Infectious Disease Alert Updates
By Carol A. Kemper, MD, FIDSA
Medical Director, Infection Prevention, El Camino Hospital, Palo Alto Medical Foundation
Pushing for STI Testing in Those at Risk
SOURCE: Brown EE, Patel EU, Poteat TC, et al. Prevalence of sexually transmitted infections among transgender women with and without HIV in the Eastern and Southern United States. J Infect Dis 2024;229:1614-1627.
The Leading Innovation for Transgender Women’s Health and Empowerment (LITE) project is a multisite study designed to assess the health and social vulnerabilities of a group of transfeminine/transgender women living in six eastern and southern cities in the United States.
A total of 1,018 transfeminine/transgender women were recruited for the project, nearly one-third of whom were either white, non-Hispanic Black, or Hispanic (any race). The median age was 31 years and 27.1% were human immunodeficiency virus (HIV)-positive. The prevalence of sexually transmitted infections (STIs), and information about sexual activity, types of partners, use of pre-exposure prophylaxis (PrEP), as well as other factors, including access to care, insurance status, alcohol use, homelessness, and history of incarceration, were collected. STI testing was done at a facility with self-collected urine, anogenital or vaginal swabs, as well as with self-administered OraQuick in-home HIV tests. Syphilis infection was determined by initial antibody testing, followed by confirmatory rapid plasma reagin (RPR) testing. The diagnosis of syphilis was made based on newly reactive RPR or a four-fold increase in previous RPR results following an earlier diagnosis.
Nearly one-third of the participants described multiple types of partners within the previous 12 months, while 61% had only cisgender male partners and 13% had only non-cisgender men for partners. PrEP was currently used by 16%, while 11% had taken PrEP more than 30 days ago. Fifty (5%) had a history of vaginoplasty.
STIs were detected in 16% of participants, including chlamydia (5%), gonorrhea (2%), and syphilis (11%). Chlamydia was detected primarily at rectal sites (92%), while six patients (11.3%) had chlamydia detected at urogenital sites and one patient with a history of vaginoplasty had chlamydia detected at both urogenital and neovaginal sites. Gonorrhea also was detected primarily at rectal sites (100%), although two patients also had urogenital infection.
STIs, including chlamydia (34%), gonorrhea (4%), and syphilis (27%), were three times more prevalent in participants with HIV infection. Two or more STIs were detected in 5% of those with HIV, compared with 0.8% of those without HIV. STI also was significantly more prevalent in Black participants (adjusted prevalence ratio [PR] = 6.37) compared with white or Hispanic participants.
The current use of PrEP also was significantly associated with STI in univariate analysis (PR = 1.71), although this association was diminished in the demographic-adjusted model. Other factors that increased the risk of STI included a history of homelessness or incarceration, or a history of multiple partners and/or non-cisgender partner(s), alcohol use, and a history of sex work. Age was not a risk factor for STI in this cohort.
This study highlights the importance of regular panscreening for STI in transgender women, with STI testing (of all sites) — especially those at increased risk for STIs. STIs were especially more prevalent in HIV-infected transgender women — nearly one-third (31.9%) tested positive for at least one STI. STI also was more common in participants using PrEP. Current guidelines recommend STI/HIV screening every three to six months for such individuals, especially those with a history of STI or higher risk behaviors. Remember, just doing a urine GC/chlamydia test is not sufficient and would only capture a minority of the STIs in this cohort. Rectal testing is necessary. And while testing of oropharyngeal sites was not reported in the study, it should be included in regular screening, since the oral site may serve as a reservoir for gonorrhea and requires follow-up testing for cure.
Self-administered swabs and HIV testing in the clinic are a great way to engage the patient in their own care. Sadly, in our large multispecialty clinic, some of our primary care physicians report feeling “uncomfortable” caring for such patients — and push them on to infectious disease specialists. This kind of basic care is essential, especially for younger people of all genders and those at risk for STIs. I believe this lack of comfort dealing with sex and STIs is one of the leading reasons STI rates are increasing in our country, and primary care physicians should be better trained to provide safer sex counseling and STI screening and treatment.
TB Screening Dismayingly Low in Those at Risk
SOURCE: Ku JH, Fischer H, Qian LX, et al. Latent tuberculosis infection testing practices in a large U.S. integrated healthcare system. Clin Infect Dis 2024;78:1304-1312.
Screening for latent tuberculosis (TB) infection (LTBI) in persons at risk is woefully lax in our country — and yet, reactivation TB is such an eminently preventable disease. I recently saw in consultation an 80-plus-year-old chronically ill Filipino woman with suspected active pulmonary TB. She had received regular medical care at a large multispecialty clinic and at a nearby tertiary care facility for more than 20 years — and she had never been screened for TB.
Data for 2023 for our county in Northern California indicate that a whopping 97% of cases of active TB occurred in those born outside the United States, although 64% of them had lived in the United States for more than 10 years. All of these individuals were born in either the Philippines, Vietnam, India, Mexico, or China — only 3% of active TB cases in our county were born in the United States. The mortality rate for patients receiving TB therapy was 8%, up from 6% in 2022, many of whom were elderly, chronically ill, and/or immunosuppressed.
The Kaiser Permanente (KP) database provided an excellent opportunity for these authors to examine risk factors for TB and rates of testing for LTBI. From 2008 to 2019, available data on risk factors for TB and testing for LTBI were collected in adults ≥ 18 years of age who had been members of the KP system for two or more years. The authors also determined the number tested for LTBI who specifically met California Department of Public Health (CDPH) criteria for testing — including birth in or travel greater than one month to a country endemic for TB, exposure to active TB, and immunosuppression. Patients with a history of active TB were excluded.
During this 12-year surveillance period, nearly 4 million adults receiving care at Kaiser for two or more years and without a history of active TB were eligible for LTBI testing. Of these, 706,367 (18%) had been tested, including 82.6% with tuberculin skin test only, 11.4% with interferon gamma release assay (IGRA) only, and 6% with both PPD and IGRA. Of these, two-thirds were female, 45% were younger (ages 18-35 years), 22% were born in a country endemic for TB, and 5.7% received immunosuppressive therapy or were immunocompromised (IST/IC). Among those who were never tested for LTBI, 30% were foreign born and 1.4% received IST or were IC.
This means that among those 1,087,237 persons who were born in a country endemic for TB, only 14% were screened for LTBI, and of those 183,741 receiving IST, only 48% were screened for LTBI.
Among those who met CDPH criteria for screening, rates of LTBI positivity were 34% for close contacts to active TB, 22% for those born in a country endemic for TB, 18% for a history of travel greater than one month to a country endemic for TB, and 8% of those prior to first receiving immune suppressive therapy.
Thus, screening for LTBI was less likely to occur if you were born outside the United States in a country endemic for TB. It was more likely to occur in women, younger persons (ages 18-35 years of age), those with higher household income, those with a history of travel and/or exposure to TB, people with end-stage renal disease (where screening usually is a requirement for hemodialysis), and those with HIV infection.
Based on these data, an estimated 935,000 people in Southern California met criteria for LTBI screening between 2008 and 2019 and were not screened, at least through the Kaiser system. Suppose 22% of them tested positive for LTBI, and the lifetime rate of reactivation TB is 5% to 10%. That suggests that 10,285 to 20,570 cases of active TB could occur in this group over their lifetimes. This figure completely aligns with the 9,615 cases of active TB reported in California in 2023.
While TB generally is no longer considered a fatal disease in the United States, 8% of those with active TB in our county died last year on therapy. What is saddest about these data is that three-fourths of those diagnosed with TB are 65 years of age or older, many with chronic medical conditions, and often are the most difficult to treat for active TB. They could easily have received preventive therapy — if their primary care doctors had thought about it. Alarm bells should be ringing.
Pushing for STI Testing in Those at Risk; TB Screening Dismayingly Low in Those at Risk
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.