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Background Both the global incidence and prevalence of sexually transmitted infections continue to increase, affecting hundreds of millions of individuals, particularly in low-to middle-income countries. While a definitive diagnosis is desirable to inform STI treatment, syndromic management is the most widely used strategy in resource-limited settings. With the development of point-of-care (POC) tests, it is important to discuss how laboratories will need to adapt to new training and supervisory roles in support of testing which will largely be performed by peripheral clinical staff. Objectives To discuss potential applications of STI POC tests, how they could improve existing STI control strategies and the role of clinical and reference laboratories in support of initiatives to improve STI management and control activities. Sources Narrative literature review and expert opinion. Content The paper outlines the current status of the STI epidemic worldwide and discusses the problems associated with current approaches to control these infections, particularly in low resource settings. The roles of clinical and reference laboratories will need to change in order to provide support for POC and near-patient STI testing as these technologies are introduced into clinical as well as laboratory settings. Implications Laboratories will be expected to play a leading role in the introduction and implementation of POC and near-patient STI testing. They will be required to facilitate training and provide technical and supervisory support to clinical staff on the use of these technologies to augment existing STI management and surveillance programs. In order to provide quality service, they will need to develop, introduce and maintain sustainable local QC and EQA systems. Evidence from implementation research for introduction and scale up of STI POCTs in different STI epidemic and laboratory infrastructure settings is required.

Background Syndromic management for STIs can result in treating for several pathogens, which can lead to mistreatment and/or overtreatment. We implemented the PlexPCR® VHS, a qualitative real-time PCR assay for simultaneous detection of four pathogens: Treponema pallidum (TP), herpes simplex virus (HSV) types 1/2, and varicella zoster virus (VZV) in genital and extragenital lesions of STI-clinic users diagnosed with early syphilis. Methods We enrolled patients presenting early syphilis in Lima and Pucallpa, Peru. From any lesions, we collected lesion exudate with a dacron swab in a microtube with 500µl of lysis buffer, followed by DNA extraction and amplification using a conventional PCR assay to detect tp0574 and tp0548 target genes for TP. DNA samples were also amplified using the PlexPCR® VHS kit (SpeeDx, Australia). We assessed the performance of the PlexPCR® VHS kit TP component and conventional PCR compared to clinical diagnosis. Results We screened 51 lesions, most (86%) from patients with primary syphilis, 17% were atypical syphilis lesions (painful ulcers). PlexPCR® VHS detected only TP among 31/51 (61%), only HSV-2 among 7/51 (14%) and four (8%) co-infections (two of HSV-1/TP and two of HSV-2/TP). Nine (17%) were negative for all pathogens (four without detectable DNA) and none were VZV positive. The PlexPCR® VHS kit detected TP in 35/51 (69%) lesions compared to 29/51 (57%) detected by conventional PCR, indicating the percent agreement with clinical diagnosis. Among the nine atypical lesions, PlexPCR® VHS found four TP positive and three HSV-2 positive, while conventional PCR detected only three TP positive. Among the cases of primary syphilis, 32/44 (73%) had detectable TP DNA using PlexPCR® VHS and 27/44 (61%) using conventional PCR. Conclusions The PlexPCR® VHS kit increases the accuracy of TP detection from lesion samples. Other STI pathogens were also detected in lesions.

We read with great interest the manuscript by Marra et al that described the attenuation of syphilis detection in the blood and cerebrospinal fluid (CSF) in subsequent episodes of syphilis. The authors describe how asymptomatic infection significantly increased with the number of prior syphilis episodes, and that the odds of detecting Treponema pallidum DNA in blood or CSF at the index episode were lower in those with prior syphilis. This information validates prior studies we have conducted, which found differences in cytokine expression among individuals with serofast and treated syphilis. In our studies, we identified 20 pairs of cytokines that differed between active and treated syphilis and identified 3 cytokine networks that could potentially be useful for identifying active syphilis...

Objective: Using mixed methods, we conducted an acceptability study of an existing eHealth couples-based HIV prevention intervention with 42 male couples in Lima, Peru. Methods: Via individual-level interviews, 90% of couples reported high acceptability of the intervention, and liked the agreement builder activity the most. Results: Three key themes emerged, indicating couples wanted: more information about HIV treatment as prevention; suggestions to strengthen their own and familial relationships; the intervention to be more accessible for use (i.e., mobile). Conclusions: Findings suggest adaptation of the eHealth intervention is warranted to help fill a current gap in Public Health services: a couples-based HIV prevention intervention.

A study of men who have sex with men, transwomen, and female sex workers in Lima, Peru found that lifetime prevalence of syphilis was substantially lower in female sex workers compared with other groups., Background The syphilis epidemic continues to cause substantial morbidity worldwide and is worsening despite ongoing control efforts. Syphilis remains an important public health problem among 3 key populations: men who have sex with men (MSM), transgender women, and female sex workers. Methods We conducted a retrospective chart review of patients that received rapid point-of-care treponemal antibody tests from January 2019 to July 2019 in 4 sexually transmitted infection (STI) clinics in Lima, Peru. We assessed patient medical records for human immunodeficiency virus (HIV) infection, history of STIs, as well as sociodemographic and behavioral characteristics. Cross-sectional descriptive analyses were used to determine factors associated with treponemal positivity. Results We included 401 patient records in our analyses: 252 MSM, 31 transgender women, and 118 female sex workers. The overall median age of patients was 29.0 years (interquartile range, 24.0–36.0 years). Positivity on the treponemal test was 28.9% (95% confidence interval [CI], 24.3%–33.3%) overall, 37.7% (95% CI, 31.7%–44.0%) for MSM, 54.8% (95% CI, 36.0%–72.7%) for transgender women, and 3.4% (95% CI, 0.9%–8.5%) for female sex workers. In the bivariate analysis, treponemal positivity was also associated with receptive anal sex in the last 6 months in MSM (P < 0.01). Additionally, treponemal positivity increased with age (P = 0.0212) and varied by socioeconomic status (P < 0.01). Multivariate Least Absolute Shrinkage and Selection Operator logistic regression showed that treponemal positivity was highly associated with HIV coinfection (adjusted odds ratio, 5.42) and previous STI other than HIV or syphilis (adjusted odds ratio, 1.54). Conclusions A review of the medical records of members of 3 key populations who had recently received a rapid point-of-care treponemal test in Lima, Peru, revealed that lifetime prevalence of syphilis was high among MSM and transgender women, but low among female sex workers. Those results may indicate a need for more frequent, regular testing among MSM and transgender women—possibly in conjunction with HIV testing, and appropriate treatment of those shown to be positive.

Background Men who have sex with men (MSM) and male-to-female transgender women (transwomen) are disproportionately at risk of syphilis infection in Peru. Methods From 2013 to 2014, MSM and transwomen seeking human immunodeficiency virus (HIV) or sexually transmitted infection (STI) testing and/or treatment were recruited into a 2-year observational cohort study to determine predictors of recently acquired syphilis infection (defined as a rapid plasma reagin [RPR] titer ≥1:16 and a reactive treponemal antibody test) in Lima, Peru. At baseline, interviewers collected sociodemographic, behavioral, and medical characteristics from participants. All cohort participants were tested for syphilis, HIV, Chlamydia trachomatis (CT), and Neisseria gonorrhoeae (NG) infection. Using cross-sectional analyses, bivariate and multivariate models were used to determine factors associated with recently acquired syphilis infection and calculate adjusted prevalence ratios. Results We recruited 401 participants, 312 MSM and 89 transwomen, with median ages of 29.0 and 32.5 years old (interquartile ranges: 23.3, 37.4 and 27.2, 39.5, respectively). The prevalence of recently acquired syphilis infection at baseline was 16.8% for MSM and 6.7% for transwomen. Among MSM and transwomen, 30.1 and 33.7% were infected with HIV, 18.6 and 24.7% were infected with CT, and 14.2 and 19.1% were infected with NG, respectively. Co-infection rates among MSM with recently acquired syphilis infection included: 44.2% with HIV, 40.4% with CT (32.7% with anal CT and 7.7% with pharyngeal CT), and 19.2% with NG (11.5% with anal NG and 7.7% with pharyngeal NG). Co-infection rates among transwomen with recently acquired syphilis infection included: 66.7% with HIV, 0% with CT, and 16.7% with anal NG. In multivariate analysis among the entire cohort, recently acquired syphilis infection was independently associated with younger age (adjusted prevalence ratio [aPR] = 0.96, 95% confidence interval [CI] = 0.93–0.99), receptive role during anal sex (aPR = 2.56, 95% CI = 1.05–6.25), prior HIV diagnosis (aPR = 1.70, 95% CI = 1.11–2.61), anal CT or NG infection (aPR = 1.69, 95% CI = 1.09–2.60), and prior syphilis diagnosis (aPR = 3.53, 95% CI = 2.20–5.68). Conclusions We recruited a cohort of MSM and transwomen who had a high prevalence of recently acquired syphilis infection in Lima, Peru. Recently acquired syphilis infection was associated with socio-demographic characteristics, sexual risk, and sexually transmitted co-infections.

Background Bacterial sexually transmitted infections (STIs) are preventable, treatable, and have been increasing among men who have sex with men due to limited STIs/HIV screening and high-risk sexual behaviors, including partner concurrency and condomless anal sex. Within stable relationships, sexual behavior patterns may change over time. This analysis was conducted to estimate if relationship length is associated with STIs prevalence among gay men couples. Methods Gay men who reported having a primary relationship answered a survey and were tested for bacterial STIs (syphilis, chlamydia or gonorrhea) during 2015 in Lima, Peru. Among couples, discordant STI status (only one partner had an STI) and concordant status (both partners had the STI) were compared by STI. Generalized linear models, controlling for correlation between couple members, were used to estimate adjusted prevalence ratios (aPRs). Results Overall, 254 individuals were included (98 couples and 58 one partner only). Median age was 26 years (IQR: 22–30), 62 individuals (24.4%) reported sex outside their relationship and 76 (29.9%) were diagnosed with at least one bacterial STI. Regarding relationship length, 86 (33.9%) had been in their current relationship Conclusion Our data suggest STIs prevalence is lower among gay men in longer term relationships. Future studies on gay male couples should consider the effect of relationship length on sexual behavior patterns to implement interventions for reducing STIs occurrence based on findings in a gay couple context. Disclosure No significant relationships.

HIV status awareness is key to prevention, linkage-to-care and treatment. Our study evaluated the accessibility and potential willingness of HIV self-testing among men who have sex with men (MSM) and transgender women in Peru. We surveyed four pharmacy chains in Peru to ascertain the commercial availability of the oral HIV self-test. The pharmacies surveyed confirmed that HIV self-test kits were available; however, those available were not intended for individual use, but for clinician use. We interviewed 147 MSM and 45 transgender women; nearly all (82%) reported willingness to perform the oral HIV self-test. However, only 55% of participants would definitely seek a confirmatory test in a clinic after an HIV-positive test result. Further, price may be a barrier, as HIV self-test kits were available for 18 USD, and MSM and transgender women were only willing to pay an average of 5 USD. HIV self-testing may facilitate increased access to HIV testing among some MSM/transgender women in Peru. However, price may prevent use, and poor uptake of confirmatory testing may limit linkage to HIV treatment and care.

Background Syphilis incidence worldwide has rebounded since 2000, particularly among men who have sex with men (MSM). A predictive model for syphilis infection may inform prevention counselling and use of chemoprophylaxis. Methods: Data from a longitudinal cohort study of MSM and transgender women meeting high-risk criteria for syphilis who were followed quarterly for 2 years were analysed. Incidence was defined as a four-fold increase in rapid plasma reagin (RPR) titres or new RPR reactivity if two prior titres were non-reactive. Generalised estimating equations were used to calculate rate ratios (RR) and develop a predictive model for 70% of the dataset, which was then validated in the remaining 30%. An online risk calculator for the prediction of future syphilis was also developed. Results: Among 361 participants, 22.0% were transgender women and 34.6% were HIV-infected at baseline. Syphilis incidence was 19.9 cases per 100-person years (95% confidence interval (CI) 16.3–24.3). HIV infection (RR 2.22; 95% CI 1.54–3.21) and history of syphilis infection (RR 2.23; 95% 1.62–3.64) were significantly associated with incident infection. The final predictive model for syphilis incidence in the next 3 months included HIV infection, history of syphilis, number of male sex partners and sex role for anal sex in the past 3 months, and had an area under the curve of 69%. The online syphilis risk calculator based on those results is available at: www.syphrisk.net. Conclusions: Using data from a longitudinal cohort study among a population at high risk for syphilis infection in Peru, we developed a predictive model and online risk calculator for future syphilis infection. The predictive model for future syphilis developed in this study has a moderate predictive accuracy and may serve as the foundation for future studies.

Venue-based testing may improve screening efforts for HIV and syphilis, thereby reducing transmission. We offered onsite rapid dual HIV and syphilis testing at venues popular among MSM and/or transgender women in Lima, Peru. We used Poisson regression to calculate adjusted prevalence ratios (aPRs) for factors associated with each infection. Most (90.4%) of the 303 participants would test more frequently if testing was available at alternative venues. New cases of HIV (69) and syphilis infection (84) were identified. HIV was associated with recent sex work (aPR 1.11; 95% CI 1.02–1.22), sex with a partner of unknown serostatus (aPR 1.18; 95% CI 1.09–1.27), exclusively receptive anal sex role (aPR 1.16; 95% CI 1.03–1.30) or versatile sex role (aPR 1.17; 95% CI 1.06–1.30) compared to insertive. Syphilis was associated with reporting role versatility (aPR = 2.69; 95% CI 1.52–5.74). Sex work venues had higher syphilis prevalence 47% versus 28% in other venues, p value = 0.012. Venue-based testing may improve case finding.

Extra-genital Neisseria gonorrhoeae and Chlamydia trachomatis infections are associated with antimicrobial resistance and HIV acquisition. We analyzed data from a cohort of men who have sex with men (MSM) and transgender women followed quarterly for two years in Peru. Incident cases were defined as positive N. gonorrhoeae or C. trachomatis nucleic acid tests during follow-up. Repeat positive tests were defined as reinfection among those with documented treatment. We used generalized estimating equations to calculate adjusted incidence rate ratios (aIRRs). Of 404 participants, 22% were transgender. Incidence rates of rectal N. gonorrhoeae and C. trachomatis infection were 28.1 and 37.3 cases per 100 person-years, respectively. Incidence rates of pharyngeal N. gonorrhoeae and C. trachomatis infection were 21.3 and 9.6 cases per 100 person-years, respectively. Incident HIV infection was associated with incident rectal (aIRR = 2.43; 95% CI 1.66–3.55) N. gonorrhoeae infection. Identifying as transgender versus cisgender MSM was associated with incident pharyngeal N. gonorrhoeae (aIRR = 1.85; 95% CI 1.12–3.07) infection. The incidence of extra-genital N. gonorrhoeae and C. trachomatis infections was high in our population. The association with incident HIV infection warrants evaluating the impact of rectal N. gonorrhoeae screening and treatment on HIV transmission.

Objectives Syphilis infection persists globally contributing to preventable and treatable morbidity and mortality. How extensive early syphilis disseminates is unknown. To better understand the relationship between early syphilis infection and inflammation over time, our study enrolled six individuals recently infected with syphilis for sequential positron emission tomography (PET) scans. Methods We evaluated a case series of six individuals with high syphilis titres (two secondary, two early latent and two latent, unknown duration, but with high titre) who received sequential PET scans to assess inflammation over time and its response to treatment. Results At time of PET scan, four of the six individuals were co-infected with HIV. One of the four was not on antiretroviral therapy and three of the four were not virally suppressed (viral load of >400 copies/mL). Baseline rapid plasma reagin (RPR) titres ranged from 1:64 to 1:256 (four of the six participants had prior non-reactive RPR results). Five of the six participants had mild to intense hypermetabolic PET scan activity consistent with cervical (n=5), axillary (n=4), inguinal (n=5) and retroperitoneal (n=1) adenopathy. Mild hypermetabolic activity in the thoracic aortic wall, suggesting aortitis, was present among the same five participants and resolved within 30 days for four of the five participants and 60 days for the other participant. However, widespread lymphadenopathy remained present in PET scans up to 3 months following treatment in two participants. We did not find any abnormal PET scan activity of the central nervous system. Conclusion We found abnormal aortic wall PET scan activity suggesting aortitis to be common in a case series of patients with early syphilis. In research settings, PET scans may be a sensitive tool to monitor inflammation associated with syphilis.

Introduction Syphilis incidence worldwide has rebounded since 2000, especially among men who have sex with men (MSM). A predictive model for incident syphilis infection may inform prevention counselling and use of chemoprophylaxis. Methods We analysed data from a longitudinal study of a STD clinic-based cohort of MSM and transgender women reporting a history of HIV or syphilis infection and/or high-risk sexual behaviour, followed quarterly for two years. Incident infection was defined as a four-fold increase in RPR titers or new RPR reactivity if two prior titers were non-reactive. We used generalised estimating equations with a Poisson regression to develop a predictive model of syphilis incidence in one-half of the data set, and verified the model in the second half, calculating an area under the curve (AUC), summarising specificity and sensitivity. We then applied the final model to the full baseline dataset. Finally we developed an online risk calculator from our model. Results Among 401 participants enrolled, 22% were transgender women and 31% were HIV-infected at baseline. Syphilis incidence was 19.9 cases per 100-person years (95% CI 16.3–24.3). Predictors of syphilis incidence were HIV infection, high number of male sex partners (categorised as: 0, 1, 2–3, 4–9,>10), history of syphilis infection, receptive and versatile anal sex role and condomless receptive anal sex. The AUC was 71% (95% CI 64%–78%) in the validation dataset for incident syphilis infection in the next 3 months. Those at highest risk had a 1-in-7 likelihood of syphilis infection in the next 3 months. When applied to the baseline dataset the AUC was 71% (95% CI 65%–77%) for predicting recent syphilis infection. The online syphilis risk calculator is available at: www.syphrisk.net (English), www.sifriesgo.net (Spanish). Conclusion Our results show that the likelihood of syphilis infection among a high-risk STD clinic-based cohort can be estimated accurately. Our calculator may guide STD clinical management by directing risk behaviour counselling and potential use of doxycycline chemoprophylaxis.

Introduction Non-urethral N. gonorrhoeae infections have been associated with antimicrobial resistance as well as increased HIV transmission and acquisition, however, incidence data from low and middle-income countries are lacking. Methods We collected anal and pharyngeal specimens from MSM and transgender women seeking sexually transmitted disease clinical services quarterly for 2 years. Incident infection was defined as having a positive nucleic acid test among those with no prior infection or prior treatment. We used generalised estimating equations to calculate adjusted incident rate ratios (aIRR). We grouped infections by anatomic site. All models included any condomless sex and number of male sex partners in prior 3 months. Results Of 401 participants, 22% identified as transgender and 31% had HIV infection at baseline. Incidence of anal infection was 30 and 40 cases per 100 person-years with N. gonorrhoeae and C. trachomatis , respectively, while incidence of pharyngeal infection was 22 and 12 cases per 100 person-years with N. gonorrhoeae and C. trachomatis , respectively. In the pharyngeal infection model with either organism, transgender identification was positively associated (aIRR=2.1; 95% CI 1.4–3.0) compared with MSM, whereas each decade increase in age was negatively associated (aIRR=0.7; 95% CI 0.6–0.9). In the anal infection model with either organism, HIV infection was positively associated (aIRR=1.6; 95% CI 1.2–2.1), whereas each decade increase in age was negatively associated (aIRR=0.7; 95% CI 0.6–0.9). Anal infection incidence was increased in those reporting receptive (aIRR=2.7; 95% CI 1.5–4.9) and both receptive/insertive (aIRR=2.6; 95% CI 1.5–4.6) sex versus reporting exclusively insertive sex. Conclusion Incident non-urethral N. gonorrhoeae and C. trachomatis infections were common among MSM and transgender women in Lima, Peru, adding to the paucity of data from Latin America, especially among transgender women. Our findings support World Health Organisation recommendations for anal screening and argue for the addition of pharyngeal screening.

Alcohol abuse can influence sexual risk behavior; however, its measurement is not straightforward. This study compared self-reported alcohol use, via the AUDIT and CAGE, with levels of phosphatidylethanol (Peth), a phospholipid biomarker that forms with chronic, heavy drinking, among high-risk MSM and TW in Lima, Peru. Chi-square, Fisher’s exact, Wilcoxon ranksum tests compared the instruments. Receiver operating curves determined sensitivity and specificity of the self-reported measures. Among 69 MSM and 17 TW, PEth was positive for 86% (95% CI 77% – 93%) of participants, while 67% reported binge-drinking in the last 2 weeks. The AUDIT classified 25% as hazardous drinkers while CAGE identified 6% as problem drinkers. Self-reported binge drinking was more sensitive than the AUDIT for PEth positivity (71% vs. 27%, p=0.022). Among high-risk MSM and TW in Lima, validated, self-report measures of alcohol abuse underestimated biological measures. Further research correlating bio-markers and self-reported alcohol abuse measures is needed.

BACKGROUND: Men who have sex with men (MSM) and transgender women (TW) in Peru bear a disproportionate burden of human immunodeficiency virus (HIV) and sexually transmitted infections (STIs). In a context of quickly expanding communication technology, increasing numbers of MSM and TW are using social media applications to seek sex partners. Understanding social media users and their sex partnering practices is needed to update HIV and STI prevention programming. METHODS: In Lima, Peru, 312 MSM and 89 TW from 2 STI clinics underwent HIV and STI testing and participated in a survey of demographics, behaviors, sexual health, and social media practices. chi, t tests, and Wilcoxon Mann-Whitney tests were used to compare those with and without recent social media sex partners. RESULTS: Men who have sex with men with social media sex partners were younger, more educated, and more likely to identify as gay. They were significantly more likely to report greater numbers of sex partners, including anonymous sex partners; sex in higher-risk venues, orgies, and have rectal Neisseria gonorrhoeae or Chlamydia trachomatis infection. Transgender women with social media sex partners were also younger, more likely to participate in sex work, and have a lower rate of rapid plasma reagin positivity or history of syphilis. Participants reported using several social media sites including sexual hook-up applications, websites for gay men, pornographic websites, and chat sites, but the most common was Facebook. CONCLUSIONS: Prevention strategies targeting Peruvian MSM and TW who use social media are needed to address higher-risk sexual behavior and the high burden of STIs.

We report the circulating genotypes and the frequency of macrolide-resistance patterns among Treponema pallidum pallidum DNA isolated from syphilitic lesions from patients who attended 2 sexual health clinics in Lima, Peru. We implemented and used a molecular typing scheme to describe local T. pallidum pallidum strains. Among 14 specimens, subtype 14d/f was the most prevalent strain in 7 fully typed T. pallidum DNA specimens obtained from men who have sex with men and transgender women presenting with chancre-like lesions. No macrolide-resistance mutations were found in T. pallidum DNA from 10 lesions.

BACKGROUND: Alcohol use disorders (AUDs) may enhance the likelihood of risky sexual behaviors and the acquisition of sexually transmitted infections (STIs). Associations between AUDs with condomless anal intercourse (CAI) and STI/HIV prevalence were assessed among men who have sex with men (MSM) and transgender women (TW) in Lima, Peru. METHODS: MSM and TW were eligible to participate based on a set of inclusion criteria which characterized them as high-risk. Participants completed a bio-behavioral survey. An AUDIT score >/=8 determined AUD presence. Recent STI diagnosis included rectal gonorrhea/chlamydia, syphilis, and/or new HIV infection within 6 months. Prevalence ratios (PR) were calculated using Poisson regression. RESULTS: Among 312 MSM and 89 TW, 45% (181/401) had an AUD. Among those with an AUD, 164 (91%) were hazardous/harmful drinkers, and 17 (9%) had alcohol dependence. Higher CAI was reported by participants with an AUD vs. without, (82% vs. 72% albeit not significant). Reporting anal sex in two or more risky venues was associated with screening AUD positive vs. not (24% vs. 15%, p=0.001). There was no difference in recent STI/HIV prevalence by AUD status (32% overall). In multivariable analysis, screening AUD positive was not associated with CAI or recent STI/HIV infection. CONCLUSIONS: In our sample AUDs were not associated with CAI or new HIV infection/recent STI. However higher prevalence of CAI, alcohol use at last sex, and anal sex in risky venues among those with AUDs suggests that interventions to reduce the harms of alcohol should be aimed toward specific contexts.

ObjectivesThe relationship between sexual practices, identity and role among Latino men who have sex with men (MSM) and HIV risk is the subject of ongoing investigation but less is known about how these aspects of sexuality relate to human papilloma-virus (HPV), an independent risk factor for HIV. This observational study investigated the relationship between HPV and sexual practices, identity and role as well as other sexually transmitted infection (STI)/HIV risk factors among HIV-negative heterosexually and homosexually identified Peruvian MSM.SettingCommunity-based clinic for MSM in Lima, Peru.Participants756 subjects were screened based on inclusion criteria of: born anatomically male; age ≥18 years; had any anal intercourse with a man during the previous 12 months; residing in metropolitan Lima; HIV negative; willing to commit to twice-yearly clinic visits for 24 months; had not participated in an HIV or HPV vaccine study. 600/756 participants met the inclusion criteria and were enrolled, of whom 48% (284) identified as homosexual and 10% (57) as heterosexual, the basis of the analyses performed.ResultsCompared with homosexually identified MSM, heterosexually identified MSM had completed fewer years of formal education and were less likely to have: anogenital HPV or visible anal warts; given oral sex to a man; or used a condom with their most recent female sexual partner (all pConclusionsHPV burden, wart type (penile vs anal) and select HIV/STI risk behaviours differed between heterosexually and homosexually identified Peruvian MSM. Understanding the implications of these differences can lead to tailored HIV/STI prevention interventions for heterosexually identified MSM.Trial registration numberNCT01387412.

In Latin America, sexual role, sexual identity and sexual practices are intricately related; the roles activo , pasivo and moderno often encompass sexual identity and sexual practices. We aimed to understand the association between sexual role and HIV status in Peruvian men who have sex with men. HIV-testing services at Epicentro Salud, a Peruvian gay men’s health centre, were paired with clinic data on demographics and sexual behaviour. Bidirectional stepwise logistic regression was conducted to determine associations between sexual role and HIV status. Of 366 clients who underwent HIV testing, 86 (23.5%) tested positive. There was a strong association between sexual role (‘activo’ or typically insertive, ‘pasivo’ or typically receptive, ‘moderno’ or typically versatile) and a positive HIV test ( p = 0.002). Compared to clients with an activo role, those who reported a pasivo (OR = 6.14) and moderno (OR = 6.26) role were more likely to test positive for HIV. Sexual role was associated with sexual identity (gay, straight and bisexual) and gender of partners in the past six months. Self-reported pasivo and moderno sexual roles were strongly associated with a positive HIV test result. Further research should examine differences in sexual practices between sexual role groups.

Peruvian men who have sex with men (MSM) and transwomen (TW) could benefit from a rectal microbicide (RM) formulated as a rectal douche to prevent HIV infection. However, little is known about rectal douching practices among Peruvian MSM and TW, information necessary to inform RM douche development and future uptake. Using a self-administered interview, we examined the prevalence of and factors associated with rectal douching among a convenience sample of 415 Peruvian MSM and 68 TW. In the previous 6 months, 18 % of participants reported rectal douching using pre-filled commercial kits or plastic bottles or enema bags filled with water, water/soap or saltwater. Multivariate logistic analysis found that "equally insertive and receptive" or "exclusively/mainly receptive" sex roles were associated with douche use. Rectal douching among Peruvian MSM and TW is similar to reports from other studies and supports the potential uptake of a douche-formulated RM in these populations.

Background: Visible, anogenital warts may be associated with risk factors for HIV infection. This cross-sectional study examined the factors associated with visible anogenital warts among HIV-uninfected Peruvian men who have sex with men (MSM) and transwomen. Methods: Six hundred HIV-uninfected MSM and transwomen were recruited from a community-based setting in metropolitan Lima, Peru, through outreach activities. Participants were tested for syphilis, completed a behavioral questionnaire, and were examined for visible anogenitalwarts. Logistic regression was used to assess the independent association between sample characteristics, HIV-related risk factors, and visible anogenitalwarts. Results: A tertiary education versus a primary/secondary (adjusted odds ratio [AOR], 1.79; 95%confidence interval [CI], 1.07-2.99), a first experience of anal intercourse at age 20 years or older versus younger ages (AOR, 2.80; 95%CI, 1.45-5.38), and self-reporting of current sexually transmitted infection symptoms (AOR, 2.38; 95%CI, 1.61-3.52) were significant correlates of visible anogenitalwarts, whereas syphilis infection, transactional sex, receptive anal intercourse, and self-identifying as a transwoman were not. Conclusions: Although not associated with key risk factors for HIV infection in Peruvian MSM and transwomen, the presence of visible anogenital warts should prompt clinicians to consider the possibility of unreported same-sex sexual behaviors and other risk sexually transmitted infection/HIV risk factors.

Introduction The HIV epidemic in Latin America is concentrated among men who have sex with men (MSM) and transgender women (TGW) with transmission predominately occurring during unprotected anal intercourse. This mode of transmission is also responsible for other sexually transmitted infections (STIs) such as herpes simplex, chlamydia and gonorrhoea, human papillomavirus (HPV)/genital warts and syphilis. Studies assessing the prevalence of HIV and HPV among MSM have not addressed the role of genital warts and HPV-related diseases in the acquisition of HIV infection. Community-based testing programmes are a potentially important way to remove barriers including stigma for individuals to learn about their STI status. Methods and analysis The prospective cohort study will recruit 600 MSM/TGW at a community centre in Lima, Peru, named Epicentro. Half of the participants will have a history of or have current anogenital warts (AGW), and the other half will have no history of AGW. We will measure the prevalence and acquisition of STIs including syphilis, HPV, chlamydia and gonorrhoea and the HIV-incidence in the two groups. To the best of our knowledge, it will be the first study that specifically examines the impact of genital warts on incident HIV infection. This study will help to understand the relationship between AGW and HIV infection among MSM/TGW in Peru. Furthermore, it may facilitate the development of preventive intervention strategies to reduce the prevalence of AGW and prevent incident HIV infection. HPV-related manifestations may be a good proxy for HIV risk. Ethics and dissemination This study was approved by institutional review boards at the University of California, Los Angeles (UCLA) in the USA and Impacta in Peru. Study findings will be shared with the Peruvian Ministry of Health as well as other international and national public health organisations. Study results will be translated into Spanish for participants. Trial registration number The Clinicaltrials.gov registration number is NCT01387412

Background In Peru an estimated 70% of people who are HIV positive do not know their status. Knowing one’s HIV status is critical in HIV prevention. Oraquick® in-home HIV test is the first rapid HIV self-test U. S FDA-approved for home use. We aimed to assess its availability and the willingness of men who have sex with men (MSM) and transgender women (TW) to use it in Peru. Methods Four Pharmacy chains in Peru were surveyed to ascertain commercial availability of the Oraquick® in-home HIV test kits. High-risk MSM and TW who attended either of two STI clinics in Lima from June 2013 to May 2014 were surveyed. Data on demographics and willingness to use Oraquick® IN HOME HIV TEST kit were collected using an interviewer administered computer-based questionnaire. Results The Oraquick® Rapid HIV-1/2 test kit was available for purchase for home use by 4 (100%) pharmacy chains, 3 in Lima and one in northern Peru. The average test kit cost was 54 soles (18 USD); kits were available to clients 18 years or older for over-the-counter purchase. Of the 137 interviewed survey participants, 85% (n = 117) reported they would use a rapid home HIV self-test at least twice yearly. Respondents reported willingness to pay up to 21 soles (approximately 7 USD) for the test and in the event of positive results, to do the confirmatory blood test in a clinic. Also, 78% (n = 117) of participants reported being comfortable getting an HIV self-test kit by mail or for home use from a clinic. Conclusion Our findings show the potential utility for home HIV self-testing to enhance HIV serostatus awareness in Peru. Further studies are needed on utilisation and linkage to care and prevention services.

Background In Peru, syphilis disproportionally affects men who have sex with men (MSM) and male-to-female transgender women (TW) with prevalence rates as high as 21%. To our knowledge, there are no available data describing circulating strains of T. pallidum in Lima, Peru. We used the CDC subtyping scheme to identify T. pallidum circulating subtypes among MSM and TW from two STI clinics in Lima, Peru. Methods A cohort of 401 MSM and TW were assessed for syphilis infection at baseline and quarterly with RPR (BD Macro-Vue, USA) and TPPA (Fujirebio, Japan) testing up to 24 months. A dacron swab was used to collect exudate from chancre-like lesions and placed into 500 µL of lysis buffer. DNA extraction was performed using QIAamp mini kit (Qiagen, Valencia, CA). Using specific primers for Tp47 region target, an aliquot of the DNA sample was amplified using conventional PCR. Subtyping of T. pallidum TP47 positives was performed using detection of number of 60-bp tandem repeats in the arp gene and analysis by RFLP of 3 tpr genes (TprE, G, J) according to CDC guidelines. Results Among 401 participants, 26 presented with primary syphilitic lesions at baseline or follow-up with RPR (TPPA confirmed) titers ranging from 1:2–1:64. Of those 26 total lesions, 1 (7%) of 14 tested was dark-field positive. TP DNA screening using TP47 PCR yielded 12 (44.4%) positives. Among eight typable, four were subypes 14d (33.3%), two 15d (16.7%), one 16d (8.3%) and one 0d (16.7%) where 0 = non-typable arp. Conclusion T. pallidum subtypes 14d and 15d were the most prevalent strains in lesions obtained from MSM/TW who had chancre-like lesions in Lima, Peru. Dark field testing results and typing difficulties could be due to low bacterial load and needs to be considered in sampling methods. Disclosure of interest statement The study Picasso is funded by a NIAID grant and was implemented by Cayetano Heredia in collaboration with the University of California Los Angeles. The molecular part of the study was implemented under the supervision of the University of Washington. No pharmaceutical grants were received during the development of this study.

Introduction HIV in Peru is concentrated among men who have sex with men (MSM) and transgender women (TW). Over 70% of HIV+ MSM/TW ignore their status, as HIV testing frequency is low, delaying diagnosis and treatment. We aimed to assess the relationship between HIV testing frequency and perceived HIV risk among MSM/TW. Methods This analysis included baseline data from MSM/TW who reported a negative or unknown HIV status from a STI clinic cohort of MSM/TW at high risk in Lima. The behavioural survey assessed HIV risk perception (high, moderate, low) and prior testing frequency (testing was defined as frequent if it had occurred at least biannually). For HIV diagnosis, we used a 3 rd generation rapid test, a 4 th generation EIA, and Western Blot confirmation. Chi-square tests and multivariable regression were used to estimate adjusted prevalence ratios (aPRs). Results Among eligible subjects (243 MSM and 67 TW), 122 (39%) reported frequent prior HIV testing, while HIV risk was perceived as high, moderate and low by 72 (23%), 148 (48%) and, 90 (29%) participants, respectively. Frequent HIV testing was more prevalent among participants reporting low/no HIV risk (aPR: 1.62; CI: 1.20–2.20) and among those reporting previous syphilis infection (aPR: 1.58; CI: 1.22–2.04); but was less prevalent among participants reporting recent condomless anal intercourse (aPR: 0.67; CI: 0.51–0.90). Baseline HIV status and HIV risk perception were not associated: HIV prevalence was 11%, 13% and 10% among those reporting high, moderate and low/no HIV risk (chi-square p-value >0.1). Conclusion Frequent HIV testing was more prevalent among MSM/TW reporting low/no HIV risk. Risk perception did not correlate with HIV status among previously undiagnosed subjects. WHO-recommended biannual HIV testing should be promoted, and factors potentially affecting risk perception and testing frequency (e.g. access, stigma) should be identified and addressed by HIV programming for MSM/TW in Peru.

Introduction Low HIV serostatus awareness and delayed treatment initiation among people living with HIV (PLHIV) contribute to HIV sexual transmission. An unacceptably low proportion of PLHIV are aware of their HIV status in Latin America. Improved understanding of sexual risk among PLHIV could help guide HIV prevention strategies. Methods A cohort of 401 men who have sex with men (MSM) and transgender women at high risk were enrolled and assessed every three months for condomless sex and sexually transmitted infections (i.e. syphilis, HIV and anal chlamydia, and anal gonorrhoea). Among those who were positive at entry, we compared condomless sex and anal chlamydia/gonorrhoea according to prior knowledge of HIV serostatus; among those who seroconverted during follow-up, we compared condomless sex and anal chlamydia/gonorrhoea before vs. after HIV diagnosis, using McNemar’s Chi-square test. Results At baseline, 82 (20.5%) participants self-identified as HIV positive and an additional 42 (10.5%) were diagnosed with HIV. Among the 42 unknown HIV positives, 71% reported recent condomless receptive anal sex compared to 55% of known HIV positives (p-value = 0.078). No difference was observed in condomless insertive anal sex; 48% in each group. Among the 24 sero-converters during follow-up, 79% reported condomless receptive anal sex prior to their diagnosis and 32% after their diagnosis (59% decline, p-value = 0.001); 46% reported condomless insertive anal sex prior to their diagnosis and 14% after diagnosis (70% decline, p-value = 0.011). Anal gonorrhoea and/or chlamydia were diagnosed among 46% prior and 27% after diagnosis among the observed sero-converters (41% decline, p-value = 0.096). Conclusions Risk behaviours and concurrent STIs diminish after a new diagnosis, following the patterns previously reported elsewhere. Current prevention efforts for PLHIV are insufficient and must take into account motivations for sexual risk taking, encourage people to reach viral suppression, and improve available prevention strategies to prevent onward transmission of HIV. Disclosure of interest statement None.