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Mycoplasma genitalium acquisition and macrolide resistance after initiation of HIV pre-exposure prophylaxis in men who have sex with men
  1. Jens Tomas Van Praet1,2,
  2. Sanne Steyaert1,
  3. Stefaan Vandecasteele1,
  4. Barbara Van Den Bergh1,
  5. Hilde Mahieu1,
  6. Stefanie De Buyser3,
  7. Veerle Grootaert4,
  8. Patrick Descheemaeker5,
  9. Marijke Reynders5
  1. 1Nephrology and Infectious Diseases, AZ Sint-Jan AV, Brugge, Belgium
  2. 2Internal Medicine and Pediatrics, Ghent University, Gent, Belgium
  3. 3Biostatistics Unit, Ghent University, Gent, Belgium
  4. 4Pharmacy, AZ Sint-Jan AV, Brugge, Belgium
  5. 5Laboratory Medicine, AZ Sint-Jan AV, Brugge, Belgium
  1. Correspondence to Dr Jens Tomas Van Praet, Nephrology and Infectious Diseases, Algemeen Ziekenhuis Sint-Jan Brugge, 8000 Brugge, Belgium; jens.vanpraet{at}


Objectives Recent evidence shows that patients using HIV pre-exposure prophylaxis (PrEP) have an increased rate of bacterial STIs, including syphilis, chlamydia and gonorrhoea. Our study aimed to describe the acquisition and the susceptibility for macrolides of Mycoplasma genitalium in men who have sex with men (MSM) on PrEP.

Methods We studied all MSM who started PrEP in the AZ Sint-Jan Hospital Bruges from 1 June 2017 to 31 March 2019 with at least one follow-up visit. Patients were screened for M. genitalium and other STIs with pooled rectal swabs, pharyngeal swabs and first-voided urine, and blood samples at baseline and quarterly intervals after initiating PrEP. TaqMan Array Card technology was used to detect M. genitalium and determine macrolide-resistance mediating mutations in region V of the 23S rRNA gene (A2058G, A2059G, A2058C and others). Patients with an STI were treated based on a national guideline.

Results 131 MSM (median age 40 years, range 20–79) were included in the study. The median follow-up time was 12 months (IQR 6.1–17). Baseline prevalence of M. genitalium was 6.9% and incidence rate after PrEP initiation was 28.8 per 100 person-years (95% CI 21.7 to 37.2), without significant differences in proportions between the first four quarterly intervals. All but one acquisitions were asymptomatic. Younger age and positivity for M. genitalium at baseline were significantly associated with incident M. genitalium acquisition. The observed proportion of macrolide resistance increased not significantly from 44% at baseline to 57%–86% after PrEP initiation. None of the 27 macrolide-resistant M. genitalium acquisitions could be linked to azithromycin exposure in the three preceding months.

Conclusions After initiation of PrEP, we found a stable incidence of almost exclusively asymptomatic M. genitalium. However, a non-significant trend of an increased percentage of macrolide-resistant strains was observed.

  • mycoplasma
  • HIV pre-exposure prophylaxis
  • azithromycin

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  • Handling editor Federico Garcia

  • Contributors JTVP, SV and BVDB collected the patient data. MR and PD collected the STI data and supervised the laboratory testing. JTVP and SDB analysed the data. All authors contributed to the preparation of the manuscript.

  • Funding This work was supported by an unrestricted grant from Gilead Sciences.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval This study was approved by the local ethical committee (advice no. 1905).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon request