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Unprotected oral and anal sex may result in extragenital sexually transmitted infections. The purposes of this study were to describe sexual behaviors, barrier use, and chlamydia/gonorrhea (Ct/GC) positivity among young Black men who have sex with women, and to examine the potential influence of extragenital infections on genital infections.Young Black men who had vaginal sex were screened for Ct/GC in New Orleans, LA, from August 14, 2019, to February 29, 2020. Audio/computer-assisted self-interviews were used to collect data on demographics and sexual behaviors. χ2 /Fisher exact or t test/Wilcoxon rank tests were used to assess differences in behaviors by Ct/GC positivity.Among 373 men studied, 619 female partnerships were reported in the past 2 months. Vaginal sex was reported in all partnerships per study protocol, receiving fellatio in 42.7%, performing cunnilingus in 35.7%, and penile-anal sex in 5.9%. Although 31.4% of the men consistently used condoms for vaginal sex with all partners, consistent barrier use was low during cunnilingus (0.5%) and fellatio (5.1%). Urethral infection rates among all men in the sample were 12.6% for Ct and 1.6% for GC. There was no significant difference in Ct/GC rates between those using and not using condoms consistently during vaginal sex ( P = 0.38).Unprotected oral sex with female partners was common. The high rate of genital infection among men who used condoms consistently for vaginal sex suggests that oral infections could be serving as a reservoir of genital infection. Testing at all sites of exposure for youth who engage in heterosexual sex is merited.

OBJECTIVES: To estimate the impact of the Check It program, a novel community-based chlamydia seek, test and treat program for young Black men who have sex with women, on test positivity rates for chlamydia in young Black women. METHODS: We used a synthetic control model to compare chlamydia test positivity rates in Orleans Parish (intervention site) to other similar parishes (control sites) in Louisiana. We estimated a model that used all other parishes as potential contributors to a synthetic control for Louisiana as well as a sample limited to the 40 parishes in Louisiana with the largest Black populations. RESULTS: The Check It program was associated with a 1.69 percentage point decline in chlamydia positivity in the first full year of operation and a 2.44 percentage point decline in chlamydia positivity in the second full year of operation compared to control sites with the largest Black populations (p = 0.05). Results were similar when the treatment site was compared to all other sites in Louisiana. CONCLUSIONS: The Check It program was associated with a significant decline in chlamydia testing positivity rates among women in Orleans Parish compared to control sites. Screening of young Black men who have sex with women can decrease rates in women living in the same community. Future recommendations for chlamydia screening of young men should be considered.

BACKGROUND In a randomized controlled trial of 2 g (single-dose) metronidazole (MTZ) versus 500 mg twice daily for 7-days (multi-dose) for T. vaginalis treatment, multi-dose was superior. We examined if the effect was similar by select clinical factors to determine if treatment recommendations could be targeted. METHODS The primary outcome was T. vaginalis repeat infection at test-of-cure (TOC) 4-weeks post-completion of therapy. Analyses were stratified by T. vaginalis history, baseline genital symptoms, and concurrent diagnosis of bacterial vaginosis (BV) per Nugent score at baseline. RESULTS Women who returned for TOC (n = 540) were included. At baseline, 52.9% had a self-reported history of T. vaginalis, 79.3% genital symptoms, 5.8% a gonorrhea diagnosis, and 47.5% BV. During follow-up, 97.4% took all MTZ as instructed and 34.5% had interval condomless sex with a baseline partner. At TOC, 14.8% tested positive for T. vaginalis. In stratified analysis, women randomized to single-dose MTZ had a higher rate of TOC T. vaginalis positivity than those randomized to multi-dose if they were symptomatic at baseline (21.4% vs. 10.8%, p = 0.003) or had a reported history of T. vaginalis (24.1% vs. 12.6%, p = 0.01). TOC T. vaginalis positivity was higher for women receiving single-dose (18.9%) versus multi-dose (10.8%), irrespective of baseline BV status (p > 0.06). In multivariable analysis, only a history of T. vaginalis and single-dose MTZ were independently associated with a positive TOC for T. vaginalis. CONCLUSION While multi-dose MTZ is recommended for all women with T. vaginalis, it is especially important for women with a T. vaginalis history and, given high post-treatment infection rates, a TOC should be performed.

Check It is a novel, bundled, community-based seek, test, and treat Chlamydia trachomatis (Ct) screening program for 15- to 24-year-old Black men in New Orleans who have sex with women. The program design addressed barriers and facilitators to Ct screening/treatment by enlisting trusted community partners, incorporating participant input, providing free index/partner expedited treatment, developing relatable marketing materials and an educational Web site, encouraging peer referral, and providing a modest monetary incentive.Areas of high poverty were identified using census data; ethnographic/key informant interviews identified sites in those areas where the target population congregated. Black youth informed Web site design and social marketing. Content was inspirational/educational/amusing and endorsed recruitment and brand awareness. A community advisory board, participant interviews, community partner feedback, and recruitment staff involvement in the process evaluation helped refine the program in an ongoing manner.During formative stages, 41 key informant/community advisory board members informed program refinement. Community partners provided venue locations (n = 65) and participant referrals. Between May 22, 2017, and February 28, 2020, 1890 men were enrolled (acceptance rate, 96.0%) with Ct infection rate of 10.2%. Overall study treatment was provided to 86.1% (71.4%-90.9%) of participants who tested positive and 28.5% (14.5%-41.5%) of their partners. Findings from in-depth interviews with participants (n = 43) led to increased treatment uptake.C. trachomatis community screening of young Black men was successful through collaboration with trusted community partners, by tailoring implements/marketing with participant input, reducing barriers to treatment, and providing modest monetary incentives. The Check It program can serve as a roadmap for reducing health disparities in this population.

Prospective cohort studies of sexually transmitted infections (STIs) are logistically impractical owing to time and expenses. In schools, students are readily available for school-related follow-ups and monitoring. Capitalizing on the logistics that society already commits to ensure regular attendance of adolescents in school, a school-based STI screening in New Orleans made it possible to naturally observe the occurrence of chlamydia and to determine its incidence among 14-19-year-old adolescents. Among participants screened repeatedly, we calculated incidence rates, cumulative incidence, and incidence times. Male (n = 3820) and female (n = 3501) students were observed for 6251 and 5143 person-years, respectively, during which 415 boys and 610 girls acquired chlamydia. Incidence rates per 100 person-years were 6.6 cases for boys and 11.9 cases for girls. In multivariable analysis, the adjusted hazard ratio was 5.34 for boys and 3.68 for girls if the student tested positive for gonorrhea during follow-up, and 2.76 for boys and 1.59 for girls if at first participation the student tested positive for chlamydia, and it increased with age among boys but not among girls. In joinpoint trend analysis, the annual percentage change in the incidence rate was 6.6% for boys (95% CI: -1.2%, 15.1%) and 0.1% for girls (95% CI: -5.3%, 5.7%). Annual cumulative incidence was 5.5% among boys and 8.6% among girls. Median incidence time was 9.7 months for boys and 6.9 months for girls. Our findings can be used to refine assumptions in mathematical modeling and in cost analysis studies of

BackgroundHigh rates of repeat infections post-treatment are reported in women infected with Trichomonas vaginalis (TV). Determining the origin of repeat infections is generally limited to clinical queries of adherence to treatment and sexual exposure. The purpose of this study was to add micro-satellite (MS) genotype data to classification criteria for origin of repeat TV infection, and examine if the addition of TV genotype changes classification as treatment failure, re-infection, or new infectionMethodsWomen were enrolled at clinics in Birmingham, AL; Jackson, MS; and New Orleans, LA as part of a randomized clinical trial comparing single-dose (2 g) and multi-dose (500 mg twice daily x 7 days) metronidazole (MTZ) treatment regimens. Participants provided vaginal swabs and completed a behavioral audio-computer assisted self-interview (ACASI). TV specimens were genotyped at 11 microsatellite (MS) loci. Women with repeat TV infections at TOC, were classified as treatment failure, re-infection or new infections using behavioral and genotype data; classifications were compared.ResultsData were available for 45 women. Genotype concordance was defined as 2=16.00 p=0.0011, indicating differences in results.ConclusionsThe majority of women, using either criteria, were classified as treatment failure. Clinical assessment may overestimate reinfections and underestimate new infections. Patient counseling should be adapted accordingly.SummaryTo more precisely determine the origin of repeat Trichomonas vaginalis infection, we compared genotype microsatellite size polymorphism data to clinical criteria and found that clinical data overestimated reinfection and underestimated new infections. Patient counselling should consider new partners.

BackgroundTrichomonas vaginalis virus (TVV) is a non-segmented, 4.5–5.5 kilo-base pair (kbp), double-stranded RNA virus infecting T. vaginalis. The objectives of this study were to examine the TVV prevalence in US Trichomonas vaginalis isolates and TVV’s associations with patient demographics, clinical outcomes, and metronidazole resistance.MethodsArchived T. vaginalis isolates from the enrollment visits of 355 women participating in a T. vaginalis treatment trial in Birmingham, Alabama, were thawed and grown in culture. Their total RNA was extracted using a Trizol reagent. Contaminating, single-stranded RNA was precipitated using 4.0 M Lithium Chloride and centrifugation. The samples were analyzed by gel electrophoresis to visualize a 4.5 kbp band representative of TVV. In vitro testing for metronidazole resistance was also performed on 25/47 isolates obtained from the women’s test of cure visits.ResultsTVV was detected in 142/355 (40%) isolates at the enrollment visit. Women with TVV-positive (TVV+) isolates were significantly older (P = .01), more likely to smoke (P = .04), and less likely to report a history of gonorrhea (P = .04). There was no association between the presence of clinical symptoms or repeat T. vaginalis infections with TVV+ isolates (P = .14 and P = .44, respectively). Of 25 test of cure isolates tested for metronidazole resistance, 0/10 TVV+ isolates demonstrated resistance, while 2/15 TVV-negative isolates demonstrated mild to moderate resistance (P = .23).ConclusionsOf 355 T. vaginalis isolates tested for TVV, T. vaginalis isolates tested for TVV, the prevalence was 40%. However, there was no association of TVV+ isolates with clinical symptoms, repeat infections, or metronidazole resistance. These results suggest that TVV may be commensal to T. vaginalis.

In vitro studies indicate IFNγ is central to Chlamydia trachomatis (Ct) eradication, but its function may be compromised by anaerobes typically associated with bacterial vaginosis (BV), a frequent co-morbidity in women with Ct. Here we investigated the associations between natural clearance of cervical Ct infection, the vaginal microbiome, and the requirements for IFNγ by evaluating the vaginal microbial and cytokine composition of Ct treatment visit samples from women who cleared Ct infection in the interim between their Ct screening and Ct treatment visit. The pilot cohort was young, predominantly African American, and characterized by a high rate of BV that was treated with metronidazole at the Ct screening visit. The rate of natural Ct clearance was 23.6% by the Ct treatment visit (median 9 days). 16S rRNA gene sequencing revealed that metronidazole-treated women who had a Lactobacillus spp.-dominant vaginal microbiota (CST 2 or 3) at the Ct treatment visit, were more prevalent in the Ct clearing population than the non-clearing population (86% v. 50%). L. iners (CST2) was the major Lactobacillus spp. present in Ct clearers, and 33% still remained anaerobe-dominant (CST1). Vaginal IFNγ levels were not significantly different in Ct clearers and non-clearers and were several logs lower than that required for killing Ct in vitro. An expanded panel of IFNγ-induced and proinflammatory cytokines and chemokines also did not reveal differences between Ct clearers and non-clearers, but, rather, suggested signatures better associated with specific CSTs. Taken together, these findings suggest that BV-associated bacteria may impede Ct clearance, but a Lactobacillus spp.-dominant microbiome is not an absolute requirement to clear. Further, IFNγ may be required at lower concentrations than in vitro modeling indicates, suggesting it may act together with other factors in vivo. Data also revealed that the vaginal bacteria-driven inflammation add complexity to the genital cytokine milieu, but changes in this microbiota may contribute to, or provide cytokine biomarkers, for a shift to Ct clearance.

Population aging is one of the most important social trends of the 21st century and in the United States, the number of people aged ≥65 is projected to increase by nearly 50% in the next 15 years. Most biomedical and public health efforts have focused on reducing harmful risk factors when targeting chronic disease—an approach that has contributed greatly to prevention and treatment programs. However, evidence suggests that the number of years lost to disability is increasing and historic gains we have made in life expectancy are eroding, and even reversing in some groups. As our society ages and grapples with these issues, expanding the focus to include resilience, as well as psychosocial assets in our prevention and treatment programs might help inform the multidisciplinary response effort we need. Here we synthesize research evaluating associations between different dimensions of psychological well-being (e.g., purpose in life, optimism, life satisfaction) and social well-being (e.g., structural, functional, quality) with chronic conditions. We also evaluate evidence around three biopsychosocial pathways hypothesized to underlie these associations. These factors are meaningful, measurable, and potentially modifiable; thus, further pursuing this line of inquiry might unveil innovative paths to enhancing the health of our rapidly aging society.

The purpose of this study was to examine the association between institution-delivered sex education given under real-world conditions and sexually transmitted infection (STI) rates, STI fatalism, and prior STI testing among African American men aged 15–24 who have sex with women. Participants were tested at community venues for Chlamydia and gonorrhoea and undertook a survey to elicit history of sex education and sexual health information. Among 1196 participants, 73.0% reported having received institution-delivered sex education topics including STI information (90.5%), condoms (89.2%), pregnancy/birth (72.1%) and birth control (67.1%). Among a subset of participants asked about the quality of sex education, 85.7% reported it was ‘very good’ or ‘OK’. Prevalence rate for Chlamydia and/or gonorrhoea was 10.5%. Those who received sex education were more likely to have lower STI fatalism (51.0% vs. 42.4%, p=0.01) and more likely to report previous Chlamydia screening (44.1% vs. 31.6%, p

This article lays out the research priorities for Mycoplasma genitalium research agreed upon by the participants in a 2016 National Institutes of Allergy and Infectious Diseases–funded Technical Consultation focused on this organism. The state of current knowledge concerning the microbiology, epidemiology, clinical manifestations of infection, treatment, and public health significance of M. genitalium reviewed at the meeting is described in detail in the individual articles included in this supplemental edition of the Journal of Infectious Diseases. Here we summarize the points made in these articles most relevant to the formulation of the research priorities listed in this article. The most important recommendation resulting from this Technical Consultation is the initiation of clinical trials designed to determine definitively whether screening for and treatment of M. genitalium infections in women and their sexual partners improve reproductive health in women and/or prevent human immunodeficiency virus transmission.

Mycoplasmagenitalium is one of the major causes of nongonococcal urethritis (NGU) worldwide but an uncommon sexually transmitted infection (STI) in the general population. The risk of sexual transmission is probably lower than for Chlamydia trachomatis. Infection in men is usually asymptomatic and it is likely that most men resolve infection without developing disease. The incubation period for NGU caused by Mycoplasma genitalium is probably longer than for NGU caused by C. trachomatis. The clinical characteristics of symptomatic NGU have not been shown to identify the pathogen specific etiology. Effective treatment of men and their sexual partner(s) is complicated as macrolide antimicrobial resistance is now common in many countries, conceivably due to the widespread use of azithromycin 1 g to treat STIs and the limited availability of diagnostic tests for M. genitalium. Improved outcomes in men with NGU and better antimicrobial stewardship are likely to arise from the introduction of diagnostic M. genitalium nucleic acid amplification testing including antimicrobial resistance testing in men with symptoms of NGU as well as in their current sexual partner(s). The cost effectiveness of these approaches needs further evaluation. The evidence that M. genitalium causes epididymo-orchitis, proctitis, and reactive arthritis and facilitates human immunodeficiency virus transmission in men is weak, although biologically plausible. In the absence of randomized controlled trials demonstrating cost effectiveness, screening of asymptomatic men cannot be recommended.

Flow cytometry has the potential to facilitate understanding of the heterogeneous responses of diverse brain cell populations to a variety of stimuli. However, existing methods of applying flow cytometry to brain tissues are each limited in certain ways. They either require genetically labeled cells to achieve separation of specific populations, are not applicable to previously fixed tissue, or are not compatible with downstream mRNA analysis. Here, we describe a group of related methods that overcome many previous limitations and allow robust sorting and downstream molecular analysis of highly enriched populations of specific neuronal and non-neuronal cells from any mammalian brain. We illustrate these techniques, which are compatible with antibodies for both nuclear and non-nuclear epitopes and do not require transgenic animals, with three examples. First, we describe the separation and downstream mRNA analysis of four types of cortical interneurons (somatostatin, parvalbumin, calretinin, and calbindin) from paraformaldehyde-fixed rat brain sections. Second, we demonstrate separation of neurons and non-neurons from zinc-fixed mouse brain cortical sections followed by analysis of enzymatic activity (ACE2 activity) and mRNA expression. Third, we show that routinely fixed post-mortem human brain can be analyzed by isolating parvalbumin-containing neurons from cortical samples that were fixed for periods of up to 8 weeks in formalin. In each case, sorted cell identity was confirmed with mRNA analysis. The neurocytometry methodology described here has the potential to significantly expand studies to analyze the effects of drugs, environmental manipulations, and disease states on the nucleic acid and protein content of specific brain cell populations.

BACKGROUND Syphilis management is complex and demonstration of treatment response requires monitoring of nontreponemal antibody titers for a ≥ 4-fold decline and/or seroreversion to nonreactive titers. METHODS We evaluated data from a multicenter clinical trial of syphilis treatment conducted from 2000 to 2009 involving human immunodeficiency virus (HIV)-negative patients 18 years or older with early syphilis. To assess the rate of titer decline and seroreversion after effective therapy, rapid plasma reagin (RPR) titers were analyzed at 1, 3, 6, 9, and 12 months among patients with an appropriate treatment response. We plotted the rate of RPR titer decline after treatment, estimated the frequency of seroreversion, and conducted multivariate analyses to assess characteristics associated with seroreversion. RESULTS Among 369 (79.4%) of 465 HIV-negative patients with early syphilis who had an appropriate treatment response, 333 participants had complete RPR data over 12 months. Although the decline in RPR titers was ≥ 4-fold among 88.0% (293/333) of participants at 3 months and ≥ 8-fold among 77.8% at 6 months, only 9.6% achieved complete RPR seroreversion at 6 months and 17.1% at 12 months after therapy. Male sex (adjusted odds ratio, 4.3; 95% confidence interval, 1.8-10.5) and baseline RPR titers ≤ 1:32 (adjusted odds ratio, 14.5; 95% confidence interval, 6.8-31.2) were associated with higher odds of seroreversion compared with females and titers > 1:32, respectively. CONCLUSIONS Despite a ≥ 4-fold RPR titer decline after treatment, the majority of HIV-negative patients with early syphilis failed to have seroreversion at 12 months. Nontreponemal antibody titers often persist despite an appropriate treatment response.

ObjectivesWe sought to determine whether the relationship between a history of vaginal douching and pelvic inflammatory disease (PID) is mediated by endometrial infection with one or more novel bacterial vaginosis (BV)-associated organisms among Atopobium vaginae, the BV-associated bacterium 1 (BVAB1), neathia (Leptotrichia) amnionii and Sneathia sanguinegens.MethodsWe first conducted log-binomial regression analyses to identify risk factors for endometrial infection in 535 adolescent and adult women with clinically suspected PID in the PID Evaluation and Clinical Health (PEACH) study. We then examined whether endometrial infection by the BV-associated organisms mediated the association between a history of vaginal douching and histologically confirmed PID using inverse probability weighted marginal structural models.ResultsVaginal douching was significantly associated with endometrial infection with one or more of the targeted BV-associated organisms (relative risk (RR) 1.21, 95% CI: 1.08 to 1.35). The total effect estimate suggested that vaginal douching increased the risk of endometritis by 24% (RR 1.24, 95% CI: 1.03 to 1.49). The controlled direct effect of this association was attenuated with endometrial infection by one or more BV-associated organisms (adjusted RR (aRR) 1.00, 95% CI: 0.57 to 1.74) and endometrial infection by all four BV-associated organisms (aRR 0.95, 95% CI: 0.53 to 1.70) as intermediate variables.ConclusionsEndometrial infection with one or more of the novel BV-associated organisms partially mediated the relationship between vaginal douching and histologically confirmed endometritis in the PEACH study. Frequent vaginal douching may confer risk for endometritis through increasing the risk of endometrial infection by novel-BV-associated organisms. Other potential pathways should be explored.

BACKGROUND –: The optimal timing for nucleic acid amplification testing (NAAT) post-treatment for Trichomonas vaginalis has not been fully established. Testing too soon post-treatment may detect remnant nucleic acid that is not from viable organisms, falsely misclassifying person as infected. The purpose of this study was to examine how long T. vaginalis nucleic acid is detectable post metronidazole (MTZ) treatment. METHODS –: Women diagnosed with T. vaginalis treated with MTZ (2 g single-dose or 500 mg twice daily for 7 days multi-dose) self-collected a vaginal swab for NAAT at baseline and each week post completion of treatment through test of cure (TOC) at week 4, when a culture was also performed. Women who reported interim sexual exposure or who were culture positive at 4 weeks were excluded. Time to first negative NAAT was examined using Kaplan Meier analysis. RESULTS –: All women receiving multi-dose metronidazole were NAAT negative by 21 days and those receiving single-dose by 28 days post completion of treatment. Though over half (60.7%) of the cohort reinitiated sex during follow-up¸ all reported using condoms during sex or that they and their partner were treated prior to sex. Six of 89 (6.7%) had a positive NAAT following their first negative NAAT. CONCLUSIONS –: The optimal timing for T. vaginalis retesting after completion of treatment is three weeks for those receiving multi-dose MTZ and four weeks for those receiving single-dose, though sexual re-exposure and false negatives should be considered.

BACKGROUND Three recent prospective studies have suggested that the 1-g dose of azithromycin for Chlamydia trachomatis (Ct) was less effective than expected, reporting a wide range of treatment failure rates (5.8%-22.6%). Reasons for the disparate results could be attributed to geographic or methodological differences. The purpose of this study was to reexamine the studies and attempt to harmonize methodologies to reduce misclassification as a result of false positives from early test-of-cure (TOC) or reinfection as a result of sexual exposure rather than treatment failure. METHODS Men who had sex with women, who received 1-g azithromycin under directly observed therapy for presumptive treatment of nongonococcal urethritis with confirmed Ct were included. Baseline screening was performed on urethral swabs or urine, and TOC screening was performed on urine using nucleic acid amplification tests. Posttreatment vaginal sexual exposure was elicited at TOC. Data from the 3 studies were obtained and reanalyzed. Rates of Ct retest positive were examined for all cases, and a sensitivity analysis was conducted to either reclassify potential false positives/reinfections as negative or remove them from the analysis. RESULTS The crude treatment failure rate was 12.8% (31/242). The rate when potential false positives/reinfections were reclassified as negative was 6.2% (15/242) or when these were excluded from analysis was 10.9% (15/138). CONCLUSIONS In these samples of men who have sex with women with Ct-related nongonococcal urethritis, azithromycin treatment failure was between 6.2% and 12.8%. This range of failure is lower than previously published but higher than the desired World Health Organization's target chlamydia treatment failure rate of < 5%.

Objectives As pelvic inflammatory disease (PID) aetiology is not completely understood, we examined the relationship between select novel bacteria, PID and long-term sequelae. Methods Fastidious bacterial vaginosis (BV)-associated bacteria ( Sneathia (Leptotrichia) sanguinegens , Sneathia amnionii , Atopobium vaginae and BV-associated bacteria 1 (BVAB1)), as well as Ureaplasma urealyticum and Ureaplasma parvum were identified in cervical and endometrial specimens using organism-specific PCR assays among 545 women enrolled in the PID Evaluation and Clinical Health study. Risk ratios and 95% CIs were constructed to determine associations between bacteria, histologically confirmed endometritis, recurrent PID and infertility, adjusting for age, race, gonorrhoea and chlamydia. Infertility models were additionally adjusted for baseline infertility. Results Persistent detection of BV-associated bacteria was common (range 58% for A. vaginae to 82% for BVAB1) and elevated the risk for persistent endometritis (RR adj 8.5, 95% CI 1.6 to 44.6) 30 days post-cefoxitin/doxycycline treatment, independent of gonorrhoea and chlamydia. In models adjusted for gonorrhoea and chlamydia, endometrial BV-associated bacteria were associated with recurrent PID (RR adj 4.7, 95% CI 1.7 to 12.8), and women who tested positive in the cervix and/or endometrium were more likely to develop infertility (RR adj 3.4, 95% CI 1.1 to 10.4). Associations between ureaplasmas and PID sequelae were modest. Conclusions To our knowledge, this is the first prospective study to demonstrate that S. sanguinegens , S. amnionii , BVAB1 and A. vaginae are associated with PID, failure of the Centers for Disease Control and Prevention-recommended treatment to eliminate short-term endometritis, recurrent PID and infertility. Optimal antibiotic regimens for PID may require coverage of novel BV-associated microbes.

Background Identification of bacteria in human vaginal specimens is commonly performed using 16S ribosomal RNA (rRNA) gene sequences. However, studies utilize different 16S primer sets, sequence databases, and parameters for sample and database clustering. Our goal was to assess the ability of these methods to detect common species of vaginal bacteria. Methods We performed an in silico analysis of 16S rRNA gene primer sets, targeting different hypervariable regions. Using vaginal samples from women with bacterial vaginosis, we sequenced 16S genes using the V1-V3, V3-V4, and V4 primer sets. For analysis, we used an extended Greengenes database including 16S gene sequences from vaginal bacteria not already present. We compared results with those obtained using the SILVA 16S database. Using multiple database and sample clustering parameters, each primer set's ability to detect common vaginal bacteria at the species level was determined. We also compared these methods to the use of DADA2 for denoising and clustering of sequence reads. Results V4 sequence reads clustered at 99% identity and using the 99% clustered, extended Greengenes database provided optimal species-level identification of vaginal bacteria. Conclusions This study is a first step toward standardizing methods for 16S rRNA gene sequencing and bioinformatics analysis of vaginal microbiome data.

BackgroundMycoplasma genitalium has been significantly and nonsignificantly associated with cervicitis, urethritis, or vaginal discharge. This study examined the associations of M. genitalium with selected sexually transmitted infections (STIs) and demographic, behavioral, and clinical factors among women attending a sexually transmitted disease (STD) clinic in New Orleans.MethodsWomen aged ≥18 years who presented to the New Orleans STD clinic provided sociodemographic data and sexual behavior; STI, obstetric, and gynecologic history; and urine, vaginal, endocervical, and rectal specimens. Specimens were tested for M. genitalium, Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, Mycoplasma hominis, Ureaplasma species, and yeast. Bacterial vaginosis (BV) was diagnosed by Nugent score, and cervicitis was defined as ≥30 polymorphonuclear leukocytes per high-power microscopic field on a cervical Gram stain or yellow mucopus on an endocervical swab.ResultsAmong 400 women studied, M. genitalium was independently significantly associated with age ConclusionsMycoplasma genitalium in our study displayed the clinical features of C. trachomatis and N. gonorrhoeae, the 2 organisms that drive research agendas in diagnosis, treatment, and prevention of bacterial STIs.

Background The sequence of events preceding incident bacterial vaginosis (iBV) is unclear. Methods African American women who have sex with women, who had no Amsel criteria and Nugent scores of 0-3, were followed for 90 days to detect iBV (defined as a Nugent score of 7-10 on at least 2-3 consecutive days), using self-collected vaginal swab specimens. For women with iBV (cases) and women maintaining normal vaginal flora (healthy women), 16S ribosomal RNA gene sequencing targeting V4 was performed. Longitudinal vaginal microbiome data were analyzed. Results Of 204 women screened, 42 enrolled; of these, 45% developed iBV. Sequencing was performed on 448 specimens from 14 cases and 8 healthy women. Among healthy women, Lactobacillus crispatus dominated the vaginal microbiota in 75%. In contrast, prior to iBV, the vaginal microbiota in 79% of cases was dominated by Lactobacillus iners and/or Lactobacillus jensenii/Lactobacillus gasseri. The mean relative abundance of Prevotella bivia, Gardnerella vaginalis, Atopobium vaginae, and Megasphaera type I became significantly higher in cases 4 days before (P. bivia), 3 days before (G. vaginalis), and on the day of (A. vaginae and Megasphaera type I) iBV onset. The mean relative abundance of Sneathia sanguinegens, Finegoldia magna, BV-associated bacteria 1-3, and L. iners was not significantly different between groups before onset of iBV. Conclusion G. vaginalis, P. bivia, A. vaginae, and Megasphaera type I may play significant roles in iBV.

Among women, trichomoniasis is the most common non-viral sexually transmitted infection worldwide, and is associated with serious reproductive morbidity, poor birth outcomes, and amplified HIV transmission. Single-dose metronidazole is the first-line treatment for trichomoniasis. However, bacterial vaginosis can alter treatment efficacy in HIV-infected women, and single-dose metronidazole treatment might not always clear infection. We compared single-dose metronidazole with a 7-day dose for the treatment of trichomoniasis among HIV-uninfected, non-pregnant women and tested whether efficacy was modified by bacterial vaginosis.In this multicentre, open-label, randomised controlled trial, participants were recruited at three sexual health clinics in the USA. We included women positive for Trichomonas vaginalis infection according to clinical screening. Participants were randomly assigned (1:1) to receive either a single dose of 2 g of metronidazole (single-dose group) or 500 mg of metronidazole twice daily for 7 days (7-day-dose group). The randomisation was done by blocks of four or six for each site. Patients and investigators were aware of treatment assignment. The primary outcome was T vaginalis infection by intention to treat, at test-of-cure 4 weeks after completion of treatment. The analysis of the primary outcome per nucleic acid amplification test or culture was also stratified by bacterial vaginosis status. This trial is registered with ClinicalTrials.gov, number NCT01018095, and with the US Food and Drug Administration, number IND118276, and is closed to accrual.Participants were recruited from Oct 6, 2014, to April 26, 2017. Of the 1028 patients assessed for eligibility, 623 women were randomly assigned to treatment groups (311 women in the single-dose group and 312 women in the 7-day-dose group; intention-to-treat population). Although planned enrolment had been 1664 women, the study was stopped early because of funding limitations. Patients in the 7-day-dose group were less likely to be T vaginalis positive at test-of-cure than those in the single-dose group (34 [11%] of 312 vs 58 [19%] of 311, relative risk 0·55, 95% CI 0·34-0·70; p0·0001). Bacterial vaginosis status had no significant effect on relative risk (p=0·17). Self-reported adherence was 96% in the 7-day-dose group and 99% in the single-dose group. Side-effects were similar by group; the most common side-effect was nausea (124 [23%]), followed by headache (38 [7%]) and vomiting (19 [4%]).The 7-day-dose metronidazole should be the preferred treatment for trichomoniasis among women.National Institutes of Health.

BACKGROUND: While there has been increasing interest in patient engagement, few measures are publicly available and suitable for patients with limited health literacy. OBJECTIVE: We sought to develop a Consumer Health Activation Index (CHAI) for use among diverse patients. METHODS: Expert opinion, a systematic literature review, focus groups and cognitive interviews with patients were utilized to create and revise a potential set of items. Psychometric testing guided by item response theory was then conducted among 301 English-speaking, community-dwelling adults. This included differential item functioning analyses to evaluate item performance across participant health literacy levels. To determine construct validity, CHAI scores were compared to scales measuring similar personality constructs. Associations between the CHAI, physical and mental health established predictive validity. A second study among 9,478 adults was used to confirm CHAI associations with health outcomes. RESULTS: Exploratory factor analyses revealed a single factor solution with a 10-item scale. The CHAI showed good internal consistency (alpha=0.81) and moderate test-retest reliability (ICC=0.53). Its reading grade level was found to be at the 6(th) grade. Moderate to strong correlations were found with similar constructs (Multidimensional Health Locus of Control; r=0.38, p

Neisseria gonorrhoeae and Chlamydia trachomatis are well-documented urethral pathogens, and the literature supporting Mycoplasma genitalium as an etiology of urethritis is growing. Trichomonas vaginalis and viral pathogens (herpes simplex virus types 1 and 2 and adenovirus) can cause urethritis, particularly in specific subpopulations. New data are emerging regarding the potential role of bacterial vaginosis-associated bacteria in urethritis, although results are inconsistent regarding the pathogenic role of Ureaplasma urealyticum in men. Mycoplasma hominis and Ureaplasma parvum do not appear to be pathogens. Men with suspected urethritis should undergo evaluation to confirm urethral inflammation and etiologic cause. Although nucleic acid amplification testing would detect N. gonorrhoeae and C. trachomatis (or T. vaginalis if utilized), there is no US Food and Drug Administration-approved clinical test for M. genitalium available in the United States at this time. The varied etiologies of urethritis and lack of diagnostic options for some organisms present treatment challenges in the clinical setting.

Introduction A recent meta-analysis demonstrated superiority of multi-dose metronidazole (MTZ) over the CDC and WHO recommended 2 g dose for the treatment of T. vaginalis (TV). Another study among HIV+ women with TV found higher test-of-cure (TOC)+ rates among women who had asymptomatic bacterial vaginosis (BV) than those without BV. The purpose of this study was to measure the TOC TV+ rate and to examine if the presence of BV influenced that rate. Methods HIV-/TV+ women treated with 2 g oral directly observed MTZ and who completed their TOC visit 3–12 weeks post treatment were included. Women were tested for TV using NAAT and surveyed via computer at baseline and TOC. Nugent scores≥7, calculated from vaginal gram stain, were considered BV+. MTZ susceptibility testing was performed on TOC TV+ specimens. Results Of 227 TV+ women included baseline the mean age was 31.3 (S.D. 9.9), 95.2% were African American, 39.3% had multiple male partners in the prior 3 months, 32.3% regularly smoked, 19.4% were binge drinkers, 48.9% had BV and 5.4% had yeast on the gram stain. At TOC, 19.8% were NAAT TV+. Of the 45 TOC-TV+ women, 44 provided sexual exposure information and 10/44 (24.4%) reported sexual re-exposure to baseline partner or sexual exposure to a new partner. Two of 26 (7.7%) TOC+ specimens that underwent susceptibility testing had low to moderate MTZ resistance (50–100 ug/ml). There were no differences in TOC NAAT+ rates by BV, sexual re-exposure to a baseline partner, sexual exposure to a new partner, regular smoking, binge drinking, or by the presence of yeast (p>0.22). Conclusion TOC NAAT+ rate after 2 g MTZ dose was high (19.8%) and isolates from these women were susceptible to MTZ (94.3%). Most TOC+ women (75.6%) reported no sexual exposure/re-exposure during follow-up suggesting that most cases were treatment failures. Selected behavioural factors and BV did not did not appear to influence TV treatment. The 2 g MTZ dose for TV recommended by CDC and WHO, should be reevaluated in light of more sensitive NAAT.

Introduction Both Trichomonas vaginalis (TV) and bacterial vaginosis (BV) cause vaginitis and place women at higher risk for HIV infection. Both are treated with metronidazole (Mtz) but at different doses. The purpose of this study was to examine the co-occurrence of these infections and BV treatment outcomes among TV+/BV+ women multi-dose Mtz for the treatment of TV. Methods Women attending three sexually transmitted disease clinics in the southern US who had a diagnosis of TV (culture or NAAT confirmed) were interviewed and examined for BV using a Nugent score ≥7. Women were randomised to either 2 g single dose or 500 mg Mtz BID for 7 days multi-dose for the treatment of TV and followed 3–12 weeks post TV treatment and retested for both TV and BV. Medical records were abstracted for Amsel criteria for a subset of the cohort. Results Of 528 TV+ women at baseline, 49.8% also had BV per Nugent score, 44.3% reported a history of BV and 5.9% also had yeast. Of 289 women whose medical records were abstracted, 23.5% had a vaginal discharge consistent with BV (i.e. thin and white/grey), and 34.1% were BV+ per Amsel at baseline. Of the 46 women who were BV+ at baseline per Amsel (i.e. diagnosed at point of care) and per Nugent (i.e. lab diagnosed) and were treated with multi-dose Mtz, 96% reported taking all their medicine. While 36% of these women reported condomless sex during follow-up, there was no association between sexual exposure and BV status at TOC. Of these 46 women, 42.9% remained BV+ at TOC and 19.4% reported BV-related symptoms. BV status at TOC was not associated with TV cure rates (p>0.56). Conclusion A high rate of BV co-infection (49.8%) was found among women with TV, much of which was asymptomatic. The rate of BV persistence post multi-dose Mtz was also high both microbiologically (42.9%) and clinically (19.4%) and did not appear to be influenced by TV treatment status. Additional research and development of novel therapeutics (i.e. biofilm disruptors) are urgently needed for women with BV, particularly among TV+ women where BV rates are high.

Alcohol abuse is a widespread problem among those at risk for and living with HIV and can impact transmission and disease progression. In this study we sought to use the simian immunodeficiency virus (SIV)-macaque model to evaluate the immunological and virological changes in the genital microenvironment of females exposed to chronic alcohol. Female rhesus macaques were treated with alcohol (n=6) or isocaloric sucrose (n=6) for 3 months and then inoculated with SIVmac251. To assess the effects of chronic alcohol on SIV disease and the genital microenvironment, we quantified plasma and genital SIV levels, measured inflammatory cells in genital fluids, and characterized microbial flora by gram stains over 10 weeks post-SIV infection. Following 3 months of alcohol/sucrose treatment, significant differences were observed in the vaginal microenvironment of alcohol-treated animals as compared to controls. Microbial flora of alcohol-treated animals had decreased levels of lactobacillus morphotypes and increased levels of gram-positive cocci relative to sucrose controls. Alcohol-treated animals were also more likely to have white blood cells in vaginal fluids prior to SIV inoculation, which persisted through viral set point. Similar levels of cell-free SIV were observed in plasma and vaginal fluids of both groups, but alcohol-treated animals had a higher incidence and levels of cell-associated SIV shed in vaginal secretions. Chronic alcohol treatment negatively impacts the genital microenvironment prior to and over the course of SIV infection and may increase the risk of genital virus shedding and transmission.

Mycoplasma genitalium causes persistent urogenital tract infection in humans. Antigenic variation of the protein encoded by the MG192 gene has been proposed as one of the mechanisms for persistence. The aims of this study were to determine MG192 sequence variation in patients with chronic M. genitalium infection and to analyze the sequence structural features of the MG192 gene and its encoded protein. Urogenital specimens were obtained from 13 patients who were followed for 10 days to 14 months. The variable region of the MG192 gene was PCR amplified, subcloned into plasmids, and sequenced. Sequence analysis of 220 plasmid clones yielded 97 unique MG192 variant sequences. MG192 sequence shift was identified between sequential specimens from all but one patient. Despite great variation of the MG192 gene among and within clinical specimens from different patients, MG192 sequences were more related within M. genitalium specimens from an individual patient than between patients. The MG192 variable region consisted of 11 discrete subvariable regions with different degrees of variability. Analysis of the two most variable regions (V4 and V6) in five sequential specimens from one patient showed that sequence changes increased over time and that most sequences were present at only one time point, suggesting immune selection. Topology analysis of the deduced MG192 protein predicted a surface-exposed membrane protein. Extensive variation of the MG192 sequence may not only change the antigenicity of the protein to allow immune evasion but also alter the mobility and adhesion ability of the organism to adapt to diverse host microenvironments, thus facilitating persistent infection.

Objective To describe the trends in chlamydia positivity among New Orleans high school students tested in a schoolwide screening between 1996 and 2005, and to determine factors associated with chlamydia positivity among students during the 10-year period. Methods Between school years 1995–1996 and 2004–2005, students in New Orleans public high schools were tested for chlamydia using nucleic acid amplification tests (NAAT) in urine specimens (LCx assay until 1999–2000; BD assay from 2000–2001 to 2004–2005). For each year, we calculated chlamydia positivity by dividing the number of students testing positive by the total number of students tested. Data were analyzed separately by gender. Logistic regressions were performed to determine independent predictors of chlamydia positivity during the 10-year period. Results Between 1996 and 2005, the average chlamydia positivity was 7.0% (95% confidence interval 6.6–7.4) in boys and 13.1% (95% confidence interval 12.6–13.7) in girls ( P .001). Chlamydia detection increased with the switch from LCx to BD assay. In multivariate analyses, chlamydia positivity among boys and girls was significantly associated with age, black race, and gonorrhea coinfection. Additionally, positivity was significantly different by school year among boys ( P = .03) and by NAAT used among girls ( P = .008). Conclusions The trends in chlamydia positivity observed between 1996 and 2005 more likely reflected a high and stable prevalence of chlamydia in the New Orleans school-age adolescent population. Any benefit of screening on individuals tested was likely to be mitigated by participants' uninterrupted social interactions with the dynamic forces that sustain the sexual transmission of chlamydia in the population.

Objectives Recently developed genotyping tools allow better understanding of Trichomonas vaginalis population genetics and epidemiology. These tools have yet to be applied to T vaginalis collected from HIV + populations, where understanding the interaction between the pathogens is of great importance due to the correlation between T vaginalis infection and HIV transmission. The objectives of the study were twofold: first, to compare the genetic diversity and population structure of T vaginalis collected from HIV + women with parasites from reference populations; second, to use the genetic markers to perform a case study demonstrating the usefulness of these techniques in investigating the mechanisms of repeat infections. Methods Repository T vaginalis samples from a previously described treatment trial were genotyped at 11 microsatellite loci. Estimates of genetic diversity and population structure were determined using standard techniques and compared with previously reported estimates of global populations. Genotyping data were used in conjunction with behavioural data to evaluate mechanisms of repeat infections. Results T vaginalis from HIV + women maintain many of the population genetic characteristics of parasites from global reference populations. Although there is evidence of reduced diversity and bias towards type 1 parasites in the HIV + population, the populations share a two-type population structure and parasite haplotypes. Genotyping/behavioural data suggest that 36% (12/33) of repeat infections in HIV + women can be attributed to treatment failure. Conclusions T vaginalis infecting HIV + women is not genetically distinct from T vaginalis infecting reference populations. Information from genotyping can be valuable for understanding mechanisms of repeat infections.

Sexually transmitted bacterial infections are among the most commonly reported notifiable diseases in the United States [1]. Mycoplasma genitalium is an emerging cause of male and female urogenital inflammation and has been implicated in male urethritis [2] and in several lower and upper reproductive tract syndromes of women, including cervicitis, pelvic inflammatory disease, and tubal-factor infertility [3, 4]. M. genitalium can persist for extended periods at urogenital sites, including the endocervix [5–8]. However, mechanistic evidence for establishment and persistence of infection remains scarce. Importantly, the host innate and adaptive immune responses are largely unknown and serve as impediments to our understanding of the pathogenesis of M. genitalium infection. Several lines of clinical evidence exist for M. genitalium as an independent cause of cervical inflammation [3, 4]. First, M. genitalium is a common endocervical infection, with prevalence values on par with those of other sexually transmitted infections (STIs), and has been associated significantly with cervicitis in pooled calculations of risk from 14 studies of high- and low-risk populations (odds ratio, 2.2; 95% confidence interval, 1.6–2.9) [4]. In addition, persistent cervical infection appears to be common, with an incidence of chronic M. genitalium infection of >20% in one longitudinal study [6]. Last, although the primary site(s) of infection is unknown, the mechanisms of disease are intriguing because M. genitalium has the smallest genome of any known human bacterial pathogen [9] and, consequently, represents a minimal bacterium to investigate mucosal pathogenesis. Experimental evidence also supports the hypothesis that M. genitalium infection can lead to mucosal inflammation at female urogenital sites. First, the organism can survive and replicate in cultures of human vaginal, cervical, and endometrial epithelial cells [10–12], resulting in acute and persistent proinflammatory responses [10, 11]. Among lower reproductive tract sites, human endocervical epithelial cells are most responsive to M. genitalium infection [11], during which secretion of proinflammatory cytokines and chemokines appears to be mediated in part by activation of Toll-like receptors (TLRs) [13–15]. Intracellular localization is hypothesized to be an important strategy for evasion of the host immune response and has been observed clinically [16]. However, outside of focused evaluations of acute and persistent cytokine responses, the pathologic consequences of endocervical M. genitalium infection and host response are almost entirely unknown. We used a well-characterized and physiologically relevant model of human endocervical epithelial cells [17] to study interactions of M. genitalium with the host cell. This organotypic model effectively recapitulates physical structural and barrier properties necessary for studying host-microbe interactions [18]. Previously, microbial products have been shown to elicit a specific endocervical innate immune signature that included antimicrobial peptide and mucin expression [19]. Using next-generation sequencing and human transcriptome analysis, we report key cellular pathways that are activated during acute M. genitalium infection. Comparative analyses provide unique insight into the mechanisms of reproductive tract inflammation induced by M. genitalium.

This article summarizes the highlights of the expert technical consultation on bacterial vaginosis (BV), sponsored by the National Institute of Allergy and Infectious Disease and held in Washington, DC, on 8–9 April 2015. Many issues touched on in this article are discussed in much greater detail in the 6 preceding articles in this supplement to The Journal of Infectious Diseases. There was a consensus among the meeting attendees concerning the most important research issues in the field: the pathogenesis of the syndrome, way to optimize treatment, and the relative roles of sexual transmission and endogenous infection in BV epidemiology. This article concludes with a listing of BV and genitourinary tract research priorities that were discussed and agreed on by attendees. The most important of these included better characterization of vaginal microbiome community state subtypes, application of advanced “-omic” technologies to improve understanding of BV pathogenesis, further investigation of the relationships between the male and female genitourinary tract microbiomes, and the development of new drugs for BV treatment.

Background The epidemiology of bacterial vaginosis (BV) suggests it is sexually transmissible, yet no transmissible agent has been identified. It is probable that BV-associated bacterial communities are transferred from male to female partners during intercourse; however, the microbiota of sexual partners has not been well-studied. Results Pyrosequencing analysis of PCR-amplified 16S rDNA was used to examine BV-associated bacteria in monogamous couples with and without BV using vaginal, male urethral, and penile skin specimens. The penile skin and urethral microbiota of male partners of women with BV was significantly more similar to the vaginal microbiota of their female partner compared to the vaginal microbiota of non-partner women with BV. This was not the case for male partners of women with normal vaginal microbiota. Specific BV-associated species were concordant in women with BV and their male partners. Conclusions In monogamous heterosexual couples in which the woman has BV, the significantly higher similarity between the vaginal microbiota and the penile skin and urethral microbiota of the male partner, supports the hypothesis that sexual exchange of BV-associated bacterial taxa is common. Electronic supplementary material The online version of this article (doi:10.1186/s40168-016-0161-6) contains supplementary material, which is available to authorized users.

Mycoplasma genitalium , a human pathogen associated with sexually transmitted diseases, is capable of causing chronic infections, though mechanisms for persistence remain unclear. Previous studies have found that variation of the MgPa operon occurs by recombination of repetitive chromosomal sequences (known as MgPars) into the MG191 and MG192 genes carried on this operon, which may lead to antigenic variation and immune evasion. In this study, we determined the kinetics of MG192 sequence variation during the course of experimental infection using archived specimens from two chimpanzees infected with M. genitalium strain G37. The highly variable region of MG192 was amplified by PCR from M. genitalium isolates obtained at various time points postinfection (p.i.). Sequence analysis revealed that MG192 sequence variation began at 5 weeks p.i. With the progression of infection, sequence changes accumulated throughout the MG192 variable region. The presence of MG192 variants at specific time points was confirmed by variant-specific PCR assays and sequence analysis of single-colony cloned M. genitalium organisms. MG192 nucleotide sequence variation correlated with estimated recombination events, predicted amino acid changes, and time of seroconversion, a finding consistent with immune selection of MG192 variants. In addition, we provided evidence that MG192 sequence variation occurred during the process of M. genitalium single-colony cloning. Such spontaneous variation suggests that some MG192 variation is independent of immune selection but may form the basis for subsequent immune selection.

Background: In United States public schools, students in disciplinary alternative schools report engaging in risky sexual behaviors significantly more frequently than students in regular schools. We sought to determine whether the risk of chlamydia or gonorrhea infection in disciplinary alternative schools is significantly higher relative to the risk of infection in regular schools. Methods: A matched case-control study was retrospectively designed using data obtained from New Orleans public high school students tested for chlamydia and gonorrhea in a school-based screening between the years 2001 and 2003. Cases were 63 African American students tested at a disciplinary alternative school during the school years 2001-2002 (n = 36) and 2002-2003 (n = 27). Each case was matched to 4 controls by date of birth, sex and race among respectively 3029 and 2216 students contemporaneously tested in regular schools. Mantel-Haenszel procedures for matched-pair analysis were used to estimate odds ratios, confidence intervals (CI) and significance tests. Results: The odds ratio for chlamydia/gonorrhea infection associated with placement in disciplinary alternative school was 2.09 overall (95% CI 1.01, 4.30; p 0.40) among females and 3.25 (95% CI 1.18, 8.92; p < 0.025) among males. Conclusions: Behaviorally troubled adolescents in disciplinary alternative school placement are the highest risk group for sexually transmitted infection ever identified in United States public high schools. These students and the disciplinary alternative schools where they are placed would benefit most from screening. They should be considered first for inclusion in any school-wide chlamydia and gonorrhea screening initiative.