Abstract
The 34th IUSTI European Conference was held from the 3rd to the 5th of October 2020. There were presentations on STIs in Europe, many centred on Romania. A full session was devoted to syphilis, including global efforts in syphilis vaccine development. A workshop on Pre-Exposure Prophylaxis (PrEP) implementation in Europe reviewed the ‘PrEP gap’ and the East/West divide with an additional presentation on upcoming PrEP technologies. The conference featured symposia from WHO: STIs are still increasing and with no Euro universal surveillance systems. Other symposia focused on health inequalities amongst gender and sexual minorities and the recently published changes in IUSTI guidelines on gonorrhoea, syphilis and Lymphogranuloma Venereum. SARS-CoV-2 was a focus for several plenary sessions and its possibly lasting impact on service delivery. New challenges were discussed, particularly the loss of azithromycin as a useful antimicrobial. The symposia covered latest research and work into genomics of STIs. Whole-genome sequencing has revolutionised infectious disease study, particularly infection transmission and control. There was a debate on whether ‘screening and treatment of bacterial Sexually Transmitted Infection is associated with Antimicrobial Resistance and should be reconsidered’, emphasising limited damage of asymptomatic infection and the possibility of emergence of rapid antibiotic resistance. The conference closed with several IUSTI awards.
Introduction
From the third of September, the 34th IUSTI European Conference would have commenced in Bucharest, Romania. However, in response to COVID-19, a hugely ambitious virtual conference was created at quite short notice. There were a range of plenaries, symposia, workshops and free paper sessions, as well as a debate. Three hundred and ninety delegates and members of faculty attended. The meeting attracted limited commercial sponsorship but remained financially viable and may serve as a model for future events.
Workshop presentations
The conference opened with presentations on STIs in Europe, mainly centred on Romania, with additional talks on Sexually Transmitted Infection (STI) epidemiology and management. Emilian Damian Popovici concisely summarised the evolution of HIV/AIDS in Arad County, Romania, and the progression of the epidemic and its eventual control. One of the anomalies of the early Romanian HIV epidemic was the high rates of horizontal HIV transmission, particularly amongst young children in state-run orphanages. He showed how nosocomial transmission has been completely prevented in the last decade.
A full workshop session was devoted to syphilis and emergent problems. The worldwide global burden of syphilis is estimated to be possibly 56 million individuals and still causes significant infection (1.4 million) in pregnant women, accounting for over 300,000 cases of foetal loss/stillbirth and 215,000 cases of prematurity and congenital syphilis. Speakers highlighted that developed countries have seen a rise particularly in urbanised Men who have sex with men (MSM) populations with incidence currently achieving post-war highs. Daniel Richardson spoke on the rise in syphilis associated with chemsex and HIV Pre-Exposure Prophylaxis (PrEP). He explained that although these syndemics are not well-understood, fears of indirectly facilitating STIs should not get in the way of providing effective harm reduction strategies that are tailored to the needs of MSM. In his own unit, much of syphilis presents atypically and may well have been missed, routine had Polymerase Chain Reaction (PCR) tests for syphilis on all genital ulcers had not been performed.
There is currently a major effort through sponsorship by the National Institutes of Health, USA, to develop an effective syphilis vaccine. Lorenzo Giacani gave a comprehensive presentation about efforts at the University of Washington to develop a syphilis vaccine. Early experiments showed that a vaccine was achievable since animals can develop complete long-lasting immunity after massive repeated exposure. He explained that their strategy involved using targets for vaccine development that originated in the conserved regions of exposed outer membrane surface proteins and the use of the effective adjuvants (many adjuvants have failed to date). Current work is progressing with the most promising agent: modern versions of the natural RIBI adjuvants. He reported in detail on a tri-antigen protective syphilis vaccine that has been shown to enhance treponemal clearance and inhibit pathogen dissemination after three vaccine inoculations. However, he acknowledged that the failure to date to develop a complete protective immune response was limiting progression to formal human trials.
A timely session on PrEP covered implementation in Europe. Teymur Noori of the European Centres for Disease Prevention and Control (ECDC) spoke on the East/West divide in both PrEP implementation and knowledge. Currently, the bulk of patients in EURO region appear to be taking PrEP informally without the knowledge of their physicians; the ‘PrEP gap’ between those on PrEP and those likely to use it if it was available was estimated at 500,000 people. Clearly, continuing delays to PrEP access will result in more HIV infections. The three major factors limiting PrEP rollout was the anticipated cost, limited technical capacity and the cost of service delivery. The ECDC is developing operational guidance on PrEP which will be published late 2020.
Pep Coll presented on upcoming technologies that may expand the range of alternative formulations for PrEP. He gave details of the DISCOVER study (Tenofovir Alafenamide and emtricitabine) as well as trials in women of vaginal rings with dapivirine and long-acting integrase inhibitors delivered via injection every 2 months. He also showed examples of subdermal implants, with anticipated drug delivery of at least 1 year that are in development.
Pre-conference symposia
A WHO/ECDC symposium gave an STI epidemiological update in Europe; whilst HIV is nearing epidemic control, STIs are increasing. Strong STI surveillance systems are not universal even in EURO countries and poor reporting still hampers control efforts. There was an update on efforts for the elimination of mother-to-child transmission for HIV and syphilis. The goal in ending many STIs as a public health threat by 2030 was also discussed. Alexandru Rafila stressed the importance of universal health coverage, including the preventability of Hepatitis B, HPV and possibly the prevention and elimination of cervical cancer.
The BASHH-GSM organised a symposium at the congress focused on LGBTI health inequalities and intersectionality. Ford Hickson emphasised the lack of LGBTQIA health data. Despite multiple poor health risk factors being found within this group, there are few tailored services that meet this group’s needs. He suggested the inclusion of sex, gender and sexuality in standard data collection variables.
An IUSTI guidelines symposium provided comprehensive presentations discussing gonorrhoea, syphilis and Lymphogranuloma Venereum. These guidelines have all been published recently, and the authors gave presentations focusing on key changes in the management of these conditions. All the presenters commented on the limited role of azithromycin and the epidemic of emerging resistance to the agent in both gonorrhoea and syphilis.
Plenary sessions
STI service provision and adaptation in response to SARS-CoV-2 was the focus of many presentations, in addition to the actual harms to fertility that SARS-CoV-2 might pose and its potential for sexual transmission. Much early data on the agent were presented, particularly the role it may play on male factor infertility and the potential for longer term viral excretion in genital secretions.
John White’s insightful talk considered STI services post-COVID. BASHH, BHIVA and Public Health England (PHE) modified their guidelines in response to COVID-19. If STI services could learn from this experience and continue with a mix of virtual and face-to-face appointments, clinic waiting times could reduce. Vulnerable groups must be catered for to prevent healthcare inequalities.
One of the most thought-provoking talks was given by Christopher Fairley. He made a cogent argument for avoiding blame when considering new epidemic challenges and the need to invest in strategies known to work. He also pointed out that relying on long-term behaviour change was unlikely to manage the challenges currently faced. He showed that the most impressive changes in disease prevalence can be affected by investment in services that are accessible and, through political and public health policy change that limits stigma. Drawing upon PrEP access and the epidemic of extragenital gonorrhoea, he gave examples of practical innovation and made a plea for clinicians to keep an open mind about transmission dynamics. He reported within this presentation on the likely importance of the oropharynx in the spread and maintenance of Neisseria gonorrhoeae within MSM populations. In addition, he discussed the Melbourne mouthwash studies to prevent/limit the duration of N. gonorrhoeae infection that had recently been shown to have failed.
Other plenary talks involved updates on Human Papilloma Virus (HPV), the challenges of partner notification, the move to resistance-based therapy and migrant health.
Symposia
The symposia this year covered various topics including the latest research and work into genomics of STIs including syphilis, gonorrhoea and chlamydia. Whole-genome sequencing (WGS) has revolutionised the study of infectious diseases, allowing to track the spread of bacterial pathogens and especially Antimicrobial Resistance (AMR) lineages. With the appropriate bioinformatic methods, high throughput sequencing data can be processed to extract typing and AMR information simultaneously, while at the same time, informing on new high-risk clones, outbreaks, transmission chains and support the development of point-of-care tests.
Mathew Beale of the Wellcome Sanger Institute spoke on the challenges of genomic sequencing Treponema pallidum, and the latest strategies to improve rapid DNA sequencing. The recent development of sequence-capture schemes for targeted enrichment of Treponema DNA directly from mixed clinical samples is now enabling large-scale population genomic studies of syphilis populations. These preliminary studies have provided insights into the promise, but also the limitations of Treponema genomics.
Leonor Sanchez-Busosponke showed how WGS has provided further insight into how gonorrhoea spreads in different sexual networks. A recent genomic study revealed particular lineages associated with different risk populations and with different antimicrobial susceptibilities. Results showed two major lineages, which may represent two epidemiological strategies used by N. gonorrhoeae. Interestingly, genomic data from other studies have found the same pattern in different collections across the world.
Over recent years, diagnostic escape through mutations has occurred twice for Chlamydia trachomatis. Helena Seth-Smith, explained how the application of real-time sequencing technologies in the future can provide us with rapid diagnosis and typing, combined with sexual contact tracing, to identify and terminate outbreaks.
Debate
The annual IUSTI Europe debate has become a showpiece of recent congresses. This year Chris Kenyon and Peter Greenhouse battled wits on whether ‘screening and treatment of bacterial STI is associated with AMR and should be reconsidered’. Dr Kenyon spoke for the motion and won on both the majority on the final vote, as well as the swing to his position during the debate. He spoke about the wider damage of mass testing for asymptomatic infection, consequent treatment disruption to the microbiome and archiving of resistance mutations that may in time pass to other pathogens. He showed that the development of resistance in communities was closely linked to the average exposure to antibiotics in that population. He challenged Dr Greenhouse to show any evidence that screening for asymptomatic gonorrhoea and chlamydia had any positive health outcomes. Dr Kenyon advised that we should confine mass screening/testing programs to those with proven benefit of treatment to the individual or partners, such as testing for HIV, syphilis and hepatitis C.
IUSTI awards
The IUSTI first diploma, awarded to Jolinda de Korne-Elenbaas from the Department of Infectious Diseases at Amsterdam UMC, for using WGS to sequence 318 N. gonorrhoeae strains with reduced ceftriaxone susceptibility profiles, identifying a recently emerging cluster with reduced susceptibility.
The IUSTI second diploma awarded to Helene Zondag from the Department of Infectious Diseases at the GGD (Public Health Service of Amsterdam) in Amsterdam was for her ongoing study using multilocus sequencing typing of T. pallidum DNA to assess the frequency of T. pallidum DNA at various body locations and in different disease stages.
The following President’s Awards were assigned: Best Student Oral Presentation to Danayan Luxmanan. His was a service evaluation exploring the impact of the telephone triage service introduced across a large sexual health network and the consequent improvement to access for patients with gonorrhoea. Second place went to James Woodward, whose presentation was about the use of multiplex NAATs assays in the screening and diagnosis of Mycoplasma genitalium and Trichomonas Vaginalis. Best Case Report was received by Jessica Shaw for a report on spirochaetosis as a cause of bloody diarrhoea in an MSM. Best Poster, Simon Bone, for his poster on the lack of clinical value in pre-treatment determination of the presence of parC mutations in M. genitalium.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
