Ismael Maatouk

Chemsex is defined as the intentional use of psychoactive substances in sexual contexts, primarily affecting individuals who self-identify as men who have sex with men (MSM) (McCall et al., 2015). ...

We conducted a cross-sectional study to estimate the prevalence of urogenital and extragenital sexually transmitted infections (STIs) among men who have sex with men (MSM) with and without urethral discharge syndrome, to assess infections missed by syndromic management, and to describe phenotypic antimicrobial susceptibility patterns of Neisseria gonorrhoeae . The study included 189 MSM attending the Engage Men’s Health Clinic in Johannesburg, South Africa, in 2024. Urethral, rectal and oropharyngeal swabs were tested by multiplex PCR for Neisseria gonorrhoeae (NG), Chlamydia trachomatis (CT), Mycoplasma genitalium (MG) and Trichomonas vaginalis (TV). Genital ulcer swabs were tested for HSV-1/2, lymphogranuloma venereum (LGV), Haemophilus ducreyi (HD) and Treponema pallidum (TP). Serological diagnostic testing for HIV, hepatitis B virus (HBV) and syphilis was performed. NG isolates underwent culture and antimicrobial susceptibility testing. Among MSM with urethritis, NG was most prevalent (urethra: 80.3%, rectum: 41.7%), followed by CT (urethra: 14.8%, rectum: 11.7%). Pharyngeal NG was more common among MSM with urethritis than those without (18.0% vs 3.1%, p = 0.001). Among MSM without urethritis, rectal NG and CT prevalence were 13.5% and 9.5%; rectal LGV was detected in three cases. Among 22 participants with genital ulcers, an aetiology was identified in eight: HSV-2 (n = 3), TP (n = 4) and LGV (n = 1). All NG isolates were susceptible to ceftriaxone, cefixime, and azithromycin, and had low MICs of gentamicin. HIV, HBsAg and treponemal antibody seroprevalence were 31.4%, 3.2% and 50.8%. Active syphilis (RPR titres ≥1:32) was more frequent among MSM without urethral symptoms. Among MSM with urethritis, CT infection was less likely in those reporting recent insertive oro-anal sex and HIV pre-exposure prophylaxis (PrEP) use. Among MSM without urethritis, any discharge STI was associated with homosexual orientation, HIV positivity and lack of circumcision, NG with HIV positivity and being uncircumcised and CT with HIV positivity. Extragenital and asymptomatic STIs remain common among MSM in Johannesburg, stressing the need for routine multi-site molecular screening and inclusion of rapid serological syphilis testing in national STI guidelines for key populations.

Objectives: The spread of ceftriaxone-resistant Neisseria gonorrhoeae is threatening the last option for gonorrhoea treatment, ceftriaxone. Gepotidacin, the first-in-class triazaacenaphthylene bacterial topoisomerase type IIA inhibitor, recently showed non-inferiority compared to ceftriaxone-azithromycin for treatment of uncomplicated urogenital gonorrhoea in a Phase 3 randomized controlled trial. We evaluated the in vitro susceptibility to gepotidacin in clinical gonococcal isolates (n = 2912), including 125 (4.3%) ceftriaxone-resistant isolates, collected 2021–24 in eight WHO Enhanced Gonococcal Antimicrobial Surveillance Programme (EGASP) countries in three WHO regions. Methods: Isolates from Cambodia (n = 474), Indonesia (n = 107), Malawi (n = 111), the Philippines (n = 817), South Africa (n = 578), Thailand (n = 249), Uganda (n = 342) and Vietnam (n = 234) were examined. MICs of gepotidacin were determined using agar dilution. Gepotidacin target genes (gyrA and parC) were examined with Illumina sequencing. Results: Gepotidacin showed high in vitro activity, with MICs ranging from <0.016 to 4 mg/L. The modal MIC was 0.5 mg/L, MIC₅₀ 0.5 mg/L and MIC₉₀ 1 mg/L. Minor variations in the MIC distributions across countries were observed. ParC D86N, which in suboptimal gepotidacin concentrations predisposes for resistance development, was found in 35.5% of isolates. Conclusions: We show that the in vitro susceptibility to gepotidacin in N. gonorrhoeae isolates, including 4.3% ceftriaxone-resistant isolates, collected 2021–24 in eight WHO EGASP countries, including five Asian countries, is high. Our findings support gepotidacin’s continued clinical development, registration and introduction as a novel oral treatment for gonorrhoea. However, as with all new novel antimicrobials, cautious and optimal introduction, and surveillance of phenotypic and genomic susceptibility to gepotidacin internationally, pre- and post-licencing, should accompany any clinical implementation.

Tecovirimat, an antiviral treatment for smallpox, was approved as a treatment for mpox by the European Medicines Agency in January 2022. Approval was granted under “exceptional circumstances” based on effectiveness found in pre-clinical challenge studies in animals and safety studies in humans showing minimal side effects. As clinical efficacy studies are still ongoing, there is currently limited information with regard to the acceptability of tecovirimat to treat mpox. The aim of this study is to understand prospective acceptability of use of tecovirimat as treatment for mpox. A co-produced, qualitative, focus group study design was conducted with a theoretically informed sample of people from communities at higher risk and with experience of mpox illness. Thirteen participants took part: all self-identified as cisgender male, 1 self-identified as Black British, 1 as British Asian, 5 as White, 3 as White British, 3 as White Other. Inclusion criteria were as follows: experience of mpox illness; age 18 and over; living in the United Kingdom (UK); living in the UK during 2022 mpox outbreak. Focus groups were recorded, transcribed and thematically analysed using a combination inductive and deductive coding informed by the Treatment Acceptability Framework. Very few participants were aware of tecovirimat as a treatment option and none were offered it during their mpox illness. Key factors influencing acceptability found in this study were as follows: levels of trust in medicine; level of information; provider communication approach; quality of experience of mpox care. Marginalised communities at highest risk of mpox may have prior experience of structural discrimination which can greatly influence treatment acceptability. This exploratory study suggest that offering tecovirimat (or comparable emergency-licensed treatments) to people with mpox is acceptable, although uptake will depend on knowledge of mpox treatment options, trust in medicine and medical professionals and provision of relevant information and choice. To increase acceptability of such treatments, clinicians should ensure patients are aware of mpox symptom management options, including pain relief; acknowledge and address patient concerns upfront and within the context of non-stigmatising care; and communicate offers in a consistent and supportive manner in line with locally approved eligibility criteria and protocols at the time.