One limitation of this report is the study population consisted of HIV-negative MSM in Hanoi enrolled into a cohort study and is not necessarily representative of the community prevalence among MSM in Hanoi or other cities in Vietnam. Our finding of high rates of extragenital infections is also consistent with regional reports from Thailand. Among a cohort of MSM in Thailand, including those living with HIV, rectal infections accounted for nearly 70% of C. trachomatis infections and approximately 60% of N. gonorrhoeae infections, while 40% of N. gonorrhoeae infections involved the oropharynx. In another report of HIV-negative MSM in Bangkok, approximately 65% of C. trachomatis and 80% of N. gonorrhoeae infections were extragenital. Elsewhere in the region, prevalence among MSM, including those living with HIV, was lower: in Guangzhou, the overall prevalence of rectal C. trachomatis was 11.2% and rectal N. gonorrhoeae was 6.1%, and in Kunming, the anatomic site with the highest prevalence of C. trachomatis was the rectum at 15.5% and the prevalence of N. gonorrhoeae was highest in the oropharynx at 8.1%. While direct comparisons between other studies and ours are limited due to different study populations, recruitment methods, and testing strategies, the relatively higher rate of N. gonorrhoeae infections involving the oropharynx observed here is particularly concerning given this is a potential reservoir for antimicrobial resistance. The overall high prevalence of chlamydia and gonorrhea observed in our study might reflect an increase in rates of STIs within MSM communities in Vietnam. Testing at three anatomic sites also likely contributed to the high prevalence observed in our study. However,curing cannabis increasing rates of STIs among MSM is a trend observed globally and one that is often driven by stigma, discrimination, and limited access to healthcare.
Few of the study participants with CT or NG infections reported a prior diagnosis of an STI, likely reflecting limited access and engagement with appropriate sexual health services, including HIV services, observed among MSM in Vietnam. High levels of stigmatisation and low levels of STI knowledge are structural and individual barriers that can lead to alienation of MSM from sexual health services in Vietnam. A clinic-based, sexual health promotion intervention using health educators among male sex workers, a subgroup of MSM, in Vietnam was effective at increasing testing and treatment for STIs, increasing their knowledge of HIV/STI transmission risk, and health seeking intention. More efforts are needed to expand such measures among MSM in Vietnam, as well as other settings seeking to promote engagement with sexual health services. We found that half of all infections were asymptomatic, although it should be noted that oropharyngeal symptoms were not assessed by the study’s survey instruments, which might lead to an under-estimation of symptoms reported here. Nevertheless, the data shown here support routine triple-site testing for N. gonorrhoeae and C. trachomatis among MSM in Hanoi. Yet in Vietnam, as well as many other low- and middle-income countries, the cost of NAATs for C. trachomatis and N. gonorrhoeae is prohibitive and is a primary barrier limiting the widespread availability of these tests. Many other barriers to diagnosing STIs in low resource settings also exist, including availability of laboratory equipment and infrastructure, as well as limited availability of trained personnel. Expanding access to testing can not only improve the diagnosis and treatment of STIs but also help to identify those at risk for HIV who can benefit from PrEP. While PrEP was not yet available in Vietnam at the time of this study, a free-of-charge PrEP program has since been implemented in Vietnam and has engaged more than 32,000 people by the end of 2021, mostly MSM. There is considerable need for PrEP among MSM in Vietnam, and increasing funding and access to STI diagnostics and treatment are important components of scaling up PrEP recruitment and routine PrEP care.
Further research is needed to optimize STI screening among MSM in low-resource settings, including assessments of diagnostic testing strategies . Frequently observed risk factors for STIs, such as younger age, condomless anal intercourse, and having two or more recent sex partners were independently associated with gonorrhea or chlamydia in this cohort at baseline. In addition, meeting sex partners via mobile apps or the internet was associated with N. gonorrhoeae or C. trachomatis. The use of the internet or mobile apps to meet sex partners has been associated with behaviors that can increase risk for STIs, including HIV, as users tend to have greater frequency of condomless anal intercourse and more sexual partners. However, mobile app use was associated with infections independent of those factors, suggesting an additional mechanism; one plausible explanation could be related to the sexual networks of mobile app users. Determining causality of mobile app use is difficult, as it is not clear if meeting partners online or via mobile apps increases the risk of STIs or is a behavior of an individual who is already at higher risk for STIs. Nevertheless, the internet or mobile apps are becoming increasingly common ways to meet sexual partners worldwide, including in Vietnam, where a recent survey of MSM found that over three-quarters reported meeting their partners online. Given their widespread use, internet and mobile apps should be leveraged to deliver targeted sexual health interventions aimed at improving diagnosis, treatment, and prevention of STIs, among MSM in Vietnam. One limitation of our report was that all behaviors and symptoms were self-reported and might be subject to recall or social desirability biases, although the use of ACASI for the questionnaire would be expected to limit the latter. In summary, our report comprehensively documents the prevalence of N. gonorrhoeae and C. trachomatis infections at urethral, rectal, and oropharyngeal sites among a cohort of HIV-negative MSM living in Hanoi and adds to the body of recent evidence demonstrating the high burden of STIs within MSM populations globally.
Most of these infections are extragenital and asymptomatic, supporting routine screening at multiple anatomic sites. However, multilevel barriers exist that limit access to sexual health services and diagnostic testing for CT and NG in Vietnam, which include costs and availability of tests, stigma, education, and other individual and systemic barriers. Efforts are urgently needed to address these barriers in order to increase access to STI testing and treatment for MSM in Hanoi. Over 35 million people worldwide live with human immunodeficiency virus , and 1.2 million of these people live in the United States. Since the development of combination antiretroviral therapy , HIV-associated mortality has decreased in the United States, such that the lifespan of people living with HIV with reliable access to cART is comparable to those without HIV . Despite these advances in the medical management of HIV disease, the central nervous system remains vulnerable. In fact, HIV targets the CNS within days after infection leading to neurological, behavioral, and cognitive complications . Even in the current cART era, mild neurocognitive deficits are observed in about 45% of PLWH, particularly in the domains of executive function, learning, and memory . Neuroimaging studies suggest that functional and structural abnormalities in subcortical regions underlie these cognitive deficits . Neurocognitive impairment among PLWH is clinically meaningful because it is known to adversely affect daily functioning, conferring an increased risk of poor medication management , impaired driving ability , problems in employment , and early mortality . As the HIV+ population ages,how to dry cannabis understanding and addressing HIV-associated comorbidities that impact cognitive performance and everyday functioning is critical to overall healthcare for PLWH. Multiple adverse experiences such as childhood trauma, sexual abuse, physical violence, unemployment, and poverty are highly prevalent among PLWH and have known CNS consequences. For example, estimates of sexual and/or physical abuse in PLWH range from 30% to over 50% Whereas the physiological response to acute stress is typically adaptive, chronically-elevated stress exposure can disturb brain development and function, and increase risk of psychiatric disease . Chronic exposure to stress and stress hormones, glucocorticoids, can hinder immune mechanisms and amplify inflammation in the CNS and, furthermore, exacerbate injury-induced neuronal death . Chronic stress in healthy adults is linked to structural and functional alterations in the hippocampus and prefrontal cortex , and poorer memory recall ability . Due to the overlap in the inflammatory and immune mechanisms shown to be affected by stress and HIV, traumatic and stressful experiences may contribute to or compound the likelihood of CNS injury via this pathway in PLWH . Thus, PLWH with a history of trauma and adversity may be at increased risk for neurocognitive impairment and decreased functional capacity.
Among men living with HIV, a previous study found that stressful life events were related to worse executive functioning, attention, and processing speed . In women living with HIV, high levels of self-reported stress were associated with verbal memory deficits, as well as prefrontal cortex structural and functional deficits . Conversely, high stress was not associated with verbal memory performance in women without HIV, suggesting that stress may be particularly deleterious to cognitive function in the context of HIV. Another recent study found that PLWH with higher levels of social adversity showed reduced volumes of sub-cortical structures and worse learning/memory performance, and these findings did not extend to the HIV- group . Stress, emotional reactivity, and avoidant coping behaviors are related to important daily functioning behaviors such as medication non-adherence among PLWH . Although multiple studies have examined the effects of stress on cognitive function within cohorts of PLWH or individuals without HIV, few have directly compared the effects between serostatus groups while examining the combined effects of multiple traumatic and stressful experiences, or included standardized measures of daily functional abilities. In the present study, we investigated whether a composite measure of multiple adverse experiences including trauma, economic hardship, and stress exerts a negative impact on cognitive and everyday function in a cohort of adults living with and without HIV. We hypothesized that PLWH would experience more trauma, economic hardship, and stress than their HIV- counterparts. Furthermore, we hypothesized that elevated TES would relate to worse cognitive function and everyday function in both serostatus groups, but the magnitude of the association would be greater for PLWH compared to their HIV- counterparts, after controlling for established predictors of cognitive and functional status.Prior to conducting primary analyses, independent samples t-tests and Chi-square tests were used to compare HIV status groups on demographic, psychiatric, substance use, and clinical variables. Any variables that differed between the HIV+ and HIVgroups at p < .1 were added as covariates when analyzing the relationship between TES and cognitive/functional outcomes. Thus, we included gender, ethnicity, years of education, lifetime MDD, lifetime substance use disorder , lifetime alcohol use , and lifetime cannabis use in the models for cognition. We did not include current MDD as a covariate due to its low prevalence. For functional outcomes, we additionally included global neurocognitive impairment as a covariate. For PLWH-only models, any HIV disease characteristics that related to global cognition or ADL declines at p <.1 in univariable analyses were added as covariates. For our models in which a cognitive domain in PLWH wasthe outcome variable, current CD4 count was included as an additional covariate, given that it was associated with global cognition at p <.1 in univariable analyses. For our model in which a functional outcome in PLWH was the outcome variable, estimated duration of HIV infection was included as an additional covariate, given that it was associated with ADL declines at p <.1 in univariable analyses. We used multi-variable linear regression analyses to examine the independent and interactive effects of the TES composite and HIV status on cognitive function and declines in activities of daily living. Separate univariable models were run for each of the seven cognitive domains and global cognition, and alpha was set at 0.006 . We pursued multi-variable analyses only for those cognitive domains that showed a significant relationship with TES in univariable models, and in multi-variable analyses, alpha was set at 0.017 , based on the number cognitive domains tested. Post-hoc analyses examined how the components of our TES composite score correlated with each other in PLWH with Spearman’s rho correlations for continuous variables and Cohen’s d for dichotomous variables .