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  1. Rayner Kay Jin Tan1,
  2. Rachel Herbert2,
  3. Nadja A Vielot3
  1. 1 Saw Swee Hock School of Public Health, National University Singapore, Singapore
  2. 2 Infectious Diseases, Burjeel Hospital, Abu Dhabi, UAE
  3. 3 Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
  1. Correspondence to Dr Rayner Kay Jin Tan, Saw Swee Hock School of Public Health, National University Singapore, Singapore, 117549, Singapore; rayner.tan{at}nus.edu.sg

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Published in STI: Self-start HIV postexposure prophylaxis after sexual exposure to reduce time to first dose

The efficacy of HIV post-exposure prophylaxis (PEP) increases with a shorter time to treatment initiation. This randomised, prospective, open-label study among men who have sex with men (MSM) in the UK assigned 139 participants to either a 5-day PEP starter pack of emtricitabine/tenofovir disoproxil fumarate/maraviroc, or to the standard of care (SOC) PEP access through sexual health clinics or accident and emergency units. There was a significant reduction in time from sex to first PEP dose in the starter pack arm compared with the SOC (median time 7.3 hours vs 28.5 hours), with full adherence and no serious adverse events in the starter pack arm. The findings suggest the efficacy of home starter packs in HIV prevention strategies.

Fox JM, Lee MJ, Fairhead CL, et al. Self-start HIV postexposure prophylaxis (PEPSE), to reduce time to first dose and increase efficacy. Sexually Transmitted Infections 2023;99:367–372.

The importance of considering syphilitic uveitis when evaluating patients with intraocular inflammation

The initial misdiagnosis of ocular syphilis often leads to poor visual outcomes. Analysing 2010–2019 data from the Nationwide Inpatient Sample in the USA (n=444 674), this cross-sectional study identified 5581 (1.3%) hospital admissions for syphilitic uveitis. Based on this sample, the national incidence of such hospitalisation increased from 0.08 per 100 000 in 2011 to 0.23 per 100 000 in 2019. The observed rise in syphilitic uveitis-related hospitalisation, alongside a shortage of injectable penicillin G benzathine and diagnostic challenges, points to the need for heightened clinical vigilance. Clinicians should maintain a high index of suspicion for syphilis in individuals presenting with intraocular inflammation.

Mir TA, Kim SJ, Fang W, et al. Rising Incidence of Syphilitic Uveitis-Related Hospitalizations in the US. JAMA Ophthalmol 2024 Jan 1;142(1):7–14.

Does oral linezolid offer an alternative to benzathine penicillin G for the treatment of early syphilis?

There are limited alternatives to penicillin for the treatment of syphilis and a lack of controlled studies. Linezolid has shown activity against Treponema pallidum in vitro and rabbit models and is, therefore, of potential interest. This multicentre, open-label, randomised trial compared oral linezolid (600 mg per day for 5 days) with single-dose intramuscular benzylpenicillin G (BPG) (2.4 million international units) in 59 participants with confirmed syphilis (primary, secondary or early syphilis). At 48 weeks, 70% in the linezolid group vs 100% in the BPG group showed a treatment response (fourfold decline in rapid plasma reagin titre or seroreversion by week 12, 24 or 48), indicating that the linezolid arm did not meet the non-inferiority criteria compared with BPG. A regimen of linezolid at a daily dose of 600 mg for 5 days should not be considered for the treatment of early syphilis, but further research into alternative regimens is necessary, including the evaluation of higher dosages and longer treatment duration.

Maria Ubals, Patricia Nadal-Baron, Maider Arando, et al. Oral linezolid compared with benzathine penicillin G for treatment of early syphilis in adults (Trep-AB Study) in Spain: a prospective, open-label, non-inferiority, randomised controlled trial. Lancet Infect Dis 2024 Jan 8: S1473–3099 (23).

Near-to-patient sexually transmitted infection testing reduces antibiotic use and improves partner notification

Near-to-patient testing (NPT) involves diagnostic tests at the time and place of patient care. The NEPTUNE Study in Australia evaluated NPT with GeneXpert plus ResistancePlus MG FleXible for detecting Chlamydia trachomatis, Neisseria gonorrhoeae and Mycoplasma genitalium (including macrolide resistance). Participants (n=808) were adults presenting with non-gonococcal urethritis (NGU) or proctitis, attending after sexual exposure or undergoing a test of cure. NPT markedly reduced inappropriate antibiotic use and improved treatment accuracy compared with SOC laboratory testing. For NGU and proctitis, NPT reduced antibiotic prescriptions (29% vs 83% in controls), resulting in more appropriate treatment (81% vs 33%). NPT also facilitated partner notification. Among 264 NPT participants with sexually transmitted infections (STIs), 95% notified their partners, with 86% doing so on the same day they received their results. These findings indicate that NPT improves STI management by guiding appropriate treatment and allowing rapid partner notification.

Vodstrcil LA, Htaik K, Plummer EL, et al. Near-to-patient-testing to inform targeted antibiotic use for sexually transmitted infections in a public sexual health clinic: the NEPTUNE cohort study. Lancet Reg Health West Pac 2024 Jan 12;44:101005.

Doxycycline PEP shows poor efficacy in cisgender Kenyan women

Doxycycline PEP reduces the acquisition of chlamydia, gonorrhoea and syphilis in MSM and transgender women. Based on these positive findings, a controlled trial in Kenya randomised cisgender women aged 18–30 years receiving oral HIV pre-exposure prophylaxis to either PEP (n=224) or SOC with quarterly STI test and treat (n=225). In 50 randomly selected PEP arm participants, hair samples were tested for the presence of doxycycline. Over 12 months, there was no significant difference between arms in incidence or time to first STI diagnosis. STI incidence was 25.1 per 100 person-years (PEP arm) vs 29.0 per 100 person-years (SOC). Although participants in the PEP arm reported overall good adherence, doxycycline was detected in only one-third of hair samples. To improve the design of interventional trials, more research is needed on the science of drug delivery and the motivation and context for PEP use in women.1

Stewart J, Oware K, Donnell D, et al; dPEP Kenya Study Team. Doxycycline Prophylaxis to Prevent Sexually Transmitted Infections in Women. N Engl J Med 2023 Dec 21;389(25):2331–2340.

Strategies for cervical cancer screening in women living with HIV

This modelling study assessed the benefits and harms of various cervical cancer screening approaches among human papillomavirus (HPV)-unvaccinated women living with HIV in Tanzania. The analysis considered cervical cancer incidence, mortality rates and reproductive outcomes according to variations in screening intervals, primary screening test and pre-ablation triaging approach. Primary HPV testing at 3-year or 5-year intervals without triage (‘screen and treat’) in women aged 25–50 years was most effective in reducing cervical cancer incidence and mortality, with deaths declining by 67% (3-year screening) or 63% (5-year screening) compared with no screening. However, triaging HPV-positive women with additional tests maintained effectiveness while resulting in a more favourable balance of benefits and harms. The results informed the evidence base for the 2021 WHO guidelines for cervical cancer prevention, which recommend primary HPV testing with triage every 3–5 years for women living with HIV aged 25–49 years.2

Hall MT, Simms KT, Murray JM, et al. Benefits and harms of cervical screening, triage and treatment strategies in women living with HIV. Nat Med 2023 Dec;29(12):3059–3066.

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Footnotes

  • Handling editor Anna Maria Geretti

  • X @raynerkjtan

  • Contributors RKJT, RH and NAV contributed to the selection of the articles and to the writing of the summaries. RKJT submitted the final version to the journal.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.