high-burden, low-income settings: Study protocol for a cluster randomized crossover trial (the WANTAIM Trial, Papua New Guinea) [version 1; peer review: 1 approved, 1 approved with reservations]

Background: Chlamydia trachomatis , Neisseria gonorrhoeae , Trichomonas vaginalis and bacterial vaginosis have been associated with preterm birth and low birth weight, and are highly prevalent among pregnant women in many low- and middle-income settings. There is conflicting evidence on the potential benefits of screening and treating these infections in pregnancy. Newly available diagnostic technologies make it possible, for the first time, to conduct definitive field trials to fill this knowledge gap. The primary aim of this study is to evaluate whether antenatal point-of-care testing and immediate treatment of these curable sexually transmitted and genital infections (STIs) leads to reduction in preterm birth and low birth weight. Methods : The Women and Newborn Trial of Antenatal Interventions and Management (WANTAIM) is a cluster-randomised crossover trial in Papua New Guinea to compare point-of-care STI testing and immediate treatment with standard antenatal care (which includes the WHO-endorsed STI ‘syndromic’ management strategy based on clinical features alone without laboratory confirmation). The unit of randomisation is a primary health care facility and its catchment communities. The primary outcome is a composite measure of two events: the proportion of women and their newborns in each trial arm, who experience either preterm birth (delivery <37 completed weeks of gestation as determined by ultrasound) and/or low birth weight (<2500 g measured within 72 hours of birth). The trial will also evaluate neonatal outcomes, as well as the cost-effectiveness, acceptability and health system requirements of this strategy, compared with standard care. Conclusions: WANTAIM is the first randomised trial to evaluate the effectiveness, cost-effectiveness, acceptability and health system requirements of point-of-care STI testing and treatment to improve birth outcomes in high-burden settings. If the intervention is proven to have an impact, the trial will hasten access to these technologies and could improve maternal and neonatal health in high-burden settings worldwide. Registration: ISRCTN37134032

Point-of-care testing and treatment of sexually transmitted and genital infections during pregnancy in Papua New Guinea (WANTAIM trial): protocol for an economic evaluation alongside a cluster-randomised trial

INTRODUCTION: Left untreated, sexually transmitted and genital infections (henceforth STIs) in pregnancy can lead to serious adverse outcomes for mother and child. Papua New Guinea (PNG) has among the highest prevalence of curable STIs including syphilis, chlamydia, gonorrhoea, trichomoniasis and bacterial vaginosis, and high neonatal mortality rates. Diagnosis and treatment of these STIs in PNG rely on syndromic management. Advances in STI diagnostics through point-of-care (PoC) testing using GeneXpert technology hold promise for resource-constrained countries such as PNG. This paper describes the planned economic evaluation of a cluster-randomised cross-over trial comparing antenatal PoC testing and immediate treatment of curable STIs with standard antenatal care in two provinces in PNG. METHODS AND ANALYSIS: Cost-effectiveness of the PoC intervention compared with standard antenatal care will be assessed prospectively over the trial period (2017-2021) from societal and provider perspectives. Incremental cost-effectiveness ratios will be calculated for the primary health outcome, a composite measure of the proportion of either preterm birth and/or low birth weight; for life years saved; for disability-adjusted life years averted; and for non-health benefits (financial risk protection and improved health equity). Scenario analyses will be conducted to identify scale-up options, and budget impact analysis will be undertaken to understand short-term financial impacts of intervention adoption on the national budget. Deterministic and probabilistic sensitivity analysis will be conducted to account for uncertainty in key model inputs. ETHICS AND DISSEMINATION: This study has ethical approval from the Institutional Review Board of the PNG Institute of Medical Research; the Medical Research Advisory Committee of the PNG National Department of Health; the Human Research Ethics Committee of the University of New South Wales; and the Research Ethics Committee of the London School of Hygiene and Tropical Medicine. Findings will be disseminated through national stakeholder meetings, conferences, peer-reviewed publications and policy briefs. TRIAL REGISTRATION NUMBER: ISRCTN37134032

Point-of-care testing and treatment of sexually transmitted and genital infections to improve birth outcomes in high-burden, low-resource settings (WANTAIM): a pragmatic cluster randomised crossover trial in Papua New Guinea.

Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, and bacterial vaginosis have been associated with adverse maternal and perinatal outcomes, but there is conflicting evidence on the benefits of antenatal screening and treatment for these conditions. We aimed to determine the effect of antenatal point-of-care testing and immediate treatment of C trachomatis, N gonorrhoeae, T vaginalis, and bacterial vaginosis on preterm birth, low birthweight, and other adverse maternal and perinatal outcomes compared with current standard of care, which included symptom-based treatment without laboratory confirmation. In this pragmatic cluster randomised crossover trial, we enrolled women (aged ≥16 years) attending an antenatal clinic at 26 weeks' gestation or earlier (confirmed by obstetric ultrasound), living within approximately 1 h drive of a study clinic, and able to provide reliable contact details at ten primary health facilities and their catchment communities (clusters) in Papua New Guinea. Clusters were randomly allocated 1:1 to receive either the intervention or control (standard care) in the first phase of the trial. Following an interval (washout period) of 2-3 months at the end of the first phase, each cluster crossed over to the other group. Randomisation was stratified by province. Individual participants were informed about trial group allocation only after completing informed consent procedures. The primary outcome was a composite of preterm birth (livebirth before 37 weeks' gestation), low birthweight (<2500 g), or both, analysed according to the intention-to-treat population. This study is registered with ISRCTN Registry, ISRCTN37134032, and is completed. Between July 26, 2017, and Aug 30, 2021, 4526 women were enrolled (2210 [63·3%] of 3492 women in the intervention group and 2316 [62·8%] of 3687 in the control group). Primary outcome data were available for 4297 (94·9%) newborn babies of 4526 women. The proportion of preterm birth, low birthweight, or both, in the intervention group, expressed as the mean of crude proportions across clusters, was 18·8% (SD 4·7%) compared with 17·8% in the control group (risk ratio [RR] 1·06, 95% CI 0·78-1·42; p=0·67). There were 1052 serious adverse events reported (566 in the intervention group and 486 in the control group) among 929 trial participants, and no differences by trial group. Point-of-care testing and treatment of C trachomatis, N gonorrhoeae, T vaginalis, and bacterial vaginosis did not reduce preterm birth or low birthweight compared with standard care. Within the subgroup of women with N gonorrhoeae, there was a substantial reduction in the primary outcome

A qualitative scoping review of sexualised drug use (including Chemsex) of men who have sex with men and transgender women in Asia

Background: There is ongoing public health concern that sexualised drug-use (SDU) among men who have sex with men (MSM) and transgender women (TGW) results in dependence, poor mental health and increased risk of unprotected sex that may increase HIV risk. To build an evidence base from which to guide drug-related and HIV policy for MSM and TGW in Asia, a region experiencing an expanding epidemic among this population, we undertook a scoping review of locally informed qualitative research.Methods: Qualitative papers published from January 2010 to December 2019 which reported on SDU among MSM (gay, bisexual or any other identity) and transgender women in Asia were identified (Medline, Global Health and Scopus databases). Our search identified 2,413 publication titles and ten titles underwent full review. Three papers were subsequently excluded and the results of seven papers were synthesised using a narrative approach and conceptualised using a behavioural analysis framework.Results: SDU is occurring in social and sex work settings in the Asia region. The motivations for participating in SDU included enhanced and prolonged sexual activity and freedom and confidence to explore sexual fantasies. Other less commonly reported motivations included a coping mechanism for identity-based stigma and discrimination, perceptionsof beauty and status and pride and empowerment. The settings of SDU were private and secret and whilst a range of drugs were used in these settings, the literature focuses almost exclusively on methamphetamine use. Unprotected sex was reported in all settings and there was limited availability of and access to harm reduction services.Conclusion: SDU specific harm reduction needs to be considered at local, national and international levels, to ensure that MSM and gender minorities in Asia can participate in SDU more safely. To do so requires SDU to be understood as a social phenomenon and for acceptable and accessible harm reduction programs to be developed. There is also anurgent need to undertake more qualitative research in the region, and to increase the inclusion of minorities such as men who sell sex and transgender women, as well as to ensure a holistic examination of the types of drugs used