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Introduction: Homelessness is associated with an increased risk of syphilis, HIV, and other STIs and disproportionately impacts sexual and gender minorities. Method: Data for this analysis came from a longitudinal cohort study of 285 urban gay, bisexual, and other men who have sex with men (MSM). The study aimed to (1) describe the prevalence of homelessness over time (2) identify characteristics associated with homelessness, and (3) measure associations between recent homelessness and substance use and STI/HIV risk behaviors three months later. Participants were recruited from clinical and non-clinical settings and attended a baseline visit and study visits every three months for up to 18-months. Data was collected between July 2018 and September 2020. Descriptive analyses and mixed-effects logistic regression models were utilized. Results: One-third of participants (94) reported experiencing homelessness throughout the study. Homelessness was significantly and independently associated with increased risk for future drug/alcohol use before/during sex (aOR: 3.8, 95% CI: 1.7, 8.6), methamphetamine use (aOR: 6.3 95% CI: 2.6, 15.2), injection drug use (adjusted odds ratio (aOR): 3.7, 95% CI: 1.0, 13.1), and sex exchange (aOR: 12.7; 95% CI: 5.5, 29.4). Conclusion: Interventions to reduce homelessness are necessary to lower risk of substance use and STI/HIV risk behaviors. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. Background: Successful linkage to preexposure prophylaxis (PrEP) and retention in care are important for HIV prevention. We examined gaps in PrEP care following referral and factors associated with PrEP linkage and persistence in an integrated health care system in the United States. Methods: We identified individuals referred for PrEP from 2014 to 2017 at the Kaiser Permanente Southern California using electronic health records and assessed linkage to care, PrEP prescription orders and fills, and PrEP persistence (medication possession ratio ≥80%) in the year after the first fill. We evaluated demographic and clinical factors potentially associated with PrEP linkage and persistence using a series of multivariable modified Poisson regression models. Results: Of 2995 referred individuals, 74.9% were linked to PrEP care. Nearly all those linked to care were prescribed PrEP and filled a prescription, but only 47.4% of those who filled a prescription were persistent on PrEP. Individuals aged <25 years (vs ≥25 years), female subjects (vs males), and individuals with high-deductible insurance (vs no high deductible) were less likely to be linked to care. Individuals aged <25 years and Hispanics (vs non-Hispanic whites) were less likely to be persistent. Those with alcohol use disorder were more likely to be linked to PrEP care but less likely to be persistent. New HIV diagnoses occurred in 38 individuals, and only 1 had PrEP in possession at diagnosis. Conclusions: We observed PrEP care gaps and disparities among individuals referred for PrEP. Patient-centered interventions are needed in primary care to address barriers to successful PrEP linkage and persistence. [ABSTRACT FROM AUTHOR]

Background: Reducing HIV incidence requires addressing persistent racial/ethnic disparities in HIV burden. Our goal was to evaluate preexposure prophylaxis (PrEP) delivery, overall and relative to community need, among 7 clinical sites participating in a health department-led demonstration project to increase PrEP in Baltimore city, MD. Methods: PrEP care continuum stages (screened, indicated, referred, linked, evaluated, prescribed) were examined among HIV-negative individuals receiving services at participating sites between September 30, 2015 and September 29, 2019. Community need was defined using information on new HIV diagnoses (2016-2018). Differences in care continuum progression by demographics/priority population and comparison of demographic compositions between care continuum stages and new HIV diagnoses were examined using modified Poisson regression and x2 tests, respectively. Results: Among 25,886 PrEP-screened individuals, the majority were non-Hispanic (NH) black (81.1%, n = 20,998), cisgender male (61.1%, n = 15,825), and heterosexual (86.7%, n = 22,452). Overall, 31.1% (n = 8063) were PrEP-indicated; among whom, 56.8% (n = 4578), 15.6% (n = 1250), 10.8% (n = 868), and 9.0% (n = 722) were PrEP-referred, linked, evaluated, and prescribed, respectively. Among 2870 men who have sex with men (MSM), 18.7% (n = 538) were PrEP-prescribed. Across all groups, the highest attrition was between PrEP-referred and PrEP-linked. NHblack race (vs. NH-white) was independently associated with lower likelihood of PrEP prescription (aPR, 0.89; 95% confidence interval, 0.81 to 0.98 controlling for age/gender). Relative to the demographic composition of new HIV diagnoses, fewer NH-blacks (80.2% vs. 54.3%) and more NH-whites (10.7% vs. 30.3%) and MSM were PrEP prescribed (55.2% vs. 74.5%). Conclusions: This project showed promise delivering PrEP referrals and prescriptions overall and to MSM. Substantial improvement is needed to improve linkage overall and to decrease disparities in PrEP prescriptions among NH-blacks. Future work should focus on addressing service gaps that hinder PrEP utilization. [ABSTRACT FROM AUTHOR]

Experiencing violence has been associated with negative health outcomes. The objectives of this study were to determine whether experiencing violence is associated increased support service needs and suboptimal general health indicators. In addition, we explore the relationship between these and perceived social support among a select sample of urban predominantly male adults in Baltimore City. A cross-sectional survey was conducted among 187 adults being seen in one of seven urban partner agencies participating in a parent HIV prevention and treatment demonstration project. Associations were examined using a multivariable logistic regression model, adjusting for the clinic site at which the client was being seen as well as age and gender identity. There was a significant amount of violence experienced by this population; 131 (72%) reported having seen someone be physically assaulted, and 89 (49%) had been physically assaulted without a weapon. Direct victimization from violence was associated with a threefold increased odds of needing housing and mental health/substance use services. Exposure to violence was associated with a threefold increase in needing housing and mental health/substance use services, and with sub-optimal health status. Perceived social support was associated with 30% decreased reports of experiencing violence. In conclusion, our select sample of urban adults report having experienced high rates of violence, and this is associated with increased support service needs as well as suboptimal perceived health status. Incorporating care for the effects of experiencing violence as well as social service needs are important in optimizing the health of urban populations. [ABSTRACT FROM AUTHOR]

Background: Individuals with repeat gonorrhea (re- GC) may be in high-prevalence sexual networks and are an important group for prioritizing prevention strategies. Prior studies of re-GC have limited generalizability, and/or defined re-GC as evidence of a previous diagnosis. We determined the incidence and characteristics associated with a future GC diagnosis within jurisdictions participating in the STD Surveillance Network (SSuN). Methods: We combined routine surveillance with demographic and behavioral data from interviews conducted among a representative sample of GC diagnoses reported from eight SSuN jurisdictions between January 2016-September 2018. Re-GC was defined as any subsequently reported GC diagnosis occurring > 30 days after the diagnosis and for which SSuN interview data were available. Person-time was calculated as time from the initial diagnosis to date of re-GC or September 30, 2019. We applied design weights and adjusted for non-response by sex and age. Poisson regression was used to assess differences across groups. Results: We included 10,466 SSuN-interviewed individuals contributing 21,778.5 person-years of follow-up (median: 2.1 person-years) representing 245,827 reported GC diagnoses. Re-GC was reported among 27.7% (95% confidence interval [CI]: 24.3%- 31.4%); 60.7% of re-GC diagnoses occurred ≤12 months. Overall incidence was 132.3/1000 personyears (124.7-140.5). Re-GC was strongly associated with gender/sexuality: men-who-have-sex-with-men (MSM; incidence rate ratio [IRR]: 3.22; 95% CI: 2.60- 3.99), transgender persons (IRR: 2.14; 95% CI:1.03- 4.44), and cisgender women (IRR: 0.71; 95% CI: 0.60- 0.83) vs. cisgender non-MSM; infection at extragenital sites compared to urogenital-only infections, particularly rectal infections (IRR: 3.11; 95% CI: 2.51-3.84) and infections at multiple sites (IRR: 3.30; 95% CI: 2.60-4.18); recent history of gonorrhea (≤12 months; IRR: 3.05; 95% CI: 2.61-3.56) vs. those with no history; and HIV-negative individuals on pre-exposure prophylaxis (PrEP; IRR: 3.86; 95% CI: 3.16-4.72) vs. non-PrEP patients. Conclusions: Re-GC was common, and frequently occurred ≤12 months of initial diagnosis. Sexual minorities, those with extragenital infections, recent gonorrhea history, and PrEP users had highest observed rates of re-GC. Our results could reflect more frequent screenings among sexual minorities and those on PrEP rather than increased transmission. Future work to identify subgroups of MSM, non-MSM and women at highest risk of re-GC will help to inform targeted interventions. [ABSTRACT FROM AUTHOR]

Background: In March 2020, Baltimore City Sexual Health Clinics implemented procedures to triage patients to in-person visits versus remote care to mitigate spread of COVID-19. Patients reporting syphilis and HIV symptoms/exposure were prioritized and offered in-person visits. Patients with other symptoms were referred for laboratory testing and remote management by telemedicine. Visits were available walk-in pre-COVID-19, but switched to appointment-based during-COVID-19. We sought to quantify the impact of service changes on testing and treatment for syphilis, gonorrhea (NG), and chlamydia (CT). Methods: We analyzed patient data during-COVID-19 (April 1, 2020 - October 31, 2021) and pre-COVID-19 (January 1, 2018- December 31, 2019). Visits were grouped into episodes, defined as groups of visits < 14 days apart. We described setting (in-person vs telemedicine), reason for encounter, STI testing ordered, testing outcomes, and treatment offered during episodes. We used chi-squared tests to compare characteristics and testing/treatment outcomes during- vs. pre-COVID-19, stratified by pathogen (syphilis, NG/CT) and anatomic site (NG/CT only). Asymptomatic STI testing request data were excluded as these were completed via a mail-in testing service. Extragenital testing was possible only in-person or via mail-in testing. Results: There were 10,680 visits and 7,734 episodes during-COVID-19, and 23,541 visits and 19,994 episodes pre-COVID-19. The majority of during- COVID-19 care-episodes was telemedicine-only (53.8%). Syphilis testing decreased (49.7% during-COVID-19 vs. 73.9% pre-COVID-19 p< 0.0001); treatment completion among patients diagnosed with early or late syphilis was similar across periods (p >0.05). During-COVID-19, among 799 episodes with self-reported genital lesions and contact to syphilis, 69.5% and 94.5%, respectively, had testing ordered, with little drop-off at testing completion. During-COVID-19, among 3,633 episodes with symptoms indicative of urethritis or cervicitis/vaginitis, about half (44.2%) received urogenital NG/CT testing, vs. 89.1% pre-COVID-19 (p< 0.0001). During-COVID-19, a majority of patients with rectal and oropharyngeal exposure (both 54.9%) received NG/CT testing at these sites. NG/CT treatment completion was higher during-COVID (p< 0.01, all anatomic sites). Conclusions: A dramatic reduction in STI testing for symptomatic patients was observed during-COVID- 19, in line with visit prioritization protocols. Protocols favoring remote management, empiric treatment, and multiple visits per episode may have contributed to reduced testing. Greater in-person availability was prioritized during service restoration. [ABSTRACT FROM AUTHOR]

Background: The release of the first drug for HIV pre-exposure prophylaxis (PrEP) in 2012 marked the beginning of a new era of HIV prevention. Although PrEP is highly efficacious, identifying and ultimately increasing uptake among the highest risk male subgroups remains a challenge.Methods: Public health surveillance data from 2009-2016 was used to evaluate the risk of an HIV diagnosis following a syphilis (i.e. primary, secondary, or early latent), gonorrhea, and repeat diagnosis among urban males including MSM and non-MSM in Baltimore City.Results: Of the 1,531 males with 898 syphilis diagnoses and 1,243 gonorrhea diagnoses, 6.8% (n=104) were subsequently diagnosed with HIV. Within two years, one in ten syphilis or gonorrhea diagnoses were followed by an HIV diagnosis among MSM, and one in fifty syphilis or gonorrhea diagnoses were followed by an HIV diagnosis among non-MSM. Among non-MSM with gonorrhea, the rate of HIV incidence was 5.36 (95% CI: 2.37-12.14) times higher in those with (vs. without) a subsequent syphilis and/or gonorrhea diagnosis.Conclusions: Local healthcare providers should offer PrEP to MSM diagnosed with syphilis or gonorrhea and to non-MSM with a previous gonorrhea diagnosis at time of a syphilis or gonorrhea diagnosis. The high proportion and short time to an HIV diagnosis among MSM after a syphilis or gonorrhea diagnosis suggests immediate PrEP initiation.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. [ABSTRACT FROM AUTHOR]