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Background: Syphilis has recently resurfaced as a significant public health problem. Since the 2000s, isolated syphilis outbreaks have increasingly occurred in North America, Europe, and Australia; in Brazil, there have been progressive increases in both congenital and acquired syphilis. There are several possible explanations, such as misdiagnosis of acquired syphilis, which could increase the number of untreated transmitters in the population; failure to initiate or complete treatment; and nontreatment of sexual partners (leading to reinfection). Mobile technologies have been successfully used to promote behaviour changes and can positively impact treatment and follow-up adherence in patients with infectious diseases. The purpose of this clinical trial is to evaluate treatment and monitoring methods in patients with syphilis, including follow-up by telephone, via a game in a smartphone app and at public health centres.Methods: The SIM study is a single-centre, randomized controlled trial with a 12-month follow-up period. The aim is to identify the most effective method of follow-up regarding patient compliance with treatment. The tests will be performed in a mobile unit in easily accessible locations. The goal is to perform 10,000 rapid tests for syphilis. Patients with a confirmed diagnosis according to VDRL tests will be randomized to one of three arms: telephone, smartphone game, or conventional in-person follow-up. All analyses will follow the intention-to-treat principle.Conclusion: If we find differences in effectiveness, a major change in the conventional approach for this patient population may be needed, potentially affecting current Brazilian health policy strategies.

Background Syphilis has recently resurfaced as a significant public health problem. Since the 2000s, isolated syphilis outbreaks have increasingly occurred in North America, Europe, and Australia; in Brazil, there have been progressive increases in both congenital and acquired syphilis. There are several possible explanations, such as misdiagnosis of acquired syphilis, which could increase the number of untreated transmitters in the population; failure to initiate or complete treatment; and nontreatment of sexual partners (leading to reinfection). Mobile technologies have been successfully used to promote behavior changes and can positively impact treatment and follow-up adherence in patients with infectious diseases. The purpose of this clinical trial is to evaluate treatment and monitoring methods in patients with syphilis, including follow-up by telephone, via a game in a smartphone app, and at public health centers. Methods The SIM study is a single-center, randomized controlled trial with a 12-month follow-up period. The aim is to identify the most effective method of follow-up regarding patient compliance with treatment. The tests will be performed in a mobile unit in easily accessible locations. The goal is to perform 10,000 rapid tests for syphilis. Patients with a confirmed diagnosis according to VDRL tests will be randomized to one of three arms: telephone, smartphone game, or conventional in-person follow-up. All analyses will follow the intention-to-treat principle. Conclusion If we find differences in effectiveness, a major change in the conventional approach for this patient population may be needed, potentially affecting current Brazilian health policy strategies. Trial registration NTC04753125. Version 1 of protocol 1/09/2020.

Introduction: Syphilis is a major public health problem. Its incidence has increased in Brazil, particularly in the Southern Region. New tools are available, and immediate action is necessary. Objective: To describe the pilot study of an investigation aimed to assess the prevalence of syphilis, hepatitis B and C, and HIV and evaluate three strategies for adherence to syphilis treatment. Methods: A spontaneous sample of participants was evaluated with a structured questionnaire and underwent rapid tests for syphilis, HIV, and hepatitis B and C after signing an informed consent form (ICF). Rapid tests reagent for syphilis were confirmed by quantitative venereal disease research laboratory (VDRL) and Treponema pallidum hemagglutination assay (TPHA). Participants with confirmation of syphilis were randomized into three groups for follow-up: telephone calls, SIM app, and usual care at the health unit. Results: During a two-day pilot, 68 participants were included. Fourteen (20.6%) had tests reagent for syphilis, 1 (1.5%) for hepatitis B, 3 (4.4%) for hepatitis C, and 1 (1.5%) for HIV. Eight (57.1%) of the initial 14 individuals with rapid tests reagent for syphilis agreed to participate in the study. Out of the 8 rapid tests for syphilis, 2 (25%) were confirmed as active syphilis (>1/8). Conclusion: The prevalence of active syphilis estimated in this population was 3.5%. The demand for tests was high. The COVID-19 epidemic had a negative impact on the development of the study, which is ready for implementation. Discussions on the role of such a testing unit and the coverage of the research project in a context that requires increasing COVID-19-focused testing are fundamental for the future development of the project.

Sex work remains an important contributor to HIV transmission within early, advanced and regressing epidemics in sub-Saharan Africa, but its social and behavioral underpinnings remain poorly understood, limiting the impact of HIV prevention initiatives. This article systematically reviews the socio-demographics of female sex workers (FSW) in this region, their occupational contexts and key behavioral risk factors for HIV. In total 128 relevant articles were reviewed following a search of Medline, Web of Science and Anthropological Index. FSW commonly have limited economic options, many dependents, marital disruption, and low education. Their vulnerability to HIV, heightened among young women, is inextricably linked to the occupational contexts of their work, characterized most commonly by poverty, endemic violence, criminalization, high mobility and hazardous alcohol use. These, in turn, predict behaviors such as low condom use, anal sex and co-infection with other sexually transmitted infections. Sex work in Africa cannot be viewed in isolation from other HIV-risk behaviors such as multiple concurrent partnerships-there is often much overlap between sexual networks. High turn-over of FSW, with sex work duration typically around 3 years, further heightens risk of HIV acquisition and transmission. Targeted services at sufficiently high coverage, taking into account the behavioral and social vulnerabilities described here, are urgently required to address the disproportionate burden of HIV carried by FSW on the continent.

Las enfermedades de transmision sexual (ETS) constituyen un problema de salud publica con importantes consecuencias y secuelas que incluyen la enfermedad inflamatoria pelvica, la infertilidad, el carcinoma cervical y los desenlaces adversos del embarazo. En la ultima decada, la estrecha asociacion entre la presencia de ETS y el aumento del riesgo de transmision sexual del virus de la inmunodeficiencia humana ha renovado el interes por la prevencion y control de las ETS. Sin embargo, en America Latina y el Caribe, la informacion epidemiologica sobre la magnitud del problema de las ETS es escasa y, en general, esta limitada a un pequeno numero de estudios y a datos oficiales incompletos de los paises de la zona. Tras una cuidadosa revision de la literatura y un analisis de los datos que posee la Organizacion Mundial de la Salud sobre cada pais, hemos estimado la prevalencia e incidencia en America Latina y el Caribe de cuatro ETS curables (sifilis, gonorrea, infeccion por clamidias y tricomoniasis) en hombres y mujeres de 15 a 49 anos de edad. Para ello se utilizaron parametros tales como la duracion de la infeccion, la estimacion de los pacientes tratados frente a los no tratados y los datos de poblacion. En 1996, el numero estimado de casos en America Latina y el Caribe fue de 1,3 millones para la sifilis, de 7,1 millones para la gonorrea, de 10,0 millones para las infecciones clamidiales y de 17,7 millones para la tricomoniasis. Con una cifra estimada total que, en el mejor de los casos, es superior a 36 millones de casos anuales, las ETS tratables parecen constituir un importante problema de salud publica en la zona.

We conducted a systematic review and meta-analysis to assess the association between serosorting and HIV infection, sexually transmitted infections (STIs), and quality of life among men who have sex with men (MSM) and transgender people. Two reviewers independently screened abstracts and abstracted data. Meta-analyses were conducted using random effects models. Of 310 citations reviewed, 4 observational studies, all with MSM, met inclusion criteria. Compared to consistent condom use, serosorting was associated with increased risk of HIV (3 studies, odds ratio (OR): 1.80, 95% confidence interval (CI):1.21–2.70) and bacterial STIs (1 study, OR: 1.62, 95% CI: 1.44–1.83). Compared to no condom use, serosorting was associated with reduced risk of HIV (3 studies, OR: 0.46, 95% CI: 0.25–0.83) and bacterial STIs (1 study, OR: 0.81, 95% CI: 0.73–0.91). Among HIV-negative MSM, condom use appears to be more protective against HIV and STIs than serosorting and should be encouraged. However, serosorting may be better than no condom use as a harm reduction strategy.

Introduction: Virtually no African country provides HIV prevention services in sex work settings with an adequate scale and intensity. Uncertainty remains about the optimal set of interventions and mode of delivery. Methods: We systematically reviewed studies reporting interventions for reducing HIV transmission among female sex workers in sub-Saharan Africa between January 2000 and July 2011. Medline (PubMed) and non-indexed journals were searched for studies with quantitative study outcomes. Results: We located 26 studies, including seven randomized trials. Evidence supports implementation of the following interventions to reduce unprotected sex among female sex workers: peer-mediated condom promotion, risk-reduction counselling and skills-building for safer sex. One study found that interventions to counter hazardous alcohol-use lowered unprotected sex. Data also show effectiveness of screening for sexually transmitted infections (STIs) and syndromic STI treatment, but experience with periodic presumptive treatment is limited. HIV testing and counselling is essential for facilitating sex workers' access to care and antiretroviral treatment (ART), but testing models for sex workers and indeed for ART access are little studied, as are structural interventions, which create conditions conducive for risk reduction. With the exception of Senegal, persistent criminalization of sex work across Africa reduces sex workers' control over working conditions and impedes their access to health services. It also obstructs health-service provision and legal protection. Conclusions: There is sufficient evidence of effectiveness of targeted interventions with female sex workers in Africa to inform delivery of services for this population. With improved planning and political will, services - including peer interventions, condom promotion and STI screening - would act at multiple levels to reduce HIV exposure and transmission efficiency among sex workers. Initiatives are required to enhance access to HIV testing and ART for sex workers, using current CD4 thresholds, or possibly earlier for prevention. Services implemented at sufficient scale and intensity also serve as a platform for subsequent community mobilization and sex worker empowerment, and alleviate a major source of incident infection sustaining even generalized HIV epidemics. Ultimately, structural and legal changes that align public health and human rights are needed to ensure that sex workers on the continent are adequately protected from HIV.

Grosskurth and colleagues report the outcomes of a randomized controlled trial to evaluate the impact of improved treatment of sexually transmitted diseases (STD) on HIV infection. The authors congratulate the research team on the high quality of the design and execution of their study. They are amazed by the reported 43% reduction in the incidence of HIV as a result of the medium-strength intervention. The effect upon other STDs is however less apparent. The researchers discussed possible effect modifications of different co-factors but concluded that bias is negligible or very limited. These authors do not however think that the researchers sufficiently consider the implications of the difference in baseline HIV prevalence between intervention and comparison communities. It is important to correct for the initial 14% difference in initial condition since the prevalent cases form the source of subsequent HIV infections. The authors therefore recalculated risk ratios using a correction factor for each of the six matched pair communities. In so doing the overall estimate of HIV reduction as a result of the intervention would be 33% probably a better estimate than the original 43%. The confidence interval for the effect was widened by the correction. A more sophisticated analysis should consider the possibility that frequencies changed during the research period since the HIV epidemic has most likely not yet reached its dynamic equilibrium. The authors stress in closing that a 33% reduction in the frequency of HIV is nonetheless remarkable for this type of intervention.

Background The World Health Organization (WHO) Department of HIV/AIDS led the development of public health guidelines for delivering an evidence-based, essential package of interventions for the prevention and treatment of HIV and other sexually transmitted infections (STIs) among men who have sex with men (MSM) and transgender people in the health sector in low- and middle-income countries. The objective of this paper is to review the methodological challenges faced and solutions applied during the development of the guidelines. Methods The development of the guidelines followed the WHO guideline development process, which utilizes the GRADE approach. We identified, categorized and labeled the challenges identified in the guidelines development process and described the solutions through an interactive process of in-person and electronic communication. Results We describe how we dealt with the following challenges: (1) heterogeneous and complex interventions; (2) paucity of trial data; (3) selecting outcomes of interest; (4) using indirect evidence; (5) integrating values and preferences; (6) considering resource use; (7) addressing social and legal barriers; (8) wording of recommendations; and (9) developing global guidelines. Conclusion We were able to successfully apply the GRADE approach for developing recommendations for public health interventions. Applying the general principles of the approach while carefully considering specific challenges can enhance both the process and the outcome of guideline development.

Background Unprotected sex work remains a major driver of HIV/sexually transmitted infection (STI) epidemics in many countries. STI treatment can lower disease burden, complications and prevalence of HIV cofactors. Periodic presumptive treatment (PPT) has been used with sex workers to reduce their high burden of largely asymptomatic STIs. The objective of this review is to assess benefits and harms of PPT among female sex workers. Methods We searched MEDLINE for studies related to sex work and STIs during 1990-2010, extracted data from eligible studies in duplicate and conducted meta-analysis by study design using random effects models. Results Two thousand, three hundred and fifteen articles were screened, 18 studies met inclusion criteria and 14 were included in meta-analyses. One published randomized controlled trial (RCT) reported significant reductions of gonorrhoea (Neisseria gonorrhoeae) [rate ratio (RR) 0.46, 95% confidence interval (CI) 0.31-0.68] and chlamydia (Chlamydia trachomatis) (RR 0.38, 95%CI 0.26-0.57), but no effect on serologic syphilis (RR 1.02, 95%CI 0.54-1.95). Similar results were seen for N. gonorrhoeae and C. trachomatis in pooled analyses, including data from one unpublished RCT and across study designs, and correlated with initial prevalence (R(2) = 0.155). One observational study reported genital ulcer disease (GUD) declines in sex workers, and two reported impact among male client populations for N. gonorrhoeae [odds ratio (OR) 0.60, 95% CI 0.38-0.94], C. trachomatis (OR 0.47, 95% CI 0.31-0.71) and GUD (OR 0.21, 95% CI 0.11-0.42). No studies reported evidence of risk compensation or antibiotic resistance. Conclusion PPT can reduce prevalence of gonorrhoea, chlamydia and ulcerative STIs among sex workers in whom prevalence is high. Sustained STI reductions can be achieved when PPT is implemented together with peer interventions and condom promotion. Additional benefits may include impact on STI and HIV transmission at population level.

Background Social marketing interventions have been shown to both promote and change many health-related behaviours and issues. As the HIV epidemic continues to disproportionately affect MSM and transgender women around the world, social marketing interventions have the potential to increase HIV/STI testing uptake among these populations. Objectives To assess the impact of social marketing interventions on HIV/STI testing uptake among men who have sex with men and transgender women compared to pre-intervention or control group testing uptake in the same population. Search methods We searched the following electronic databasesfor results from 01 January 1980 to the search date, 14 July 2010: Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, LILACS (Latin America and Brazil), PsycINFO, PubMed, Web of Science/Web of Social Science, Chinese National Knowledge Infrastructure (CNKI), and CQ VIP (China). We also searched for conference abstracts in the Aegis archive of HIV/AIDS conference abstracts and the CROI and International AIDS Society websites. In addition to searching electronic databases, we searched the following sources of grey literature: Australasian Digital Theses Program, Canadian Evaluation Society, Eastview: China Conference Proceedings, ProQuest Dissertations and Theses, and World Health Organization Library Information System (WHOLIS). We contacted individual researchers, experts working in the field, and authors of major trials for suggestions of any relevant manuscripts that were in preparation or in press. References of published articles from the databases above were searched for additional, pertinent materials. All languages were included in this search. Selection criteria Randomized controlled trials and controlled clinical trials that compared social marketing interventions with a control were included. Interrupted time series and pretest-posttest design studies (controlled or uncontrolled) that compared social marketing interventions with no intervention or a control were also included. Posttest-only studies and studies that combined pre-post data were excluded. Interventions that targeted at general public but did not include MSM or transgender women as a segment or did not have outcome data for an MSM or transgender segment were excluded. Data collection and analysis Two authors independently extracted data from each included study and assessed study quality. Meta-analyses were conducted to compare pre- and post-intervention and intervention and control group outcomes of HIV and STI testing uptake. Quality of evidence was assessed using the GRADE approach. Main results Three serial, cross-sectional pretest-posttest study designs (one with a control group and two without) were included in the final analysis. Statistical pooling was conducted for two studies and compared to pre-intervention level testing uptake, which showed that multi-media social marketing campaigns had a significant impact on HIV testing uptake (OR=1.58, 95%CI = 1.40 - 1.77). However, the campaigns were not found to be effective in increasing STI testing uptake (OR=0.94, 95%CI = 0.68 - 1.28). Overall, risk of bias was high and quality of evidence was low. None of the studies were conducted in developing countries or included male-to-female transgender women. Authors' conclusions This review provided limited evidence that multi-media social marketing campaigns can promote HIV testing among MSM in developed countries. Future evaluations of social marketing interventions for MSM should employ more rigorous study designs. Long-term impact evaluations (changes in HIV or STI incidence over time) are also needed. Implementation research, including detailed process evaluation, is needed to identify elements of social marketing interventions that are most effective in reaching the target population and changing behaviours.

In the last decade there have been considerable advances in the field of STDs. These have been fuelled to a large extent by the HIV/AIDS epidemic, but also by increased recognition of the range and severity of complications and sequelae that can be linked to these infections a& the development of new case-management approaches. More than 30 bacterial, viral, and parasitic In 1996, WHO generated a new set of global estimates for four major STDs drawing on an extensive review of the published and unpublished prevalence data.‘,’ These estimates suggest that there were more than 333 million new cases of syphilis, gonorrhoea, chlamydia, and trichomoniasis in adults aged 1549 years in 1995: 12.2 million cases of syphilis, 62.2 million cases of gonorrhoea, 89.1 million of chlamydia, and 167.2 million of trichomoniasis (panel). Geographically, the vast majority of these new cases occurred in the developing world, which reflects the global distribution of population. The largest number of new infections occurred in the diseases

BackgroundThe core-group theory of sexually transmitted infections suggests that targeting prevention to high-risk groups (HRG) could be very effective. We aimed to quantify the contribution of heterosexual HRGs and the potential impact of focused interventions to HIV transmission in the wider community.MethodsWe systematically identified studies published between 1980 and 2011. Studies were included if they used dynamical models of heterosexual HIV transmission, incorporated behavioural heterogeneity in risk, and provided at least one of the following primary estimates in the wider community (a) the population attributable fraction (PAF) of HIV infections due to HRGs, or (b) the number per capita or fraction of HIV infections averted, or change in HIV prevalence/incidence due to focused interventions.FindingsOf 267 selected articles, 22 were included. Four studies measured the PAF, and 20 studies measured intervention impact across 265 scenarios. In low-prevalence epidemics (≤5% HIV prevalence), the estimated impact of sex-worker interventions in the absence of risk compensation included: 6-100% infections averted; 0.9-6.2 HIV infections averted per 100,000 adults; 11-94% and 4-47% relative reduction in prevalence and incidence respectively. In high-prevalence epidemics (>5% HIV prevalence), sex-worker interventions were estimated to avert 6.8-40% of HIV infections and up to 564 HIV infections per 100,000 adults, and reduce HIV prevalence and incidence by 13-27% and 2-14% respectively. In both types of epidemics, greater heterogeneity in HIV risk was associated with a larger impact on the fraction of HIV infections averted and relative reduction in HIV incidence.ConclusionFocused interventions, as estimated by mathematical models, have the potential to reduce HIV transmission in the wider community across low- and high-prevalence regions. However, considerable variability exists in estimated impact, suggesting that a targeted approach to HIV prevention should be tailored to local epidemiological context.

Background Mathematical modelling of sexually transmitted infections suggests that targeting intervention (TI) to high-risk heterosexual risk groups (HRG) who have disproportionately high exposure and potential for transmission within populations can be very effective. We reviewed HIV transmission modelling studies to better understand the potential impact of TIs or the contribution of HRG to overall HIV transmission across geographical regions and epidemic phases. Methods We systematically searched PubMed with relevant key words to identify publications that used dynamical models of heterosexual HIV transmission, and then searched papers to identify studies that incorporated heterogeneity in risk, and provided estimates of the population attributable fraction of HIV infections due to HRGs (PAF), or fraction of infections prevented (PF) or change in prevalence due to TIs. Results Of 917 titles, 283 were excluded on abstract review. Of 634 papers searched, 96 modelled heterogeneity, of which 26 were included. Six studies used non-regionalised models, 9 studied generalised epidemics (GE) in sub-Saharan Africa, nine studied concentrated epidemics (CE) in Asia, West Africa, Japan, and Europe, and two studied both epidemic types. The PAF of HRGs ranged from 13% to 17% in mature GEs with an HIV prevalence of 16%–22% across three studies. Five models explored TIs in GEs and predicted a PF of 12%–73% and a 0%–27% reduction in prevalence with >50% coverage of commercial partnerships. Ten studies modelled TIs in CEs, with overall HIV prevalence at the mature phase between 0.7% and 3.5%, and suggested that TIs could reduce prevalence by 14%–30%, with PFs of 25%–48% if >75% coverage of commercial partnerships. With Conclusion Modelling studies suggest that TIs have the potential to reduce HIV in the overall population in generalised and concentrated epidemics. The relative impact of TIs depends on coverage, epidemic phase, differential risk between HRGs and remainder of the population, and the time-scale of outcome measurement.