Jonathan S. Schultz, Adam J. Atherly and Andrés F. Henao-Martínez

Abstract. Uninsured and unprepared travelers to countries with endemic tropical diseases pose great health-care burdens and financial risks on returning to the United States. We discuss the delayed presentation of an uninsured U.S. traveler returning from West Africa with severe malaria who required intensive care measures to save his life. Despite being critically ill on his return, he sat rigoring on his couch taking antipyretics for 3 days, while he applied for insurance on the Affordable Care Act website and waited for approval because he was fearful of the costs of seeking care. He also had limited access to affordable pretravel consultation and prophylactic medications and did not take them because he had no insurance. Average fees for a malaria hospitalization cost $25,789; however, this patient accumulated fees nearing $300,000—and his care was reimbursed by emergency Medicaid with $39,000, because his newly accepted insurance did not cover his hospitalization. This patients’ experience in the U.S. health-care system with a deadly tropical disease exemplifies the need for affordable universal coverage of pretravel consultation and malaria prophylaxis. In this uncertain political time and the recent removal of the health insurance mandate, along with the White House and Congress wanting to reform health care, this case supports the American Society of Tropical Medicine and Hygiene (ASTMH) statements showing the need for funding of tropical medicine education, research, and public health services for travelers, not cuts to important agencies and insurances that keep our country safe from imported deadly tropical diseases.

Thomas Weitzel, Ju Jiang, Gerardo Acosta-Jamett, Constanza Martínez-Valdebenito, Javier López, Allen L. Richards, Katia Abarca

by Thomas Weitzel, Ju Jiang, Gerardo Acosta-Jamett, Constanza Martínez-Valdebenito, Javier López, Allen L. Richards, Katia Abarca Background Scrub typhus is a potentially life-threatening vector-borne infection caused by Orientia species. It occurs mainly in the Asian-Pacific region, where it causes significant morbidity and mortality. Recently, an endemic focus of scrub typhus has been described in South America, on Chiloé Island in southern Chile. Dogs have been used as sentinel hosts to determine the presence and spatial distribution of various vector-borne infections. Their suitability to gain insight into human exposure to Orientia tsutsugamushi has been suggested in studies from Asia. Methodology In January 2016, we conducted a cross-sectional study, which included the two main cities on Chiloé Island. Canine blood samples were obtained in households, chosen by double stratified random sampling in urban and by convenience in rural locations. Specimens were tested by ELISA for IgG antibodies against whole-cell antigen preparations from three strains of O. tsutsugamushi. Data were further analyzed for factors associated with seropositivity including spatial clustering. Results Serum samples from 202 dogs (104 urban, 98 rural) were tested for IgG against O. tsutsugamushi, of which 43 (21.3%) were positive. Seroprevalence rates were higher in rural than in urban settings (p…

Reyniers, Thijs; Nöstlinger, Christiana; Laga, Marie; De Baetselier, Irith; Crucitti, Tania; Wouters, Kristien; Smekens, Bart; Buyze, Jozefien; Vuylsteke, Bea

Background: Daily and event-driven Pre-Exposure Prophylaxis (PrEP) are efficacious in reducing HIV transmission among men who have sex with men (MSM). We analysed baseline data from a PrEP demonstration project ‘Be-PrEP-ared’ in Antwerp, Belgium to understand preferences for daily or event-driven PrEP among MSM at high risk for HIV, and factors influencing their initial choice. Methods: Cross-sectional data from an open-label prospective cohort study, using mixed methods. Participants who pre-registered online were screened for eligibility and tested for sexually transmitted infections (STIs). Eligible participants chose between daily and event-driven PrEP and reported on behavioural data through an electronic questionnaire. In-depth interviews were conducted with a selected sub-sample. Bivariate associations were examined between preferred PrEP regimens and sociodemographic factors, sexual behaviour, and STIs at screening. Results: In total, 200 participants were enrolled between October 2015 and December 2016. Self-reported levels of sexual risk-taking before enrolment were high. STI screening revealed that 39.5% had at least one bacterial STI. At baseline, 76.5% of participants preferred daily and 23.5% event-driven PrEP. Feeling able to anticipate HIV risk was the most frequent reason for preferring event-driven PrEP. Regimen choice was associated with sexual risk-taking behaviour in the last three months. Almost all participants (95.7%) considered it likely that they would change their dosing regimen the following year. Conclusion: Event-driven PrEP was preferred by 23.5% of the participants, which better suits their preventive needs. Event-driven PrEP should be included in PrEP provision as a valuable alternative to daily PrEP for MSM at high risk for HIV. Corresponding Author: Dr. Thijs Reyniers, Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, 2000 Antwerp, Belgium, Email: treyniers@itg.be, telephone: +32 247 65 39 Conflict of Interest and Source of Funding: A grant was obtained from the Flemish Agency for Innovation and Entrepreneurship. Gilead Sciences donated the drugs (Truvada) for the study. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

Bassett, Ingrid V.; Xu, Ai; Govere, Sabina; Thulare, Hilary; Frank, Simone C.; Psaros, Christina; Parker, Robert A.

No abstract available…

Noret, Marion; Balavoine, Stéphanie; Noret, Marion; Pintado, Claire; Siguier, Martin; Brun, Alexandre; Bauer, Rebecca; Loze, Bénédicte; Leplatois, Anne; Aslan, Alexandre; Moudachirou, Khafil; Delaugerre, Constance; Rozenbaum, Willy; Molina, Jean-Michel

Background: On Demand oral TDF/FTC has been approved for pre-exposure prophylaxis (PrEP) in men who have sex with men (MSM) in France following the results of clinical studies but data are limited on real-world experience. Design: A single center, open-label, prospective cohort study that recruited people at high risk of HIV infection in Paris. Methods: Subjects were enrolled in a single hospital-based outpatient clinic and were proposed to start PrEP with daily or on demand TDF/FTC. At baseline and every 3 months thereafter subjects were tested for HIV and creatinine plasma levels and data on sexual behavior, other sexually transmitted infections (STIs), and tolerability were collected. Results: From November 10, 2015 to April 30, 2017, 1069 subjects were screened and 1049 (98.1%) started PrEP. Median age was 36 years, 99.4% were MSM with a median number of partners of 10, and 793 (75.6%) opted for on demand PrEP. Over 486 person-years (PY) of follow-up, 4 HIV-infection were diagnosed in poorly or non-adherent subjects (incidence: 0.82/100 PY). Rate of condomless sex at last intercourse increased from 53.3% at baseline to 79% at month 12 (p …

Jason R. Gantenberg, Maximilian King, Madeline C. Montgomery, Omar Galárraga, Mattia Prosperi, Philip A. Chan, Brandon D. L. Marshall

by Jason R. Gantenberg, Maximilian King, Madeline C. Montgomery, Omar Galárraga, Mattia Prosperi, Philip A. Chan, Brandon D. L. Marshall Objectives Identifying prescribing strategies that improve the efficiency of PrEP should increase its impact at the population level. This study identifies PrEP allocation criteria that most effectively reduce 10-year HIV incidence by 25%, in accordance with the US National HIV/AIDS Strategy’s goal for the proportionate reduction in new diagnoses. Methods We used a discrete-time stochastic agent-based model to simulate several PrEP engagement strategies. The model represented MSM aged 15–74 in Rhode Island and was calibrated to statewide prevalence from 2009–2014. We simulated HIV transmission in the absence of PrEP and compared the following PrEP engagement scenarios: 1) allocation to the current patient population; 2) random allocation; 3) allocation to MSM with greater than 5 sexual partners in one year; 4) allocation to MSM with greater than 10 sexual partners in one year.For each scenario and coverage level we estimated the number and proportion of infections averted and the person-years on PrEP per averted infection. Results In 2014, HIV prevalence before PrEP implementation was between 4% and 5%. In the No PrEP scenario 826 new infections (95% simulation limits [SL]: 711, 955) occurred over 10 years, with an incidence rate of 3.51 per 1000 person-years (95% SL: 3.00, 4.08). Prevalence rose to 7.4% (95% SL: 6.7, 8.1). None of the PrEP scenarios reduced new HIV infections by 25% while covering less than 15% of the HIV-uninfected population. At 15% coverage, allocating PrEP to the current patient population, MSM with greater than 5 sexual partners in a year, and MSM with greater than 10 partners reduced new infections by at least 25%, requiring 161 (95% SL: 115, 289), 150 (95% SL: 107, 252), and 128 (95% SL: 100, 184) person-years on PrEP per averted infection, respectively. Conclusions Engaging MSM with high numbers of sexual partners would improve the population-level impact and efficiency of PrEP in settings where PrEP coverage remains low. However, the sustained population-level PrEP coverage needed to reduce new infections by 25% is substantially higher than current levels of PrEP uptake.

Daniela Gonzalez, Jorge Ragusa, Peter C. Angeletti, Gustavo Larsen

by Daniela Gonzalez, Jorge Ragusa, Peter C. Angeletti, Gustavo Larsen In this study, heparin-loaded poly-ɛ-caprolactone (PCL) fibrous mats were prepared and characterized based on their physical, cytotoxic, thermal, and biological properties. The main objective of the work described here was to test the hypothesis that incorporation of heparin into a PCL carrier could serve as bio-compatible material capable of inhibiting Human Papillomavirus (HPV) infection. The idea of firmly anchoring heparin to capture soluble virus, vs. a slow heparin release to inhibit a virus in solution was tested. Thus, one material was produced via conventional heparin matrix encapsulation and electrohydrodynamic fiber processing in one step. A second type of material was obtained via heparin crosslinking. This was achieved by running a carbodiimide/N-hydroxysuccinimide (EDC/NHS) coupling reaction on preformed PCL fibers. In vitro HPV16 L1 protein binding capacity studies were performed. Infectivity assays were done using HPV16 pseudoviruses (PsVs) carrying a GFP plasmid to directly test the ability of the fibrous mats to prevent internalization of HPV PsVs. The crosslinked heparin material presented a dissociation constant (Kd) value comparable to those found in the literature for different heparin-protein L1 peptide interactions. Both materials significantly reduced internalization of HPV PsVs, with a reduction of 94% of PsVs internalization when matrix encapsulated heparin-loaded material was present. Differences in performance between the two proposed structures are discussed.