Background . Minimal data exist that describe the epidemiology of sexually transmitted infections (STI) in human immunodeficiency virus (HIV) positive populations across the pre- and post-diagnosis periods for HIV. Purpose . The purpose of this study was to identify and describe the epidemiology of gonorrhea, chlamydia, syphilis, herpes simplex virus, and human papillomavirus in an HIV-positive population. Methods . All 1,961 HIV seropositive United States active duty military personnel from 2000–2010 were identified. STI diagnoses relative to HIV diagnosis from 1995, which was the earliest electronic medical record available, to 2010 were examined. Results . The incidence diagnosis rates of STI generally increased during the period leading up to eventual HIV diagnosis. The rates of STI during the post-HIV diagnosis period fluctuated, but remained elevated compared to pre-HIV diagnosis period. Approximately 45%–69% with an STI in the HIV seropositive military population were diagnosed with their first STI greater than one year after their HIV diagnosis. Of those who were diagnosed with an STI in the post-HIV diagnosis period, 70.6% had one STI diagnosis, 23.5% had two STI diagnoses, and 5.8% had three or more STI diagnoses. Conclusions . Despite aggressive counseling, high-risk sexual behavior continues to occur in the HIV-positive military population.
The Global Emerging Infectious Surveillance Program of the U.S. Department of Defense, Armed Forces Health Surveillance Branch supports a repository for Neisseria gonorrhoeae (GC) clinical isolates recovered from routine care at U.S. Military Treatment Facilities in the continental US (CONUS) and at several overseas (OCONUS) labs though collaborative surveillance projects. Here we report the use of phenotypic data in conjunction with molecular typing and whole genome sequencing (WGS) of GC to describe the antimicrobial resistance trends from isolates collected from three geographically different clinics in Lima, Callao and Iquitos, Peru.
Methods
Putative GC collected from patients between 2012 and 2015 were confirmed as GC using standard biochemical and serological methods. Susceptibility to eight different antibiotics was determined by Etest. β-lactamase (ßL) activity was determined by nitrocefin hydrolysis. NG-MAST types were determined by standard methods and WGS analysis.
Results
Sixty eight out of 90 isolates examined were confirmed as GC. Antimicrobial susceptibility testing showed a high level of resistance to ciprofloxacin (70%) and lower percentages of resistant strains to other common antibiotics. Although 63% percent of isolates were β-lactamase positive by the nitrocefin test, only 70% of these isolates were PenR. The other 30% had reduced susceptibility to Pen (PenRS). Whole Genome Sequencing (WGS) revealed mutations in the blaTEM-1B gene for these PenRS isolates. These isolates were collected from different clinics, but showed genetic relatedness based on nucleotide polymorphism (SNP)-based analysis. Several novel NG-MAST types were detected among the isolates.
Conclusion
These findings highlight the high prevalence of multidrug resistant GC in Peru. The identification of NG-MAST types not identified in surveillance reports from Europe or the United States is important. Further, WGS allowed us to discern false positive β-lactamase isolates by detecting mutations in the blaTEM genes observed in PenRS isolates and showed the clonally relatedness of these isolates.
Prescription drug misuse (PDM) has markedly increased over the last decade and is a significant contributor to the national opioid epidemic. HIV+ individuals are particularly vulnerable to PDM as they experience high levels of chronic pain, anxiety and depression. We examined the prevalence of PDM and associated risk factors among HIV-infected subjects in our cohort. The US Military HIV Natural History Study (NHS) is comprised of HIV+ active duty, retired military personnel and dependents. Since 2014, participants have completed a computerized behavioral survey regarding patterns of drug use and sexual behavior. We specifically queried topics including use of narcotics, benzodiazepines or stimulants without a prescription or use of medications not as prescribed. Logistic regression was used to compare those reporting and not reporting a lifetime history of PDM. Analyses used anonymous data. Among 1,558 respondents, 292 (18.7%) reported a history of PDM. The median age of individuals reporting history of PDM was 45 years (interquartile range [IQR] 31–53) compared with individuals without PDM (41 years; IQR 29–35; P = 0.049); the groups did not differ by race, CD4 count or viral load. The prevalence of lifetime PDM was highest among dependent individuals (31.8%), compared with retired (20.6%) or active-duty personnel (15.9%; P = 0.003 for comparison). After adjusting for age and duty status, military officers were significantly less likely to report PDM than enlisted personnel (OR 0.51; IQR 0.31–0.85). Those with a history of PDM were more likely to consume ≥3 alcoholic drinks/day (OR 1.9; IQR 1.4–2.5). In a sub-analysis of active-duty personnel only (median age 30 years), individuals reporting a history of PDM had fewer years since HIV diagnosis (median 2.9 years vs. 3.9 years, P = 0.019). We found prevalent PDM among HIV-infected military personnel and beneficiaries, and PDM was associated with at-risk drinking. This is the first estimate of PDM among HIV+ active-duty personnel, and longitudinal studies in similar cohorts will be useful in further characterizing the epidemiology of PDM. The higher prevalence among recently diagnosed active-duty personnel may suggest an increasing scope of PDM in this group, and interventions to decrease PDM are urgently needed. All authors: No reported disclosures.
ABSTRACT Introduction Sexually transmitted infections (STIs) continue to plague militaries and defense forces. While the historical recognition of the impact of STIs on operations is evident, contemporary surveillance and research activities are limited. As Neisseria gonorrhoeae and other sexually transmitted pathogens become increasingly resistant to antibiotics, the role of the Department of Defense (DoD) in disease surveillance and clinical research is essential to military Force Health Protection. Methods The Infectious Disease Clinical Research Program (IDCRP) of the Uniformed Services University of the Health Sciences partnered with the DoD Global Emerging Infections Surveillance (GEIS) program to monitor the distribution of gonorrhea antimicrobial resistance (AMR) both domestically and abroad. The DoD gonococcal reference laboratory and repository was established in 2011 as a resource for confirmatory testing and advanced characterization of isolates collected from sites across the continental United States (CONUS) and GEIS-funded sites outside the continental United States (OCONUS). The IDCRP is currently implementing surveillance efforts at CONUS military clinics, including Madigan Army Medical Center, Naval Medical Center Camp Lejeune, Naval Medical Center Portsmouth, Naval Medical Center San Diego, and San Antonio Military Medical Center (efforts were also previously at Womack Army Medical Center). The reference laboratory and repository receives specimens from OCONUS collaborators, including Armed Forces Research Institute of Medical Sciences (AFRIMS; Bangkok, Thailand), Naval Medical Research Unit No. 3 (NAMRU-3), Ghana Detachment (Accra, Ghana), Naval Medical Research Unit No. 6 (NAMRU-6; Lima, Peru), U.S. Army Medical Research Unit – Georgia (USAMRD-G; Tbilisi, Republic of Georgia), and U.S. Army Medical Research Directorate – Kenya (USAMRD-K; Nairobi, Kenya). The gonococcal surveillance program, to include findings, as well as associated clinical research efforts are described. Results Among N. gonorrhoeae isolates tested within the United States, 8% were resistant to tetracycline, 2% were resistant to penicillin, and 30% were resistant to ciprofloxacin. To date, only one of the 61 isolates has demonstrated some resistance (MIC=1 μg/ml) to azithromycin. No resistance to cephalosporins has been detected; however, reduced susceptibility (MIC=0.06–0.125 μg/ml) has been observed in 13% of isolates. Resistance is commonly observed in N. gonorrhoeae isolates submitted from OCONUS clinical sites, particularly with respect to tetracycline, penicillin, and ciprofloxacin. While no azithromycin-resistant isolates have been identified from OCONUS sites, reduced susceptibility (MIC=0.125–0.5 μg/ml) to azithromycin was observed in 23% of isolates. Conclusion Continued monitoring of circulating resistance patterns on a global scale is critical for ensuring appropriate treatments are prescribed for service members that may be infected in the U.S. or while deployed. Domestic surveillance for gonococcal AMR within the Military Health System has indicated that resistance patterns, while variable, are not dramatically different from what is seen in U.S. civilian data. Global patterns of gonococcal AMR have been described through the establishment of a central DoD gonococcal reference laboratory and repository. This repository of global isolates provides a platform for further research and development into biomedical countermeasures against gonococcal infections.
Objectives: Health events emerge from a multifactorial milieu involving host, community, environment, and pathogen factors. Therefore, developing accurate forecasting models to improve epidemic prediction towards better prevention and capabilities management is a complex task. Here, we describe an exploratory analysis to identify non-health risk factors that could improve the forecast and events risk signals using a feasible and practical approach by combining surveillance report data with non-health data from open data sources. Methods: A line listing was developed using the World Health Organization Disease Outbreaks News from 2016-2018 and merged with non-health indicators data from the World Bank. Poisson regression models employing forward imputations were used to establish relationships and predict values over the dependent variable (health event frequency). Findings: The resulting regression model provided evidence that changes in non-health factors important to community experiences impact the risk of the number of major health events that a country could experience. Three non-health indicators (extrinsic factors) were associated significantly to event frequency (population urban change, gross domestic product change per capita—a novel factor, and average forest area). An exploratory analysis of the current COVID-19 pandemic suggested similar associations, but confounding by global disease burden is likely. Interpretation: Continued development of forecasting approaches capturing available whole-of-society extrinsic factors (non-health factors); could improve the risk management process through earlier hazard identification, and as importantly inform strategic decision processes in multisectoral strategies to preventing, detecting, and responding to pandemic-threat events.Funding: USUHS intramural funding to a Henry M. Jackson Foundation post-doctoral fellowship award.Declaration of Interests: The authors declare no conflicts of interest.Ethics Approval Statement: This manuscript was approved by USUHS clearance publication committee.
Abstract Objectives Health events emerge from a multifactorial milieu involving host, community, environment, and pathogen factors. Therefore, developing accurate forecasting models to improve epidemic prediction towards better prevention and capabilities management is a complex task. Here, we describe an exploratory analysis to identify non-health risk factors that could improve the forecast and events risk signals using a feasible and practical approach by combining surveillance report data with non-health data from open data sources. Methods A line listing was developed using information from the World Health Organization Disease Outbreaks News from 2016-2018. A database was created merging the line listing data with non-health indicators from the World Bank. Poisson regression models employing forward imputations were used to establish relationships and predict values over the dependent variable (health event frequency); which are the health events reported by each country to WHO during 2016-2018. Findings The resulting regression model provided evidence that changes in non-health factors important to community experiences impact the risk of the number of major health events that a country could experience. Three non-health indicators (extrinsic factors) were associated significantly to event frequency (population urban change, gross domestic product change per capita—a novel factor, and average forest area). An exploratory analysis of the current COVID-19 pandemic suggested similar associations, but confounding by global disease burden is likely. Conclusion Continued development of forecasting approaches capturing available whole-of-society extrinsic factors (non-health factors); could improve the risk management process through earlier hazard identification, and as importantly inform strategic decision processes in multisectoral strategies to preventing, detecting, and responding to pandemic-threat events.
ABSTRACT Redundant TonB systems which function in iron transport from TonB-dependent ligands have recently been identified in several gram-negative bacteria. We demonstrate here that in addition to the previously described tonB locus, an alternative system exists for the utilization of iron from hemoglobin, transferrin, or lactoferrin in Neisseria meningitidis and Neisseria gonorrhoeae . Following incubation on media containing hemoglobin, N. meningitidis IR3436 ( tonB exbB exbD deletion mutant) and N. gonorrhoeae PD3401 ( tonB insertional mutant) give rise to colonies which can grow with hemoglobin. Transfer of Hb + variants (PD3437 or PD3402) to media containing hemoglobin, transferrin, and/or lactoferrin as sole iron sources resulted in growth comparable to that observed for the wild-type strains. Transformation of N. meningitidis IR3436 or N. gonorrhoeae PD3401 with chromosomal DNA from the Hb + variants yielded transformants capable of growth with hemoglobin. When we inactivated the TonB-dependent outer membrane hemoglobin receptors (HmbR or HpuB) in the Neisseria Hb + variants, these strains could not grow with hemoglobin; however, growth was observed with transferrin and/or lactoferrin. These results demonstrate that accumulation of iron from hemoglobin, transferrin, and lactoferrin in the pathogenic neisseriae can occur via a system that is independent of the previously described tonB locus.
Neisseria gonorrhoeae is the second most common reportable infection in the United States, which if undiagnosed and untreated, can lead to severe long-term sequelae. Active duty U.S. Military service members are risk-taking young adults; however, military service offers some inherent control for social determinants often associated with increased risk of sexually-transmitted infections. Even in the absence of disparities in income and education, increased burden of disease among racial and ethnicity minorities may still exist. Herein, we describe the association between race/ethnicity and gonorrhea among active duty service members.
Methods
This study was conducted among symptomatic and high risk patients enrolled at military infectious disease clinics from 2012 to 2017. Outcome variables were based on nucleic acid amplification test results extracted from medical records. The magnitude of association was assessed using adjusted odds ratios and 95% confidence intervals.
Results
Data from 488 active duty participants were analyzed. The crude prevalence of gonorrhea and chlamydia among this clinic population was 17% and 25%, respectively. After adjusting for sex and age, non-Hispanic black service members had 3.5 times greater odds (p=0.000) and Hispanic service members had 2.9 times greater odds (p=0.009) of gonorrhea compared to non-Hispanic white service members. This phenomenon was not observed when comparing odds of chlamydia among blacks or Hispanics to whites.
Conclusion
Despite similarities in income and education, black and Hispanic service members still bear a disproportionate burden of gonorrhea illness. Service members of color may have unique risk factors that predispose them to gonorrhea. Findings suggest that interventions aimed at reducing gonorrhea should be targeted towards persons of color to ensure disparities in disease burden are effectively addressed. Future studies should examine sexual behaviors among black and Hispanic service members that may be contributing to increased odds of gonorrhea within the military population.
ABSTRACT To address the ongoing epidemic of sexually transmitted infections (STIs) in the United States, the National Academies of Sciences, Engineering, and Medicine (National Academies) conducted a consensus study on STI control and prevention in the United States to provide recommendations to the Centers for Disease Control and Prevention and the National Association of County and City Health Officials. The culminating report identified military personnel as one of the priority groups that require special consideration given the high prevalence of STIs and their associated behaviors (e.g., concurrent sexual partners and infrequent condom use) that occur during active duty service. Universal health care access, the relative ease and frequency of STI screening, and the educational opportunities within the military are all assets in STI control and prevention. The report offers a comprehensive framework on multiple and interrelated influences on STI risk, prevention, health care access, delivery, and treatment. It also provides an overview of the multilevel risk and protective factors associated with STIs that could be applied using a sexual health paradigm. The military context must integrate the multilevel domains of influences to guide the effort to fill current gaps and research needs. The Department of Defense, with its large clinical and preventive medicine workforce and its well-established universal health care system, is well positioned to enact changes to shift its current approach to STI prevention, treatment, and control. STI control based on highlighting behavioral, social, cultural, and environmental influences on service members’ sexual health and wellness may well drive better STI care and prevention outcomes.
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