STI 2018 Understanding and Addressing the HIV and STI Syndemics 21-22 July 2018 Kenneth Mayer & Henry de Vries

Disclosures Unrestricted research grants Gilead ViiV Relations that could be relevant for the meeting Company names Unrestricted research grants Gilead ViiV NIH (NIAID, NIMH, NICHD) Scientific Advisory boards Merck

HIV and STI Synergy Inflammation and/or ulceration BIOLOGY PrEP and TasP ↑HIV transmission and/or acquisition BEHAVIOR STI Condomless sex Multiple partners EPIDEMIOLOGY Higher risk partners, ↑ risk of HIV-infected partner

HIV and STI Synergy Inflammation and/or ulceration BIOLOGY PrEP and TasP ↑HIV transmission and/or acquisition BEHAVIOR STI Condomless sex Multiple partners EPIDEMIOLOGY Higher risk partners, ↑ risk of HIV-infected partner

WHO Global STI Estimates of 4 Curable STIs Curable STIs: chlamydia, gonorrhea, syphilis, trichomoniasis Newman, PloS One 2015

Countries with reported decreased susceptibility or with resistance to antibiotics for gonorrhoea GASP 2014 51/77 (66%) countries decreased susceptibility to Cephalosporins (26 countries ≥ 5%) Superbugs reported in Japan, Spain and France 47/58 (81%) countries - resistance to azithromycin (29 countries ≥ 5%) 70/72 (97%) countries resistance to ciprofloxacin (14 countries ≥ 90%) (52 countries ≥ 5%) Wi et al PLOS Med

Need for better global STI epidemiology data Often only have numerator data, so the size of, and burdens for populations are unknown (Kyle Bernstein) Not only from L/MIC but also for the EU region (Andrew Amato) Should not lump key populations with each other e.g. trans feminine, trans masculine, non-binary persons (Adhina Aher) Heterogeneity of HIV/STI incidence among European migrants (Julia del Amo) e.g. 72% of MSM and 50% of heterosexual migrants acquire HIV post migration.

Structural issues in STI/HIV program implementation Legal, societal, stigma, transphobia issues Tackle stigma towards key populations among health care workers/policy makers for drug users, sexual and gender minorities (Adam Bourne) Roll back of sex work legality: criminalizing clients (Scandinavian model) is harmful to programs for sex workers (Kate Shannon)

Need for program integration De-silo STI and HIV care Key population programs that are HIV-focused need to be expanded Policy and resource silos should be broken e.g. machines for HIV RNA, Malaria, and TB testing could be used for STI screening Synergistic training is needed on the provider level PrEP cohorts offer opportunities to assess new STI prevention strategies (Jean Michel Molina)

New biomedical interventions Mouth gargle to prevent gonorrhoea transmission (Eric Chow)? Rectal microbicides? (Ian McGowan) New treatment options for gonorrhoea urgently needed (Kim Workowski) More research on LGV transmission for better prevention measures (Henry de Vries) Universal HPV vaccination (Andrew Grulich) N. meningitis vaccination is effective against GC?

Emerging infections sexually transMITTED vs sexually transMISSIBLE Hepatitis C is a highly endemic STI among HIV+ MSM Via HIV induced immune activation (Theo Geijtenbeek) Ulcerative STI important risk factor (Maria Prins) Hepatitis C starts to spread among HIV- MSM PrEP users Mixing of HIV+ and HIV- sex partners? TaSP rx with DAA could eliminate hepatitis C among MSM New pathogens (Kyle Bernstein): Ebola virus and Zika virus require other prevention measures Known pathogens: N meningitis deadly outbreak among HIV+ MSM (crowding?) Shigella outbreaks among MSM populations

Improved diagnostics Better and more simple (serological) tests for syphilis (Ned Hook) Rapid test paradox: Sens <65% more cases treated than conventional sens 90% PCR test if return rate is <65% (Rosanna Peeling). Avoid blind multiplex testing (Nicola Low) Self/home testing breakdown stigma but linkage to care needs to be in place (John de Wit). Molecular AMR testing to guide therapy, but GC is outsmarting us.

Future of sexual healthcare Test, treat (vaccinate, PEP PrEP), and trace (Sheena McCormack) Once a month STI testing for PEP users? Expedited partner treatment opportunities (Hannelore Götz) Regional differences in acceptance, SOC Regionally customized approach: urban vs rural settings. Decentralization? (Silke Davids) Tailored social media and self sampling to scale up sexual health interventions and fight health disparities (Patrick Sullivan) Syndromic management in Africa needs to be removed inadequate for mixed and asymptomatic infections, overtreatment and AMR (Linda Gail Bekker)

STI2018 Organizing Committee Birgit van Benthem, National Institute for Public Health and the Environment (RIVM), The Netherlands Jan van Bergen, Soa Aids Nederland, Amsterdam | Academic Medical Center, University of Amsterdam |  National Institute for Public Health and the Environment (RIVM), The Netherlands Silke David, National Institute for Public Health and the Environment (RIVM), The Netherlands Udi Davidovich, Public Health Service of Amsterdam (GGD), The Netherlands Arjan Hogewoning, Public Health Service of Amsterdam (GGD), The Netherlands Elske Hoornenborg, Public Health Service of Amsterdam (GGD) The Netherlands Marina Klein, McGill University and CIHR Canadian HIV Trials Network, Canada Kenneth Ngure, Jomo Kenyatta University of Agriculture and Technology, Kenya | Department of Global Health, University of Washington, United States Nneka Nwokolo, Chelsea and Westminster Hospital, United Kingdom Maria Oud, Public Health Service of Amsterdam (GGD), The Netherlands Sébastien Morin, International AIDS Society, Switzerland Maria Prins, Public Health Service of Amsterdam (GGD) | Academic Medical Center, University of Amsterdam, The Netherlands Jürgen Rockstroh, University of Bonn, Germany Mauro Schechter, Universidade Federal do Rio de Janeiro, Brazil Maarten Schim van der Loeff, Public Health Service of Amsterdam (GGD) | Academic Medical Center, University of Amsterdam, The Netherlands Darrell Tan, Li Ka Shing Knowledge Institute, Canada Clarissa Vergunst, Public Health Service of Amsterdam (GGD), The Netherlands

Thanks to STI 2018 partners