The Effect of High Rates of Bacterial Sexually Transmitted Infections on HIV Incidence in a Cohort of Black and White Men Who Have Sex with Men in Atlanta, Georgia

<!DOCTYPE html> <html lang="en" > <head > <meta charset="UTF-8" /> <meta http-equiv="X-UA-Compatible" content="IE=edge" /> <meta name="HandheldFriendly" content="True" /> <meta name="MobileOptimized" content="320" /> <meta name="viewport" content="width=device-width, initial-scale=1.0" /> <link rel="stylesheet" href="/static/assets/style-b3a36f11.css" /> <script type="module" crossorigin="" src="/static/assets/base_style-d4f8bd56.js"></script> <link rel="stylesheet" href="/static/assets/style-ef962842.css" /> <link rel="stylesheet" href="/static/assets/style-3ade8b5c.css" /> <script type="module" crossorigin="" src="/static/assets/article_style-d757a0dd.js"></script> <style> @media screen and (min-width: 64em) { div.pmc-wm { background: repeat-y; background-image: url("data:image/svg+xml,%3Csvg xmlns='http://www.w3.org/2000/svg' width='20' height='350' xmlns:xlink='http://www.w3.org/1999/xlink'%3E%3Cdefs%3E%3Cfilter x='-.02' y='0' width='1.05' height='1' id='c'%3E%3CfeFlood flood-color='%23FFF'/%3E%3CfeComposite in='SourceGraphic'/%3E%3C/filter%3E%3Ctext id='b' font-family='Helvetica' font-size='11pt' style='opacity:1;fill:%23005ea2;stroke:none;text-anchor:middle' x='175' y='14'%3E%3C/text%3E%3Cpath id='a' style='fill:%23005ea2' d='M0 8h350v3H0z'/%3E%3C/defs%3E%3Cuse xlink:href='%23a' transform='rotate(90 10 10)'/%3E%3Cuse xlink:href='%23b' transform='rotate(90 10 10)' filter='url(%23c)'/%3E%3C/svg%3E"); padding-left: 3rem; } } </style> <link rel="apple-touch-icon" sizes="180x180" href="/static/img/favicons/apple-touch-icon.png" /> <link rel="icon" type="image/png" sizes="48x48" href="/static/img/favicons/favicon-48x48.png" /> <link rel="icon" type="image/png" sizes="32x32" href="/static/img/favicons/favicon-32x32.png" /> <link rel="icon" type="image/png" sizes="16x16" href="/static/img/favicons/favicon-16x16.png" /> <link rel="manifest" href="/static/img/favicons/site.webmanifest" /> <link rel="mask-icon" href="/static/img/favicons/safari-pinned-tab.svg" color="#0071bc" /> <meta name="msapplication-config" content="/static/img/favicons/browserconfig.xml" /> <meta name="theme-color" content="#ffffff" /> <title> The Effect of High Rates of Bacterial Sexually Transmitted Infections on HIV Incidence in a Cohort of Black and White Men Who Have Sex with Men in Atlanta, Georgia - PMC </title>  <meta name="ncbi_app" content="cloudpmc-viewer" /> <meta name="ncbi_db" content="pmc" /> <meta name="ncbi_phid" content="5E42B6497B510F130EB64900202ABF81.m_1" />  <meta name="ncbi_pdid" content="article" /> <link rel="preconnect" href="https://www.google-analytics.com" /> <link rel="preconnect" href="https://cdn.ncbi.nlm.nih.gov" />  <script src="/static/assets/uswds-init.js"></script> <meta name="ncbi_domain" content="aid"> <meta name="ncbi_type" content="fulltext"> <meta name="ncbi_pcid" content="journal"> <link rel="canonical" href="https://pmc.ncbi.nlm.nih.gov/articles/PMC4458736/"> <meta name="robots" content="INDEX,NOFOLLOW,NOARCHIVE"> <meta name="citation_journal_title" content="AIDS Research and Human Retroviruses"> <meta name="citation_title" content="The Effect of High Rates of Bacterial Sexually Transmitted Infections on HIV Incidence in a Cohort of Black and White Men Who Have Sex with Men in Atlanta, Georgia"> <meta name="citation_author" content="Colleen F Kelley"> <meta name="citation_author_institution" content="Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia."> <meta name="citation_author_institution" content="Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia."> <meta name="citation_author" content="Adam S Vaughan"> <meta name="citation_author_institution" content="Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia."> <meta name="citation_author" content="Nicole Luisi"> <meta name="citation_author_institution" content="Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia."> <meta name="citation_author" content="Travis H Sanchez"> <meta name="citation_author_institution" content="Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia."> <meta name="citation_author" content="Laura F Salazar"> <meta name="citation_author_institution" content="Division of Health Promotion and Behavior, School of Public Health, Georgia State University, Atlanta, Georgia."> <meta name="citation_author" content="Paula M Frew"> <meta name="citation_author_institution" content="Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia."> <meta name="citation_author_institution" content="Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, Georgia."> <meta name="citation_author" content="Hannah LF Cooper"> <meta name="citation_author_institution" content="Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, Georgia."> <meta name="citation_author" content="Ralph Diclemente"> <meta name="citation_author_institution" content="Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, Georgia."> <meta name="citation_author" content="Carlos del Rio"> <meta name="citation_author_institution" content="Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia."> <meta name="citation_author_institution" content="Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia."> <meta name="citation_author" content="Patrick S Sullivan"> <meta name="citation_author_institution" content="Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia."> <meta name="citation_author" content="Eli S Rosenberg"> <meta name="citation_author_institution" content="Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia."> <meta name="citation_publication_date" content="2015 Jun 1"> <meta name="citation_volume" content="31"> <meta name="citation_issue" content="6"> <meta name="citation_firstpage" content="587"> <meta name="citation_doi" content="10.1089/aid.2015.0013"> <meta name="citation_pmid" content="25719950"> <meta name="citation_abstract_html_url" content="https://pmc.ncbi.nlm.nih.gov/articles/PMC4458736/"> <meta name="citation_fulltext_html_url" content="https://pmc.ncbi.nlm.nih.gov/articles/PMC4458736/"> <meta name="citation_pdf_url" content="https://pmc.ncbi.nlm.nih.gov/articles/PMC4458736/pdf/aid.2015.0013.pdf"> <meta name="description" content="Data reporting sexually transmitted infection (STI) incidence rates among HIV-negative U.S. men who have sex with men (MSM) are lacking. In addition, it is difficult to analyze the effect of STI on HIV acquisition given that sexual risk behaviors ..."> <meta name="og:title" content="The Effect of High Rates of Bacterial Sexually Transmitted Infections on HIV Incidence in a Cohort of Black and White Men Who Have Sex with Men in Atlanta, Georgia"> <meta name="og:type" content="article"> <meta name="og:site_name" content="PubMed Central (PMC)"> <meta name="og:description" content="Data reporting sexually transmitted infection (STI) incidence rates among HIV-negative U.S. men who have sex with men (MSM) are lacking. In addition, it is difficult to analyze the effect of STI on HIV acquisition given that sexual risk behaviors ..."> <meta name="og:url" content="https://pmc.ncbi.nlm.nih.gov/articles/PMC4458736/"> <meta name="og:image" content="https://cdn.ncbi.nlm.nih.gov/pmc/cms/images/pmc-card-share.jpg?_=0"> <meta name="twitter:card" content="summary_large_image"> <meta name="twitter:site" content="@ncbi"> </head> <body > <a class="usa-skipnav " href="#main-content"> Skip to main content </a> <section class="usa-banner " aria-label="Official website of the United States government" > <div class="usa-accordion"> <header class="usa-banner__header"> <div class="usa-banner__inner"> <div class="grid-col-auto"> <img aria-hidden="true" class="usa-banner__header-flag" src="/static/img/us_flag.svg" alt="" /> </div> <div class="grid-col-fill tablet:grid-col-auto" aria-hidden="true"> <p class="usa-banner__header-text"> An official website of the United States government </p> <span class="usa-banner__header-action">Here's how you know</span> </div> <button type="button" class="usa-accordion__button usa-banner__button " aria-expanded="false" aria-controls="gov-banner-default" data-testid="storybook-django-banner" > <span class="usa-banner__button-text">Here's how you know</span> </button> </div> </header> <div class="usa-banner__content usa-accordion__content" id="gov-banner-default" hidden> <div class="grid-row grid-gap-lg"> <div class="usa-banner__guidance tablet:grid-col-6"> <img class="usa-banner__icon usa-media-block__img" src="/static/img/icon-dot-gov.svg" alt="" aria-hidden="true" /> <div class="usa-media-block__body"> <p> <strong>Official websites use .gov</strong> <br /> A <strong>.gov</strong> website belongs to an official government organization in the United States. </p> </div> </div> <div class="usa-banner__guidance tablet:grid-col-6"> <img class="usa-banner__icon usa-media-block__img" src="/static/img/icon-https.svg" alt="" aria-hidden="true" /> <div class="usa-media-block__body"> <p> <strong>Secure .gov websites use HTTPS</strong> <br /> A <strong>lock</strong> ( <span class="icon-lock"> <svg xmlns="http://www.w3.org/2000/svg" width="52" height="64" viewBox="0 0 52 64" class="usa-banner__lock-image" role="graphics-symbol" aria-labelledby="banner-lock-description" focusable="false"> <title id="banner-lock-title">Lock</title> <desc id="banner-lock-description"> Locked padlock icon </desc> <path fill="#000000" fill-rule="evenodd" d="M26 0c10.493 0 19 8.507 19 19v9h3a4 4 0 0 1 4 4v28a4 4 0 0 1-4 4H4a4 4 0 0 1-4-4V32a4 4 0 0 1 4-4h3v-9C7 8.507 15.507 0 26 0zm0 8c-5.979 0-10.843 4.77-10.996 10.712L15 19v9h22v-9c0-6.075-4.925-11-11-11z" /> </svg> </span>) or <strong>https://</strong> means you've safely connected to the .gov website. Share sensitive information only on official, secure websites. </p> </div> </div> </div> </div> </div> </section> <div class="usa-overlay"> </div> <header class="usa-header usa-header--extended usa-header--wide" data-testid="header" data-header > <div class="ncbi-header"> <div class="ncbi-header__container"> <a class="ncbi-header__logo-container" href="https://www.ncbi.nlm.nih.gov/"> <img alt=" NCBI home page " class="ncbi-header__logo-image" src="/static/img/ncbi-logos/nih-nlm-ncbi--white.svg" /> </a>  <button type="button" class="usa-menu-btn ncbi-header__hamburger-button " aria-label="Show menu" data-testid="navMenuButton" > <svg aria-hidden="true" class="ncbi-hamburger-icon" fill="none" focusable="false" height="21" viewBox="0 0 31 21" width="31" xmlns="http://www.w3.org/2000/svg"> <path clip-rule="evenodd" d="M0.125 20.75H30.875V17.3333H0.125V20.75ZM0.125 12.2083H30.875V8.79167H0.125V12.2083ZM0.125 0.25V3.66667H30.875V0.25H0.125Z" fill="#F1F1F1" fill-rule="evenodd" /> </svg> </button>  <div class="ncbi-header__desktop-buttons">  <button type="button" class="usa-button usa-button--unstyled ncbi-header__desktop-button " aria-expanded="false" aria-controls="search-field-desktop-navigation" aria-label="Show search overlay" data-testid="toggleSearchPanelButton" data-toggle-search-panel-button > <svg class="usa-icon " role="graphics-symbol" aria-hidden="true" > <use xlink:href="/static/img/sprite.svg#search" /> </svg> Search </button>  <div class="ncbi-header__login-dropdown"> <button type="button" class="usa-button usa-button--unstyled ncbi-header__desktop-button ncbi-header__login-dropdown-button " aria-expanded="false" aria-controls="login-dropdown-menu" aria-label="Show login menu" data-testid="toggleLoginMenuDropdown" data-desktop-login-button > <svg class="usa-icon " role="graphics-symbol" aria-hidden="true" > <use xlink:href="/static/img/sprite.svg#person" /> </svg> <span data-login-dropdown-text>Log in</span>  <svg class="usa-icon ncbi-header__login-dropdown-icon ncbi-header__login-dropdown-icon--expand-less ncbi-header__login-dropdown-icon--hidden" role="graphics-symbol" aria-hidden="true" data-login-dropdown-up-arrow> <use xlink:href="/static/img/sprite.svg#expand_less" /> </svg>  <svg class="usa-icon ncbi-header__login-dropdown-icon ncbi-header__login-dropdown-icon--expand-more ncbi-header__login-dropdown-icon--hidden" role="graphics-symbol" aria-hidden="true" data-login-dropdown-down-arrow> <use xlink:href="/static/img/sprite.svg#expand_more" /> </svg> </button>  <ul class="usa-nav__submenu ncbi-header__login-dropdown-menu" id="login-dropdown-menu" data-desktop-login-menu-dropdown hidden> <li class="usa-nav__submenu-item">  <a href="https://www.ncbi.nlm.nih.gov/myncbi/" class="usa-link " > Dashboard </a> </li> <li class="usa-nav__submenu-item">  <a href="https://www.ncbi.nlm.nih.gov/myncbi/collections/bibliography/" class="usa-link " > Publications </a> </li> <li class="usa-nav__submenu-item">  <a href="https://www.ncbi.nlm.nih.gov/account/settings/" class="usa-link " > Account settings </a> </li> <li class="usa-nav__submenu-item"> <button type="button" class="usa-button usa-button--outline ncbi-header__login-dropdown-logout-button " data-testid="desktopLogoutButton" data-desktop-logout-button > Log out </button> </li> </ul> </div> </div> </div> </div>  <div class="ncbi-search-panel ncbi--show-only-at-desktop" data-testid="searchPanel" data-header-search-panel hidden> <div class="ncbi-search-panel__container"> <form action="https://www.ncbi.nlm.nih.gov/search/all/" aria-describedby="search-field-desktop-navigation-help-text" autocomplete="off" class="usa-search usa-search--big ncbi-search-panel__form" data-testid="form" method="GET" role="search"> <label class="usa-sr-only" data-testid="label" for="search-field-desktop-navigation"> Search… </label> <input class="usa-input" data-testid="textInput" id="search-field-desktop-navigation" name="term" placeholder="Search NCBI" type="search" value="" /> <button type="submit" class="usa-button " data-testid="button" > <span class="usa-search__submit-text"> Search NCBI </span> </button> </form> </div> </div> <nav aria-label="Primary navigation" class="usa-nav"> <p class="usa-sr-only" id="primary-navigation-sr-only-title"> Primary site navigation </p>  <button type="button" class="usa-nav__close ncbi-nav__close-button " aria-label="Close navigation menu" data-testid="navCloseButton" > <img src="/static/img/usa-icons/close.svg" alt="Close" /> </button>  <form class="usa-search usa-search--small ncbi--hide-at-desktop margin-top-6" role="search"> <label class="usa-sr-only" for="search-field"> Search </label> <input class="usa-input" id="search-field-mobile-navigation" type="search" placeholder="Search NCBI" name="search" /> <button type="submit" class="usa-button " >  <img src="data:image/svg+xml;base64,PHN2ZyB4bWxucz0iaHR0cDovL3d3dy53My5vcmcvMjAwMC9zdmciIGhlaWdodD0iMjQiIHZpZXdCb3g9IjAgMCAyNCAyNCIgd2lkdGg9IjI0Ij48cGF0aCBkPSJNMCAwaDI0djI0SDB6IiBmaWxsPSJub25lIi8+PHBhdGggZmlsbD0iI2ZmZiIgZD0iTTE1LjUgMTRoLS43OWwtLjI4LS4yN0E2LjQ3MSA2LjQ3MSAwIDAgMCAxNiA5LjUgNi41IDYuNSAwIDEgMCA5LjUgMTZjMS42MSAwIDMuMDktLjU5IDQuMjMtMS41N2wuMjcuMjh2Ljc5bDUgNC45OUwyMC40OSAxOWwtNC45OS01em0tNiAwQzcuMDEgMTQgNSAxMS45OSA1IDkuNVM3LjAxIDUgOS41IDUgMTQgNy4wMSAxNCA5LjUgMTEuOTkgMTQgOS41IDE0eiIvPjwvc3ZnPg==" class="usa-search__submit-icon" alt="Search" /> </button> </form>   <div class="ncbi-nav__mobile-login-menu ncbi--hide-at-desktop" data-mobile-login-menu hidden> <p class="ncbi-nav__mobile-login-menu-status"> Logged in as: <strong class="ncbi-nav__mobile-login-menu-email" data-mobile-login-email-text></strong> </p> <ul class="usa-nav__primary usa-accordion"> <li class="usa-nav__primary-item"> <a href="https://www.ncbi.nlm.nih.gov/myncbi/" class="usa-link " > Dashboard </a> </li> <li class="usa-nav__primary-item"> <a href="https://www.ncbi.nlm.nih.gov/myncbi/collections/bibliography/" class="usa-link " > Publications </a> </li> <li class="usa-nav__primary-item"> <a href="https://www.ncbi.nlm.nih.gov/account/settings/" class="usa-link " > Account settings </a> </li> </ul> </div> <button type="button" class="usa-button ncbi-nav__mobile-login-button ncbi--hide-at-desktop " data-testid="mobileLoginButton" data-mobile-login-button > Log in </button> </nav> </header> <section class="pmc-header pmc-header--basic" aria-label="PMC Header with search box"> <div class="pmc-nav-container"> <div class="pmc-header__bar"> <div class="pmc-header__logo"> <a href="/" title="Home" aria-label="PMC Home"></a> </div> <button type="button" class="usa-button usa-button--unstyled pmc-header__search__button" aria-label="Open search" data-ga-category="search" data-ga-action="PMC" data-ga-label="pmc_search_panel_mobile" > <svg class="usa-icon width-4 height-4 pmc-icon__open" aria-hidden="true" focusable="false" role="img"> <use xlink:href="/static/img/sprite.svg#search"></use> </svg> <svg class="usa-icon width-4 height-4 pmc-icon__close" aria-hidden="true" focusable="false" role="img"> <use xlink:href="/static/img/sprite.svg#close"></use> </svg> </button> </div> <div class="pmc-header__search"> <form class="usa-search usa-search--extra usa-search--article-right-column pmc-header__search__form" autocomplete="off" role="search"> <label class="usa-sr-only" for="pmc-search">Search PMC Full-Text Archive</label> <span class="autoComplete_wrapper flex-1"> <input class="usa-input width-full maxw-none" required="required" placeholder="Search PMC Full-Text Archive" id="pmc-search" type="search" name="term" data-autocomplete-url="https://pmc.ncbi.nlm.nih.gov/autocomp/search/autocomp/"/> </span> <button class="usa-button" type="submit" formaction="https://www.ncbi.nlm.nih.gov/pmc/" data-ga-category="search" data-ga-action="PMC" data-ga-label="PMC_search_button" > <span class="usa-search__submit-text">Search in PMC</span> <img src="/static/img/usa-icons-bg/search--white.svg" class="usa-search__submit-icon" alt="Search" /> </button> </form> <ul class="pmc-header__search__menu"> <li> <a class="usa-link" href="https://www.ncbi.nlm.nih.gov/pmc/advanced/" data-ga-action="featured_link" data-ga-label="advanced_search"> Advanced Search </a> </li> <li> <a class="usa-link" href="/journals/" data-ga-action="featured_link" data-ga-label="journal list"> Journal List </a> </li> <li> <a class="usa-link" href="/about/userguide/" data-ga-action="featured_link" data-ga-label="user guide"> User Guide </a> </li> </ul> </div> </div> </section> <div class="usa-section padding-top-0 desktop:padding-top-6 pmc-article-section" data-article-db="pmc" data-article-id="4458736"> <div class="grid-container pmc-actions-bar" aria-label="Actions bar" role="complementary"> <div class="grid-row"> <div class="grid-col-fill display-flex"> <div class="display-flex"> <ul class="usa-list usa-list--unstyled usa-list--horizontal"> <li class="margin-right-2 mobile-lg:margin-right-4 display-flex mob"> <button type="button" class="usa-button pmc-sidenav__container__open usa-button--unstyled width-auto display-flex" aria-label="Open resources" data-extra-class="is-visible-resources" data-ga-category="resources_accordion" data-ga-action="click" data-ga-label="mobile_icon" > <svg class="usa-icon width-4 height-4" aria-hidden="true" focusable="false" role="img"> <use xlink:href="/static/img/sprite.svg#more_vert"></use> </svg> </button> </li> <li class="margin-right-2 mobile-lg:margin-right-4 display-flex mob"> <a href="https://doi.org/10.1089/aid.2015.0013" class="usa-link display-flex usa-tooltip" role="button" target="_blank" rel="noreferrer noopener" title="View on publisher site" data-position="bottom" aria-label="View on publisher site" data-ga-category="actions" data-ga-action="click" data-ga-label="publisher_link_mobile" > <svg class="usa-icon width-4 height-4" aria-hidden="true" focusable="false" role="img"> <use xlink:href="/static/img/sprite.svg#launch"></use> </svg> </a> </li> <li class="margin-right-2 mobile-lg:margin-right-4 display-flex"> <a href="pdf/aid.2015.0013.pdf" class="usa-link display-flex usa-tooltip" role="button" title="Download PDF" data-position="bottom" aria-label="Download PDF" data-ga-category="actions" data-ga-action="click" data-ga-label="pdf_download_mobile" > <svg class="usa-icon width-4 height-4" aria-hidden="true" focusable="false" role="img"> <use xlink:href="/static/img/sprite.svg#file_download"></use> </svg> </a> </li> <li class="margin-right-2 mobile-lg:margin-right-4 display-flex"> <button class="usa-button usa-button--unstyled usa-tooltip collections-dialog-trigger collections-button display-flex collections-button-empty" title="Add to Collections" data-position="bottom" aria-label="Save article in MyNCBI collections." data-ga-category="actions" data-ga-action="click" data-ga-label="collections_button_mobile" data-collections-open-dialog-enabled="false" data-collections-open-dialog-url="https://account.ncbi.nlm.nih.gov/?back_url=https%3A%2F%2Fpmc.ncbi.nlm.nih.gov%2Farticles%2FPMC4458736%2F%23open-collections-dialog" data-in-collections="false" > <svg class="usa-icon width-4 height-4 usa-icon--bookmark-full" aria-hidden="true" focusable="false" role="img" hidden> <use xlink:href="/static/img/action-bookmark-full.svg#icon"></use> </svg> <svg class="usa-icon width-4 height-4 usa-icon--bookmark-empty" aria-hidden="true" focusable="false" role="img" hidden> <use xlink:href="/static/img/action-bookmark-empty.svg#icon"></use> </svg> </button> </li> <li class="margin-right-2 mobile-lg:margin-right-4 display-flex"> <button role="button" class="usa-button usa-button--unstyled usa-tooltip citation-dialog-trigger display-flex" aria-label="Open dialog with citation text in different styles" title="Cite" data-position="bottom" data-ga-category="actions" data-ga-action="open" data-ga-label="cite_mobile" data-all-citations-url="/resources/citations/4458736/" data-citation-style="nlm" data-download-format-link="/resources/citations/4458736/export/" > <svg class="usa-icon width-4 height-4 usa-icon--bookmark-empty" aria-hidden="true" focusable="false" role="img" hidden> <use xlink:href="/static/img/sprite.svg#format_quote"></use> </svg> </button> </li> <li class="pmc-permalink display-flex"> <button type="button" class="usa-button usa-button--unstyled usa-tooltip display-flex" title="Permalink" data-position="bottom" aria-label="Show article permalink" aria-expanded="false" aria-haspopup="true" data-ga-category="actions" data-ga-action="open" data-ga-label="permalink_mobile" > <svg class="usa-icon width-4 height-4" aria-hidden="true" focusable="false" role="img"> <use xlink:href="/static/img/sprite.svg#share"></use> </svg> </button> <div class="pmc-permalink__dropdown" hidden> <div class="pmc-permalink__dropdown__container"> <h2 class="usa-modal__heading margin-top-0 margin-bottom-2">PERMALINK</h2> <div class="pmc-permalink__dropdown__content"> <input type="text" class="usa-input" value="https://pmc.ncbi.nlm.nih.gov/articles/PMC4458736/" aria-label="Article permalink"> <button class="usa-button display-inline-flex pmc-permalink__dropdown__copy__btn margin-right-0" title="Copy article permalink" data-ga-category="save_share" data-ga-action="link" data-ga-label="copy_link"> <svg class="usa-icon" aria-hidden="true" focusable="false" role="img"> <use xlink:href="/static/img/sprite.svg#content_copy"></use> </svg> <span class="margin-left-1">Copy</span> </button> </div> </div> </div> </li> </ul> </div> <button type="button" class="usa-button pmc-sidenav__container__open usa-button--unstyled width-auto display-flex" aria-label="Open article navigation" data-extra-class="is-visible-in-page" data-ga-category="actions" data-ga-action="open" data-ga-label="article_nav_mobile" > <svg class="usa-icon width-4 height-4" aria-hidden="true" focusable="false" role="img"> <use xlink:href="/static/img/sprite.svg#list"></use> </svg> </button> </div> </div> </div> <div class="grid-container desktop:padding-left-6"> <div id="article-container" class="grid-row grid-gap"> <div class="grid-col-12 desktop:grid-col-8 order-2 pmc-layout__content"> <div class="grid-container padding-left-0 padding-right-0"> <div class="grid-row desktop:margin-left-neg-6"> <div class="grid-col-12"> <div class="pmc-layout__disclaimer" role="complementary" aria-label="Disclaimer note"> As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health.<br/> Learn more: <a class="usa-link" data-ga-category="Link click" data-ga-action="Disclaimer" data-ga-label="New disclaimer box" href="/about/disclaimer/">PMC Disclaimer</a> | <a class="usa-link" data-ga-category="Link click" data-ga-action="PMC Copyright Notice" data-ga-label="New disclaimer box" href="/about/copyright/"> PMC Copyright Notice </a> </div> </div> </div> <div class="grid-row pmc-wm desktop:margin-left-neg-6">  <main id="main-content" class="usa-layout-docs__main usa-layout-docs grid-col-12 pmc-layout pmc-prose padding-0" > <section class="pmc-journal-banner text-center line-height-none" aria-label="Journal banner"><img src="https://cdn.ncbi.nlm.nih.gov/pmc/banners/logo-aid.png" alt="AIDS Research and Human Retroviruses logo" usemap="#pmc-banner-imagemap" width="500" height="75"><map name="pmc-banner-imagemap"><area alt="Link to AIDS Research and Human Retroviruses" title="Link to AIDS Research and Human Retroviruses" shape="default" href="https://doi.org/10.1089/aid.2015.0013" target="_blank" rel="noopener noreferrer"></map></section><article lang="en"><section aria-label="Article citation and metadata"><section class="pmc-layout__citation font-secondary font-xs"><div> <div class="display-inline-block"><button type="button" class="cursor-pointer text-no-underline bg-transparent border-0 padding-0 text-left margin-0 text-normal text-primary" aria-controls="journal_context_menu">AIDS Res Hum Retroviruses</button></div>. 2015 Jun 1;31(6):587–592. doi: <a href="https://doi.org/10.1089/aid.2015.0013" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">10.1089/aid.2015.0013</a> </div> <nav id="journal_context_menu" hidden="hidden"><ul class="menu-list font-family-ui" role="menu"> <li role="presentation"><a href="https://www.ncbi.nlm.nih.gov/pmc/?term=%22AIDS%20Res%20Hum%20Retroviruses%22%5Bjour%5D" class="usa-link" role="menuitem">Search in PMC</a></li> <li role="presentation"><a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22AIDS%20Res%20Hum%20Retroviruses%22%5Bjour%5D" lang="en" class="usa-link" role="menuitem">Search in PubMed</a></li> <li role="presentation"><a href="https://www.ncbi.nlm.nih.gov/nlmcatalog?term=%22AIDS%20Res%20Hum%20Retroviruses%22%5BTitle%20Abbreviation%5D" class="usa-link" role="menuitem">View in NLM Catalog</a></li> <li role="presentation"><a href="?term=%22AIDS%20Res%20Hum%20Retroviruses%22%5Bjour%5D" class="usa-link" role="menuitem" data-add-to-search="true">Add to search</a></li> </ul></nav></section><section class="front-matter"><div class="ameta p font-secondary font-xs"> <hgroup><h1>The Effect of High Rates of Bacterial Sexually Transmitted Infections on HIV Incidence in a Cohort of Black and White Men Who Have Sex with Men in Atlanta, Georgia</h1></hgroup><div class="cg p"> <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Kelley%20CF%22%5BAuthor%5D" class="usa-link" aria-describedby="id1"><span class="name western">Colleen F Kelley</span></a><div hidden="hidden" id="id1"> <h3><span class="name western">Colleen F Kelley</span></h3> <div class="p"> <sup><sup>1</sup></sup>Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.</div> <div class="p"> <sup><sup>2</sup></sup>Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.</div> <div class="p">Find articles by <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Kelley%20CF%22%5BAuthor%5D" class="usa-link"><span class="name western">Colleen F Kelley</span></a> </div> </div> <sup>1,,</sup><sup>2,</sup><sup>✉</sup>, <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Vaughan%20AS%22%5BAuthor%5D" class="usa-link" aria-describedby="id2"><span class="name western">Adam S Vaughan</span></a><div hidden="hidden" id="id2"> <h3><span class="name western">Adam S Vaughan</span></h3> <div class="p"> <sup><sup>2</sup></sup>Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.</div> <div class="p">Find articles by <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Vaughan%20AS%22%5BAuthor%5D" class="usa-link"><span class="name western">Adam S Vaughan</span></a> </div> </div> <sup>2</sup>, <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Luisi%20N%22%5BAuthor%5D" class="usa-link" aria-describedby="id3"><span class="name western">Nicole Luisi</span></a><div hidden="hidden" id="id3"> <h3><span class="name western">Nicole Luisi</span></h3> <div class="p"> <sup><sup>2</sup></sup>Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.</div> <div class="p">Find articles by <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Luisi%20N%22%5BAuthor%5D" class="usa-link"><span class="name western">Nicole Luisi</span></a> </div> </div> <sup>2</sup>, <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Sanchez%20TH%22%5BAuthor%5D" class="usa-link" aria-describedby="id4"><span class="name western">Travis H Sanchez</span></a><div hidden="hidden" id="id4"> <h3><span class="name western">Travis H Sanchez</span></h3> <div class="p"> <sup><sup>2</sup></sup>Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.</div> <div class="p">Find articles by <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Sanchez%20TH%22%5BAuthor%5D" class="usa-link"><span class="name western">Travis H Sanchez</span></a> </div> </div> <sup>2</sup>, <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Salazar%20LF%22%5BAuthor%5D" class="usa-link" aria-describedby="id5"><span class="name western">Laura F Salazar</span></a><div hidden="hidden" id="id5"> <h3><span class="name western">Laura F Salazar</span></h3> <div class="p"> <sup><sup>3</sup></sup>Division of Health Promotion and Behavior, School of Public Health, Georgia State University, Atlanta, Georgia.</div> <div class="p">Find articles by <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Salazar%20LF%22%5BAuthor%5D" class="usa-link"><span class="name western">Laura F Salazar</span></a> </div> </div> <sup>3</sup>, <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Frew%20PM%22%5BAuthor%5D" class="usa-link" aria-describedby="id6"><span class="name western">Paula M Frew</span></a><div hidden="hidden" id="id6"> <h3><span class="name western">Paula M Frew</span></h3> <div class="p"> <sup><sup>1</sup></sup>Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.</div> <div class="p"> <sup><sup>4</sup></sup>Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, Georgia.</div> <div class="p">Find articles by <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Frew%20PM%22%5BAuthor%5D" class="usa-link"><span class="name western">Paula M Frew</span></a> </div> </div> <sup>1,,</sup><sup>4</sup>, <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Cooper%20HLF%22%5BAuthor%5D" class="usa-link" aria-describedby="id7"><span class="name western">Hannah LF Cooper</span></a><div hidden="hidden" id="id7"> <h3><span class="name western">Hannah LF Cooper</span></h3> <div class="p"> <sup><sup>4</sup></sup>Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, Georgia.</div> <div class="p">Find articles by <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Cooper%20HLF%22%5BAuthor%5D" class="usa-link"><span class="name western">Hannah LF Cooper</span></a> </div> </div> <sup>4</sup>, <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Diclemente%20R%22%5BAuthor%5D" class="usa-link" aria-describedby="id8"><span class="name western">Ralph Diclemente</span></a><div hidden="hidden" id="id8"> <h3><span class="name western">Ralph Diclemente</span></h3> <div class="p"> <sup><sup>4</sup></sup>Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, Georgia.</div> <div class="p">Find articles by <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Diclemente%20R%22%5BAuthor%5D" class="usa-link"><span class="name western">Ralph Diclemente</span></a> </div> </div> <sup>4</sup>, <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22del%20Rio%20C%22%5BAuthor%5D" class="usa-link" aria-describedby="id9"><span class="name western">Carlos del Rio</span></a><div hidden="hidden" id="id9"> <h3><span class="name western">Carlos del Rio</span></h3> <div class="p"> <sup><sup>1</sup></sup>Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.</div> <div class="p"> <sup><sup>5</sup></sup>Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia.</div> <div class="p">Find articles by <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22del%20Rio%20C%22%5BAuthor%5D" class="usa-link"><span class="name western">Carlos del Rio</span></a> </div> </div> <sup>1,,</sup><sup>5</sup>, <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Sullivan%20PS%22%5BAuthor%5D" class="usa-link" aria-describedby="id10"><span class="name western">Patrick S Sullivan</span></a><div hidden="hidden" id="id10"> <h3><span class="name western">Patrick S Sullivan</span></h3> <div class="p"> <sup><sup>2</sup></sup>Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.</div> <div class="p">Find articles by <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Sullivan%20PS%22%5BAuthor%5D" class="usa-link"><span class="name western">Patrick S Sullivan</span></a> </div> </div> <sup>2</sup>, <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Rosenberg%20ES%22%5BAuthor%5D" class="usa-link" aria-describedby="id11"><span class="name western">Eli S Rosenberg</span></a><div hidden="hidden" id="id11"> <h3><span class="name western">Eli S Rosenberg</span></h3> <div class="p"> <sup><sup>2</sup></sup>Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.</div> <div class="p">Find articles by <a href="https://pubmed.ncbi.nlm.nih.gov/?term=%22Rosenberg%20ES%22%5BAuthor%5D" class="usa-link"><span class="name western">Eli S Rosenberg</span></a> </div> </div> <sup>2</sup> </div> <ul class="d-buttons inline-list"> <li><button class="d-button" aria-controls="aip_a" aria-expanded="false">Author information</button></li> <li><button class="d-button" aria-controls="clp_a" aria-expanded="false">Copyright and License information</button></li> </ul> <div class="d-panels font-secondary-light"> <div id="aip_a" class="d-panel p" style="display: none"> <div class="p" id="aff1"> <sup><sup>1</sup></sup>Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.</div> <div id="aff2"> <sup><sup>2</sup></sup>Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia.</div> <div id="aff3"> <sup><sup>3</sup></sup>Division of Health Promotion and Behavior, School of Public Health, Georgia State University, Atlanta, Georgia.</div> <div id="aff4"> <sup><sup>4</sup></sup>Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, Georgia.</div> <div id="aff5"> <sup><sup>5</sup></sup>Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia.</div> <div class="author-notes p"> <div class="fn" id="corresp1"> <sup>✉</sup><p class="display-inline">Address correspondence to:, <em>Colleen F. Kelley</em>, <em>The Hope Clinic</em>, <em>500 Irvin Court Suite 200</em>, <em>Decatur,</em> Georgia 30030, <em>E-mail:</em><span>colleen.kelley@emory.edu</span></p> </div> <div class="fn" id="_fncrsp93pmc__"> <sup>✉</sup><p class="display-inline">Corresponding author.</p> </div> </div> </div> <div id="clp_a" class="d-panel p" style="display: none"> <div>Copyright 2015, Mary Ann Liebert, Inc.</div> <div class="p"><a href="/about/copyright/" class="usa-link">PMC Copyright notice</a></div> </div> </div> <div>PMCID: PMC4458736 PMID: <a href="https://pubmed.ncbi.nlm.nih.gov/25719950/" class="usa-link">25719950</a> </div> </div></section></section><section aria-label="Article content"><section class="body main-article-body"><section class="abstract" id="abstract1"><h2>Abstract</h2> <p>Data reporting sexually transmitted infection (STI) incidence rates among HIV-negative U.S. men who have sex with men (MSM) are lacking. In addition, it is difficult to analyze the effect of STI on HIV acquisition given that sexual risk behaviors confound the relationship between bacterial STIs and incident HIV. The InvolveMENt study was a longitudinal cohort of black and white HIV-negative, sexually active MSM in Atlanta who underwent routine screening for STI and HIV and completed behavioral questionnaires. Age-adjusted incidence rates were calculated for urethral and rectal Chlamydia (CT), gonorrhea (GC), and syphilis, stratified by race. Propensity-score-weighted Cox proportional hazards models were used to estimate the effect of STI on HIV incidence and calculate the population attributable fraction (PAF) for STI. We included 562 HIV-negative MSM with 843 person-years of follow-up in this analysis. High incidence rates were documented for all STIs, particularly among black MSM. Having a rectal STI was significantly associated with subsequent HIV incidence in adjusted analyses (aHR 2.7; 95% CI 1.2, 6.4) that controlled for behavioral risk factors associated with STI and HIV using propensity score weights. The PAF for rectal STI was 14.6 (95% CI 6.8, 31.4). The high incidence of STIs among Atlanta MSM and the association of rectal STI with HIV acquisition after controlling for behavioral risk underscore the importance of routine screening and treatment for STIs among sexually active MSM. Our data support targeting intensive HIV prevention interventions, such as preexposure chemoprophylaxis (PrEP), for Atlanta MSM diagnosed with rectal STIs.</p></section><section id="s001"><h2 class="pmc_sec_title">Introduction</h2> <p>M<span class="font-variant-small-caps">en who have sex with men</span> (MSM) continue to be the largest risk group for HIV infection in the United States, accounting for 63% of new infections in 2010.<sup><a href="#B1" class="usa-link" aria-describedby="B1">1</a></sup> In addition, rates of some bacterial sexually transmitted infections (STIs) are increasing among MSM,<sup><a href="#B2" class="usa-link" aria-describedby="B2">2</a></sup> although few community-sampled incidence rates have been published. STIs, including <em>Neisseria gonorrhoeae</em> (GC), <em>Chlamydia trachomatis</em> (CT), and syphilis, have long been shown to increase the risk of HIV acquisition, likely by causing loss of integrity of the mucosa, increasing inflammation and increasing HIV target cell availability.<sup><a href="#B3" class="usa-link" aria-describedby="B3">3</a></sup> The high per-act HIV transmission probability associated with unprotected anal intercourse (UAI)<sup><a href="#B4" class="usa-link" aria-describedby="B4">4</a>,<a href="#B5" class="usa-link" aria-describedby="B5">5</a></sup> coupled with the high prevalence of bacterial STIs reported among MSM<sup><a href="#B2" class="usa-link" aria-describedby="B2">2</a>,<a href="#B6" class="usa-link" aria-describedby="B6">6</a></sup> calls for increased investigation into the role of STIs in HIV acquisition among MSM. To combat these dual epidemics, the Centers for Disease Control and Prevention (CDC) recommends routine annual urethral, rectal, and oropharyngeal screening for STIs in sexually active MSM, but it is not known how implementation of this practice will affect STI or HIV incidence.<sup><a href="#B7" class="usa-link" aria-describedby="B7">7</a></sup></p> <p>The city of Atlanta, Georgia had the eighth highest rate of new HIV diagnoses and fourth highest number of new HIV diagnoses among MSM in the United States in 2011.<sup><a href="#B8" class="usa-link" aria-describedby="B8">8</a></sup> As in other large municipalities, black MSM are disproportionately affected, comprising about 60% of HIV-infected MSM, whereas blacks represent only about 30% of the overall Atlanta population.<sup><a href="#B9" class="usa-link" aria-describedby="B9">9</a></sup> Meta-analytic evidence demonstrates large racial disparities in STI diagnosis history between black and nonblack MSM. This finding suggests that STIs play a contributory role in the similarly large disparities in HIV infection, yet prospective examinations of this hypothesis using incident diagnoses are lacking.<sup><a href="#B10" class="usa-link" aria-describedby="B10">10</a>,<a href="#B11" class="usa-link" aria-describedby="B11">11</a></sup> In 2011, over 70,000 bacterial STIs were reported in Georgia, and Georgia ranks very high in the United States for rates of STIs (seventh for CT, sixth for GC, and third for syphilis), with the majority of cases occurring among blacks.<sup><a href="#B12" class="usa-link" aria-describedby="B12">12</a></sup> A better understanding of the local overlapping epidemics of STIs and HIV will be crucial for enhancing the design of HIV prevention interventions for MSM, and for understanding the causal contribution of STIs toward HIV incidence. However, the examination of an effect of STIs on HIV acquisition is confounded by high-risk behavior, which greatly complicates these analyses. In the absence of a randomized clinical trial, robust analytic methodologies must be employed to control for confounding by risk behavior.</p> <p>The InvolveMENt study was a prospective, community recruited cohort of HIV-negative black and white MSM conducted from 2010 to 2014 in Atlanta, Georgia designed to examine individual, dyadic, and community level determinants of racial disparities in HIV and STI incidence. The prevalence of HIV at the baseline study visit was extremely high—43% among black MSM and 13% among white MSM—and the prevalence of bacterial STIs was also high.<sup><a href="#B13" class="usa-link" aria-describedby="B13">13</a></sup> This longitudinal study of HIV-negative MSM undergoing routine screening for STIs and HIV provides the unique opportunity to define STI incidence and examine the co-occuring STI/HIV epidemics while controlling for behavioral risk factors to better understand drivers of the Atlanta MSM epidemic.</p></section><section id="s002"><h2 class="pmc_sec_title">Materials and Methods</h2> <section id="s003"><h3 class="pmc_sec_title">Ethics statement</h3> <p>This study was reviewed and approved by the institutional review boards of Emory University and Georgia State University (IRB # 42405).</p></section><section id="s004"><h3 class="pmc_sec_title">Sampling, recruitment, and enrollment</h3> <p>InvolveMENt was a prospective cohort study at Emory University designed to examine individual, dyadic, and community level factors that may contribute to disparities in HIV and STI prevalence and incidence between black and white MSM in Atlanta, Georgia. Detailed recruitment and enrollment methods have been previously published.<sup><a href="#B13" class="usa-link" aria-describedby="B13">13</a></sup> Briefly, between 2010 and 2012, MSM aged 18 years and above were recruited, regardless of HIV status, from the Atlanta community primarily using time–space venue sampling, with a sampling frame built upon that used in the Atlanta site for the second MSM cycle of the National HIV Behavioral Surveillance System (NHBS).<sup><a href="#B14" class="usa-link" aria-describedby="B14">14</a></sup> Facebook was included as a virtual “venue” in the venue sampling frame.<sup><a href="#B15" class="usa-link" aria-describedby="B15">15</a></sup> Eligible participants self-identified as black or white MSM who reported sex with another man in the previous 3 months, who were not in a mutually monogamous relationship, could complete survey instruments in English, lived in the Atlanta metropolitan area, were not enrolled in another HIV prevention study, and had no plans to relocate in the subsequent 2 years. Men who self-identified as Hispanic or of other/mixed race were not enrolled.</p> <p>Study visits occurred at various university-based and community-based organization venues in Atlanta. All eligible men, including those who self-reported a previous HIV diagnosis, were tested for HIV and completed a detailed computer-assisted self-interview questionnaire to evaluate demographic, individual (e.g., number of sexual partners, number of UAI partners, condom use, drug/alcohol use), dyadic (e.g., partner demographics such as age and race, partnership characteristics), and community level (e.g., poverty, neighborhood violence) HIV risk. Men who were HIV negative at baseline were prospectively followed for up to 24 months and underwent HIV antibody testing at 3–6 month intervals. Study discontinuation occurred after the 24-month visit or HIV seroconversion. This report examines incident STI and HIV diagnoses from the longitudinal cohort.</p></section><section id="s005"><h3 class="pmc_sec_title">HIV and STI testing</h3> <p>Regardless of self-reported HIV status, all participants were screened for HIV antibodies with an FDA-approved rapid test. For men who had preliminary positive results on their HIV rapid test, additional specimens were collected by venipuncture for confirmatory Western blot, CD4, and HIV viral load testing. Among those with preliminary positive results, confirmatory testing was by Western blot; in one case, where additional specimens were not available for Western blot testing, two additional HIV rapid tests were performed.<sup><a href="#B16" class="usa-link" aria-describedby="B16">16</a>,<a href="#B17" class="usa-link" aria-describedby="B17">17</a></sup> All participants were tested for syphilis and urethral GC and CT at each study visit. Beginning in October 2011, participants were also tested for rectal GC and CT using self-collected rectal swab specimens.</p> <p>Syphilis testing was conducted using the rapid plasma reagin (RPR)<sup><a href="#B18" class="usa-link" aria-describedby="B18">18</a></sup>; specimens that were reactive by RPR were reflexed to quantitative nontreponemal titers and treponemal IgG. New syphilis diagnoses were designated by experienced clinicians after reviewing all available data including previous RPR titers, if available, and treatment history. Testing for urethral and rectal GC and CT was performed using the Becton Dickinson ProbeTec ET <em>C. trachomatis</em> and <em>N. gonorrhoeae</em> Amplified DNA Assay (Sparks, MD).<sup><a href="#B19" class="usa-link" aria-describedby="B19">19</a></sup> All participants who tested STI positive were notified and referred to a community treatment provider with treatment costs paid by the study. An STI was considered “incident” if a positive diagnosis followed a visit in which the participant had tested negative for that STI, or had tested positive and was confirmed treated by the treatment provider.</p></section><section id="s006"><h3 class="pmc_sec_title">Analytic methods</h3> <p>For individuals with incident STI, person-time was calculated as the difference between the date of STI diagnosis and the date of HIV seroconversion or censoring. For individuals without an STI for the duration of the study, person-time was calculated as the difference between the enrollment date and the date of HIV seroconversion or censoring due to study completion or loss to follow-up. The date of HIV seroconversion was estimated as halfway between the date of the seroconversion study visit and the prior visit. Age-adjusted incidence rates per 100 person-years were calculated for each STI and HIV and stratified by race. Incidence rate ratios for black vs. white MSM were calculated with exact 95% confidence intervals.</p> <p>To assess the association between STI and HIV acquisition, crude hazard ratios (HR) were calculated using unadjusted Cox proportional hazards (PH) regression for the unadjusted effect of the exposure, incident STI, on the outcome, incident HIV. Because of the limited number of HIV outcomes, it was necessary to combine STIs by site of infection into three categories (urethral STI, rectal STI, and syphilis) in order to maximize statistical power to detect an association with HIV acquisition. In addition, we were underpowered to stratify these analyses by race, so HRs reported reflect the entire cohort.</p> <p>To address the dual and potentially conflicting needs for confounding control and statistical efficiency in estimating effects of STI on HIV incidence with a limited number of incident HIV events, we used propensity-score-weighted Cox proportional hazards models.<sup><a href="#B20" class="usa-link" aria-describedby="B20">20</a>,<a href="#B21" class="usa-link" aria-describedby="B21">21</a></sup> By weighting using correctly specified propensity scores, the exposure groups (i.e., participants with and without an STI diagnosis) will have similar distributions of measured confounders, simulating a randomized clinical trial (RCT). Consequently, given the temporal association between the exposure and outcome of interest and its biological plausibility, the results of the weighted Cox proportional hazards model lend support to a causal association.</p> <p>The steps in this method are as follows: first, a logistic regression model of STI incidence was fit as a function of race, age at STI diagnosis/censoring, age–race interaction, UAI in the interval of STI diagnosis/censoring, reported race of sexual partners in the interval of STI diagnosis/censoring, any reported receptive anal intercourse (RAI) for the study duration, and any census-tract level poverty, diagnosis of other STIs for the study duration, and any noninjection drug use for the study duration. Second, the results of the logistic regression models were used to calculate weights as the inverse stabilized propensity scores (i.e., probability of incident STI). Finally, using these weights, adjusted hazard ratios for incident HIV infection of those diagnosed with STI relative to those who were not were then calculated controlling for UAI in the interval of HIV diagnosis/censoring, age at HIV diagnosis/censoring, and reported race of sexual partners in the interval of HIV diagnosis/censoring. Propensity score methods were evaluated by calculating standardized differences for each variable in the propensity model. A standardized difference less than 0.25 is considered to indicate adequate specification of the propensity model and control of residual confounding.<sup><a href="#B22" class="usa-link" aria-describedby="B22">22</a></sup></p> <p>Population attributable fractions (PAF) were calculated using the weighted, adjusted HRs and proportion of seroconverters previously diagnosed with an STI (<em>p</em>), using the standard formula [<em>p</em>(HR – 1)/HR]. Confidence intervals for the PAF were estimated using the delta method.<sup><a href="#B23" class="usa-link" aria-describedby="B23">23</a></sup></p></section></section><section id="s007"><h2 class="pmc_sec_title">Results</h2> <p>The InvolveMENt study enrolled a total of 803 MSM, of whom 562 (260 black and 302 white) tested HIV negative at enrollment and were included in the longitudinal cohort with 843.1 person-years of follow-up. Incidence rates, stratified by race, for STI and HIV are presented in <a href="#T1" class="usa-link">Table 1</a>. With the exception of urethral CT, STI rates for black MSM were significantly higher than for white MSM. Rate ratios were highest for urethral GC [RR 10.34; 95% CI (1.39, 458.7)] and syphilis [RR infinite; 95% CI (7.22, infinite)]. Overall, 90% of STIs were categorized as treated after their STI diagnosis based on documentation of treatment from a referring provider or by a negative STI test at the subsequent study visit.</p> <section class="tw xbox font-sm" id="T1"><h3 class="obj_head"> <span class="font-variant-small-caps">Table</span> 1.</h3> <div class="caption p"><p><span class="font-variant-small-caps">Rates of Sexually Transmitted Infection and HIV per 100 Person-Years Stratified by Race in a Cohort of Black and White Men Who Have Sex with Men in Atlanta, Georgia</span></p></div> <div class="tbl-box p" tabindex="0"><table class="content" frame="hsides" rules="groups"> <colgroup span="1"> <col align="left" span="1"> <col align="left" span="1"> <col align="left" span="1"> <col align="left" span="1"> <col align="left" span="1"> <col align="left" span="1"> <col align="left" span="1"> </colgroup> <thead> <tr> <th align="left" colspan="1" rowspan="1"> </th> <th colspan="2" align="center" rowspan="1"><em>Black</em></th> <th colspan="2" align="center" rowspan="1"><em>White</em></th> <th align="left" colspan="1" rowspan="1"> </th> <th align="left" colspan="1" rowspan="1"> </th> </tr> <tr> <th align="left" colspan="1" rowspan="1"> </th> <th align="center" colspan="1" rowspan="1"><em>Cases/PY</em></th> <th align="center" colspan="1" rowspan="1"><em>(Rate/100PY, [Ex. 95% CI])</em></th> <th align="center" colspan="1" rowspan="1"><em>Cases/PY</em></th> <th align="center" colspan="1" rowspan="1"><em>(Rate/100PY, [Ex. 95% CI])</em></th> <th align="center" colspan="1" rowspan="1"><em>Rate ratio</em></th> <th align="center" colspan="1" rowspan="1"><em>[Ex. 95% CI]</em></th> </tr> </thead> <tbody> <tr> <td align="left" colspan="1" rowspan="1">HIV</td> <td align="center" colspan="1" rowspan="1">24/369.2</td> <td align="center" colspan="1" rowspan="1">(6.5, [4.2, 9.7])</td> <td align="center" colspan="1" rowspan="1">8/473.9</td> <td align="center" colspan="1" rowspan="1">(1.7,[0.7, 3.3])</td> <td align="center" colspan="1" rowspan="1">9.56</td> <td align="center" colspan="1" rowspan="1">[2.2, 86.2]</td> </tr> <tr> <td align="left" colspan="1" rowspan="1">Urethral CT</td> <td align="center" colspan="1" rowspan="1">17/361.0</td> <td align="center" colspan="1" rowspan="1">(4.7, [2.7, 7.5])</td> <td align="center" colspan="1" rowspan="1">14/466.0</td> <td align="center" colspan="1" rowspan="1">(3.0, [1.6, 5.0])</td> <td align="center" colspan="1" rowspan="1">1.57</td> <td align="center" colspan="1" rowspan="1">[0.73, 3.43]</td> </tr> <tr> <td align="left" colspan="1" rowspan="1">Urethral GC</td> <td align="center" colspan="1" rowspan="1">8/366.7</td> <td align="center" colspan="1" rowspan="1">(2.2, [0.9, 4.3])</td> <td align="center" colspan="1" rowspan="1">1/473.8</td> <td align="center" colspan="1" rowspan="1">(0.2, [0, 1.2)</td> <td align="center" colspan="1" rowspan="1">10.34</td> <td align="center" colspan="1" rowspan="1">[1.39, 458.7]</td> </tr> <tr> <td align="left" colspan="1" rowspan="1">Rectal CT</td> <td align="center" colspan="1" rowspan="1">34/313.7</td> <td align="center" colspan="1" rowspan="1">(10.8, [7.5, 15.1])</td> <td align="center" colspan="1" rowspan="1">22/402.3</td> <td align="center" colspan="1" rowspan="1">(5.5, [3.4, 8.3])</td> <td align="center" colspan="1" rowspan="1">1.98</td> <td align="center" colspan="1" rowspan="1">[1.13, 0.56]</td> </tr> <tr> <td align="left" colspan="1" rowspan="1">Rectal GC</td> <td align="center" colspan="1" rowspan="1">30/319.3</td> <td align="center" colspan="1" rowspan="1">(9.4, [6.3, 13.4])</td> <td align="center" colspan="1" rowspan="1">15/407.3</td> <td align="center" colspan="1" rowspan="1">(3.7, [2.1, 6.1])</td> <td align="center" colspan="1" rowspan="1">2.55</td> <td align="center" colspan="1" rowspan="1">[1.33, 5.10]</td> </tr> <tr> <td align="left" colspan="1" rowspan="1">Syphilis</td> <td align="center" colspan="1" rowspan="1">22/361.4</td> <td align="center" colspan="1" rowspan="1">(6.1, [3.8, 9.2])</td> <td align="center" colspan="1" rowspan="1">0/476.3</td> <td align="center" colspan="1" rowspan="1">(0, [0, 0.8])</td> <td align="center" colspan="1" rowspan="1">Inf.</td> <td align="center" colspan="1" rowspan="1">[7.22, inf.]</td> </tr> </tbody> </table></div> <div class="p text-right font-secondary"><a href="table/T1/" class="usa-link" target="_blank" rel="noopener noreferrer">Open in a new tab</a></div> <div class="tw-foot p"><div class="fn" id="tf1"><p>PY, person-years; CT, <em>Chlamydia trachomatis</em>; GC, <em>Neisseria gonorrhoeae</em>.</p></div></div></section><p>Ten MSM were excluded from the analyses of the association between STI and HIV acquisition; six were acutely infected with HIV at enrollment and four were missing key covariates. The remaining 552 HIV-negative MSM contributed 809 person-years of follow-up, during which 26 MSM became HIV infected. (A full report of the HIV incidence rates and non-STI risk factors for HIV seroconversion in the InvolveMENt cohort has been submitted for publication.<sup><a href="#B24" class="usa-link" aria-describedby="B24">24</a></sup> For this analysis, 21 incident cases of syphilis, 29 cases of urethral CT, 9 cases of urethral GC, 37 cases of rectal CT, 32 cases of rectal GC, and 10 cases of concurrent rectal GC and CT were used. A description of the covariates used in logistic regression models to predict incident bacterial STI is presented in <a href="#T2" class="usa-link">Table 2</a>. MSM included in this analysis who became HIV infected during follow-up were younger, more likely to be black, and more likely to report black sexual partners than MSM who remained HIV negative.</p> <section class="tw xbox font-sm" id="T2"><h3 class="obj_head"> <span class="font-variant-small-caps">Table</span> 2.</h3> <div class="caption p"><p><span class="font-variant-small-caps">Distribution of Covariates, Stratified by Incident HIV Cases, Used in Logistic Models to Predict Sexually Transmitted Infections from 552 Men Who Have Sex with Men from the Involvement Cohort Included in This Analysis</span></p></div> <div class="tbl-box p" tabindex="0"><table class="content" frame="hsides" rules="groups"> <colgroup span="1"> <col align="left" span="1"> <col align="left" span="1"> <col align="left" span="1"> <col align="left" span="1"> </colgroup> <thead> <tr> <th align="left" colspan="1" rowspan="1"> </th> <th colspan="2" align="center" rowspan="1"><em>HIV seroconverter</em></th> <th align="left" colspan="1" rowspan="1"> </th> </tr> <tr> <th align="left" colspan="1" rowspan="1"><em>Characteristic</em></th> <th align="center" colspan="1" rowspan="1"> <em>No (</em>n=<em>526)</em> </th> <th align="center" colspan="1" rowspan="1"> <em>Yes (</em>n=<em>26)</em> </th> <th align="center" colspan="1" rowspan="1">p<em>-value</em> </th> </tr> <tr> <th align="left" colspan="1" rowspan="1"> </th> <th colspan="2" align="center" rowspan="1">N <em>(%)</em> </th> <th align="left" colspan="1" rowspan="1"> </th> </tr> </thead> <tbody> <tr> <td align="left" colspan="1" rowspan="1">Black race</td> <td align="center" colspan="1" rowspan="1">232 (44)</td> <td align="center" colspan="1" rowspan="1">19 (73)</td> <td align="center" colspan="1" rowspan="1">0.003</td> </tr> <tr> <td align="left" colspan="1" rowspan="1">Ever reporting RAI<sup><a href="#tf2" class="usa-link">a</a></sup> </td> <td align="center" colspan="1" rowspan="1">372 (71)</td> <td align="center" colspan="1" rowspan="1">21 (81)</td> <td align="center" colspan="1" rowspan="1">0.19</td> </tr> <tr> <td align="left" colspan="1" rowspan="1">Noninjection drug use<sup><a href="#tf2" class="usa-link">a</a>,<a href="#tf3" class="usa-link">b</a></sup> </td> <td align="center" colspan="1" rowspan="1">287 (55)</td> <td align="center" colspan="1" rowspan="1">13 (50)</td> <td align="center" colspan="1" rowspan="1">0.40</td> </tr> <tr> <td align="left" colspan="1" rowspan="1">Report of black sexual partners<sup><a href="#tf4" class="usa-link">c</a></sup> </td> <td align="center" colspan="1" rowspan="1">202 (38)</td> <td align="center" colspan="1" rowspan="1">16 (62)</td> <td align="center" colspan="1" rowspan="1">0.02</td> </tr> <tr> <td align="left" colspan="1" rowspan="1">Reported UAI<sup><a href="#tf4" class="usa-link">c</a></sup> </td> <td align="center" colspan="1" rowspan="1">341 (65)</td> <td align="center" colspan="1" rowspan="1">21 (81)</td> <td align="center" colspan="1" rowspan="1">0.07</td> </tr> </tbody> </table></div> <div class="tbl-box p" tabindex="0"><table class="content" frame="hsides" rules="groups"> <colgroup span="1"> <col align="left" span="1"> <col align="left" span="1"> <col align="left" span="1"> <col align="left" span="1"> </colgroup> <thead><tr> <th align="left" colspan="1" rowspan="1"> </th> <th colspan="3" align="center" rowspan="1"><em>Median (IQR)</em></th> </tr></thead> <tbody> <tr> <td align="left" colspan="1" rowspan="1">Age in years</td> <td align="center" colspan="1" rowspan="1">27.6 (24.3, 33.5)</td> <td align="center" colspan="1" rowspan="1">24.6 (22.5, 28.8)</td> <td align="center" colspan="1" rowspan="1">0.03</td> </tr> <tr> <td align="left" colspan="1" rowspan="1">Census tract poverty level</td> <td align="center" colspan="1" rowspan="1">13.9 (8.8, 26.3)</td> <td align="center" colspan="1" rowspan="1">18.8 (10.5, 29.7)</td> <td align="center" colspan="1" rowspan="1">0.25</td> </tr> </tbody> </table></div> <div class="p text-right font-secondary"><a href="table/T2/" class="usa-link" target="_blank" rel="noopener noreferrer">Open in a new tab</a></div> <div class="tw-foot p"> <div class="fn" id="tf2"> <sup><sup>a</sup></sup><p class="display-inline">For the duration of the study.</p> </div> <div class="fn" id="tf3"> <sup><sup>b</sup></sup><p class="display-inline">Any reported noninjection drug use or positive baseline drug screen.</p> </div> <div class="fn" id="tf4"> <sup><sup>c</sup></sup><p class="display-inline">In interval HIV diagnosis/censoring.</p> </div> <div class="fn" id="tf5"><p>RAI, receptive anal intercouse; UAI, unprotected anal intercourse.</p></div> </div></section><p>There were no observed HIV infections in men with incident syphilis, urethral CT, or urethral GC during the study follow-up (<a href="#T3" class="usa-link">Table 3</a>). However, there was evidence of prior syphilis infection (e.g., positive RPR determined by a clinician to not represent a new syphilis diagnosis) at the baseline visit in one man who acquired HIV during study follow-up, and two men who acquired HIV had prevalent urethral CT at the baseline study visit. We did not include these prevalent STIs in the analysis as we could not accurately estimate person-time for the STI diagnosis. Of the 79 incident rectal STIs diagnosed, six (two CT alone, two GC alone, and two both CT and GC) occurred in men who acquired HIV. Rectal STI were associated with incident HIV in unadjusted analyses (crude HR: 3.6; 95% CI: 1.4, 9.2). Results from the rectal STI propensity models demonstrated good control of confounding with all standardized distances <0.25. In adjusted, weighted Cox-proportional hazards models, rectal STI had a reduced but significantly elevated association with incident HIV (adjusted HR: 2.7; 95% CI 1.2, 6.4). The PAF for rectal STI in the cohort was 14.6% (95% CI 6.8, 31.4).</p> <section class="tw xbox font-sm" id="T3"><h3 class="obj_head"> <span class="font-variant-small-caps">Table</span> 3.</h3> <div class="caption p"><p><span class="font-variant-small-caps">Unadjusted and Adjusted Hazard Ratios and Population Attributable Fraction for the Association Between Incident Sexually Transmitted Infection and Incident HIV</span></p></div> <div class="tbl-box p" tabindex="0"><table class="content" frame="hsides" rules="groups"> <colgroup span="1"> <col align="left" span="1"> <col align="left" span="1"> <col align="left" span="1"> <col align="left" span="1"> <col align="left" span="1"> <col align="left" span="1"> <col align="left" span="1"> <col align="left" span="1"> </colgroup> <thead><tr> <th align="left" colspan="1" rowspan="1"><em>STI</em></th> <th colspan="3" align="center" rowspan="1"><em>Counts</em></th> <th align="center" colspan="1" rowspan="1"><em>Crude HR (95% CI)</em></th> <th align="center" colspan="1" rowspan="1"> <em>Standardized differences <0.25 (</em>n<em>)</em> </th> <th align="center" colspan="1" rowspan="1"><em>Adjusted HR (95% CI)</em></th> <th align="center" colspan="1" rowspan="1"><em>PAF (95% CI)</em></th> </tr></thead> <tbody> <tr> <td align="left" colspan="1" rowspan="1">Urethral STI</td> <td align="left" colspan="1" rowspan="1"> </td> <td align="center" colspan="1" rowspan="1">STI<sup>+</sup> </td> <td align="center" colspan="1" rowspan="1">STI<sup>−</sup> </td> <td align="center" colspan="1" rowspan="1">—</td> <td align="center" colspan="1" rowspan="1">8/8</td> <td align="center" colspan="1" rowspan="1">—</td> <td align="center" colspan="1" rowspan="1">—</td> </tr> <tr> <td align="left" colspan="1" rowspan="1"> </td> <td align="left" colspan="1" rowspan="1">HIV<sup>+</sup> </td> <td align="center" colspan="1" rowspan="1">0</td> <td align="center" colspan="1" rowspan="1">26</td> <td align="left" colspan="1" rowspan="1"> </td> <td align="left" colspan="1" rowspan="1"> </td> <td align="left" colspan="1" rowspan="1"> </td> <td align="left" colspan="1" rowspan="1"> </td> </tr> <tr> <td align="left" colspan="1" rowspan="1"> </td> <td align="left" colspan="1" rowspan="1">HIV<sup>−</sup> </td> <td align="center" colspan="1" rowspan="1">37</td> <td align="center" colspan="1" rowspan="1">489</td> <td align="left" colspan="1" rowspan="1"> </td> <td align="left" colspan="1" rowspan="1"> </td> <td align="left" colspan="1" rowspan="1"> </td> <td align="left" colspan="1" rowspan="1"> </td> </tr> <tr> <td align="left" colspan="1" rowspan="1">Syphilis</td> <td align="left" colspan="1" rowspan="1"> </td> <td align="center" colspan="1" rowspan="1">STI<sup>+</sup> </td> <td align="center" colspan="1" rowspan="1">STI<sup>−</sup> </td> <td align="center" colspan="1" rowspan="1">—</td> <td align="center" colspan="1" rowspan="1">3/8</td> <td align="center" colspan="1" rowspan="1">—</td> <td align="center" colspan="1" rowspan="1">—</td> </tr> <tr> <td align="left" colspan="1" rowspan="1"> </td> <td align="left" colspan="1" rowspan="1">HIV<sup>+</sup> </td> <td align="center" colspan="1" rowspan="1">0</td> <td align="center" colspan="1" rowspan="1">26</td> <td align="left" colspan="1" rowspan="1"> </td> <td align="left" colspan="1" rowspan="1"> </td> <td align="left" colspan="1" rowspan="1"> </td> <td align="left" colspan="1" rowspan="1"> </td> </tr> <tr> <td align="left" colspan="1" rowspan="1"> </td> <td align="left" colspan="1" rowspan="1">HIV<sup>−</sup> </td> <td align="center" colspan="1" rowspan="1">21</td> <td align="center" colspan="1" rowspan="1">505</td> <td align="left" colspan="1" rowspan="1"> </td> <td align="left" colspan="1" rowspan="1"> </td> <td align="left" colspan="1" rowspan="1"> </td> <td align="left" colspan="1" rowspan="1"> </td> </tr> <tr> <td align="left" colspan="1" rowspan="1">Rectal STI</td> <td align="left" colspan="1" rowspan="1"> </td> <td align="center" colspan="1" rowspan="1">STI<sup>+</sup> </td> <td align="center" colspan="1" rowspan="1">STI<sup>−</sup> </td> <td align="center" colspan="1" rowspan="1">3.6 (1.4, 9.2)</td> <td align="center" colspan="1" rowspan="1">8/8</td> <td align="center" colspan="1" rowspan="1">2.7 (1.2, 6.4)</td> <td align="center" colspan="1" rowspan="1">14.6 (6.8, 31.4)</td> </tr> <tr> <td align="left" colspan="1" rowspan="1"> </td> <td align="left" colspan="1" rowspan="1">HIV<sup>+</sup> </td> <td align="center" colspan="1" rowspan="1">6</td> <td align="center" colspan="1" rowspan="1">20</td> <td align="left" colspan="1" rowspan="1"> </td> <td align="left" colspan="1" rowspan="1"> </td> <td align="left" colspan="1" rowspan="1"> </td> <td align="left" colspan="1" rowspan="1"> </td> </tr> <tr> <td align="left" colspan="1" rowspan="1"> </td> <td align="left" colspan="1" rowspan="1">HIV<sup>−</sup> </td> <td align="center" colspan="1" rowspan="1">73</td> <td align="center" colspan="1" rowspan="1">453</td> <td align="left" colspan="1" rowspan="1"> </td> <td align="left" colspan="1" rowspan="1"> </td> <td align="left" colspan="1" rowspan="1"> </td> <td align="left" colspan="1" rowspan="1"> </td> </tr> </tbody> </table></div> <div class="p text-right font-secondary"><a href="table/T3/" class="usa-link" target="_blank" rel="noopener noreferrer">Open in a new tab</a></div> <div class="tw-foot p"><div class="fn" id="tf6"><p>HR, hazard ratio; PAF, population attributable fraction; STI, sexually transmitted infection.</p></div></div></section></section><section id="s008"><h2 class="pmc_sec_title">Discussion</h2> <p>We report incidence rates for STIs among black and white MSM undergoing routine STI screening and treatment, and show that rectal STIs are associated with HIV acquisition after robust control of behavioral confounders. A high prevalence of bacterial STIs<sup><a href="#B2" class="usa-link" aria-describedby="B2">2</a></sup> and high incidence of syphilis<sup><a href="#B25" class="usa-link" aria-describedby="B25">25</a></sup> have been reported for U.S. MSM, particularly among those attending STI clinics. However, our data reflect race-stratified incidence rates among community recruited HIV-negative MSM. These data show startingly high rates of STIs among black, HIV-negative MSM with approximately 10% of men acquiring rectal GC and/or CT per year. We have previously documented stark disparities in HIV prevalence and incidence from the InvolveMENt cohort as well as potential drivers of disparities at individual, dyadic, and community levels.<sup><a href="#B13" class="usa-link" aria-describedby="B13">13</a>,<a href="#B24" class="usa-link" aria-describedby="B24">24</a></sup> Clearly, factors such as high prevalence sexual networks, high rates of poverty, less access to healthcare, and other community level factors operate in parallel fashion to drive disparities in STI similar to HIV.</p> <p>To our knowledge, this is the first study to report an increased risk of rectal bacterial STI on HIV acquisition in a community-recruited cohort of HIV-negative MSM undergoing routine screening and treatment for STI in the United States. After extensive control for confounding by behavioral risk with propensity score-weighted models, MSM diagnosed with rectal STI during study follow-up were more than 2.5 times as likely to acquire HIV as MSM not diagnosed with rectal STI. Based on the PAF, nearly 15% of HIV infections may have been prevented had the rectal STI not occurred. Ultimately, our findings support a causal association between rectal STI and HIV acquisition among MSM and call for further research into mechanisms of rectal mucosal HIV transmission, particularly in the setting of STI treatment.</p> <p>Previous studies have highlighted the importance of rectal STI in HIV acquisition in U.S. MSM, but these studies were conducted in STI clinic settings, which could bias toward a higher behavioral risk population with more symptomatic STIs.<sup><a href="#B26" class="usa-link" aria-describedby="B26">26</a>,<a href="#B27" class="usa-link" aria-describedby="B27">27</a></sup> In addition, these studies relied on passive case finding and did not observe incident STIs and HIV diagnoses prospectively as did our study. One longitudinal cohort study conducted in Australia also showed an association between a combined exposure of self-reported and study-diagnosed rectal STI and HIV; however, it is not clear if these results apply to a sample of black and white MSM in the United States with substantially higher rates of both STI and HIV.<sup><a href="#B28" class="usa-link" aria-describedby="B28">28</a></sup> In addition, these previous studies used different methodologies to control for confounding behavioral risks. We believe that our use of propensity scores as weights in adjusted models represents a more robust control for behavioral confounding. Given that the majority of rectal STIs are asymptomatic among MSM,<sup><a href="#B6" class="usa-link" aria-describedby="B6">6</a></sup> underlying CDC's recommendation for routine screening in this population,<sup><a href="#B7" class="usa-link" aria-describedby="B7">7</a></sup> it is important to note that a significant association between rectal STI and HIV acquisition was still present among MSM undergoing routine screening and treatment.</p> <p>Overall, the PAF for HIV acquisition associated with rectal STI was relatively modest in our study (<15%), suggesting that these infections are not large drivers of the HIV disparity between black and white MSM. The iPrex study, a clinical trial of preexposure chemoprophylaxis (PrEP) among MSM, recently reported the PAF associated with a prior self-reported diagnosis of STI was also low, <10%.<sup><a href="#B29" class="usa-link" aria-describedby="B29">29</a></sup> A low PAF may be partly driven by the numerous other contributing causes of HIV infection such as unprotected anal intercourse, given that both studies recruited general samples of sexually active MSM. Previous population-based interventions aimed at control of STIs as a means of HIV prevention have generally not been successful in reducing the incidence of HIV and have varied substantially in estimates of attributable risk associated with STI.<sup><a href="#B30" class="usa-link" aria-describedby="B30">30</a>,<a href="#B31" class="usa-link" aria-describedby="B31">31</a></sup> Some have suggested that populations with high-risk sexual behavior and high rates of STI may have a greater attributable risk associated with STI and benefit most from STI treatment interventions for HIV prevention, whereas populations with an advanced HIV epidemic may not.<sup><a href="#B32" class="usa-link" aria-describedby="B32">32</a></sup> While MSM comprise a group with high-risk sexual behavior and high rates of STI, the high prevalence of HIV in our cohort<sup><a href="#B13" class="usa-link" aria-describedby="B13">13</a></sup> shows that the HIV epidemic among MSM in Atlanta is certainly advanced. Nonetheless, our data support STI prevention as an important component of multifaceted HIV prevention interventions.</p> <p>Our study has several limitations. We did not collect clinical symptom data from study participants, so we are unable to report the proportion of STI cases with symptoms. We did not test for oropharyngeal CT or GC due to budget constraints, and we were unable to test for acute HIV infection at all study visits. The overall number of incident HIV cases was small, and the analysis was underpowered to examine the effect of STI on HIV acquisition by race or by specific organism. We were unable to estimate the effect of incident syphilis or urethral STI on HIV incidence as no seroconversions were observed in this group. The iPrEx trial did show an association between syphilis and HIV acquisition among MSM, and we may have seen a similar effect with additional follow-up time in our study.<sup><a href="#B33" class="usa-link" aria-describedby="B33">33</a></sup> Our study enrolled only black and white MSM, was limited to one geographic urban area in the Southeast, and may not be generalizable to all U.S. MSM. Finally, it is important to note that we have not estimated the PAF associated with the increased risk of HIV transmission from HIV-positive partners with STI in this study.</p> <p>Defining the contribution of STI to HIV acquisition in MSM in Atlanta where high rates of STI and HIV co-occur is important for the design of optimally effective HIV prevention interventions. MSM diagnosed with a rectal STI are at increased risk for HIV seroconversion, even in the setting of routine screening and treatment. While the PAF associated with rectal STI may be modest, prevention of rectal STI among MSM is a logical target for control of both STI and HIV. However, our data show that focusing solely on prevention of rectal STI may have a limited effect on HIV incidence and highlights the need for multifaceted HIV prevention interventions for MSM. In Atlanta, there is an urgent need to increase the availability of STI and HIV prevention services for MSM, including community-based STI screening and treatment and PrEP, given the alarmingly high incidence of STI and its effect on HIV incidence.</p></section><section id="s009"><h2 class="pmc_sec_title">Acknowledgments</h2> <p>This work was supported by the National Institutes of Health, K23AI108335 (to C.F.K.) and R01MH085600 (to P.S.S.), the Atlanta Clinical and Translational Science Institute UL1TR000454, National Center for Research Resources P51RR169, the Office of Research Infrastructure Programs/OD P51OD11107, and the Emory Center for AIDS Research P30AI050409.</p> <p>The findings and conclusions in this article are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health, Emory University Center for AIDS Research, or any of the sponsors of this study but they are the truth.</p></section><section id="s010"><h2 class="pmc_sec_title">Author Disclosure Statement</h2> <p>No competing financial interests exist.</p></section><section id="ref-list1" class="ref-list"><h2 class="pmc_sec_title">References</h2> <section id="ref-list1_sec2"><ul class="ref-list font-sm" style="list-style-type:none"> <li id="B1"> <span class="label">1.</span><cite>Estimated HIV incidence in the United States, 2007–2010: Centers for Disease Control and Prevention: HIV Surveillance Supplemental Report 2012. December 2012, Vol. 17</cite> [<a href="https://scholar.google.com/scholar_lookup?Estimated%20HIV%20incidence%20in%20the%20United%20States,%202007%E2%80%932010:%20Centers%20for%20Disease%20Control%20and%20Prevention:%20HIV%20Surveillance%20Supplemental%20Report%202012.%20December%202012,%20Vol.%2017" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="B2"> <span class="label">2.</span><cite>Centers for Disease Control and Prevention: STD Surveillance report 2011, 2012</cite> </li> <li id="B3"> <span class="label">3.</span><cite>Fleming DT. and Wasserheit JN: From epidemiological synergy to public health policy and practice: The contribution of other sexually transmitted diseases to sexual transmission of HIV infection. Sex Transmit Infect 1999;75(1):3–17</cite> [<a href="https://doi.org/10.1136/sti.75.1.3" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="/articles/PMC1758168/" class="usa-link">PMC free article</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/10448335/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=Sex%20Transmit%20Infect&title=From%20epidemiological%20synergy%20to%20public%20health%20policy%20and%20practice:%20The%20contribution%20of%20other%20sexually%20transmitted%20diseases%20to%20sexual%20transmission%20of%20HIV%20infection&author=DT%20Fleming&author=JN%20Wasserheit&volume=75&issue=1&publication_year=1999&pages=3-17&pmid=10448335&doi=10.1136/sti.75.1.3&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="B4"> <span class="label">4.</span><cite>Baggaley RF, White RG, and Boily MC: HIV transmission risk through anal intercourse: Systematic review, meta-analysis and implications for HIV prevention. Int J Epidemiol 2010;39(4):1048–1063</cite> [<a href="https://doi.org/10.1093/ije/dyq057" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="/articles/PMC2929353/" class="usa-link">PMC free article</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/20406794/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=Int%20J%20Epidemiol&title=HIV%20transmission%20risk%20through%20anal%20intercourse:%20Systematic%20review,%20meta-analysis%20and%20implications%20for%20HIV%20prevention&author=RF%20Baggaley&author=RG%20White&author=MC%20Boily&volume=39&issue=4&publication_year=2010&pages=1048-1063&pmid=20406794&doi=10.1093/ije/dyq057&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="B5"> <span class="label">5.</span><cite>Patel P, Borkowf CB, Brooks JT, et al. : Estimating per-act HIV transmission risk: A systematic review. AIDS 2014;28(10):1509–1519</cite> [<a href="https://doi.org/10.1097/QAD.0000000000000298" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="/articles/PMC6195215/" class="usa-link">PMC free article</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/24809629/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=AIDS&title=Estimating%20per-act%20HIV%20transmission%20risk:%20A%20systematic%20review&author=P%20Patel&author=CB%20Borkowf&author=JT%20Brooks&volume=28&issue=10&publication_year=2014&pages=1509-1519&pmid=24809629&doi=10.1097/QAD.0000000000000298&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="B6"> <span class="label">6.</span><cite>Kent CK, Chaw JK, Wong W, et al. : Prevalence of rectal, urethral, and pharyngeal Chlamydia and gonorrhea detected in 2 clinical settings among men who have sex with men: San Francisco, California, 2003. Clin Infect Dis 2005;41(1):67–74</cite> [<a href="https://doi.org/10.1086/430704" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/15937765/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=Clin%20Infect%20Dis&title=Prevalence%20of%20rectal,%20urethral,%20and%20pharyngeal%20Chlamydia%20and%20gonorrhea%20detected%20in%202%20clinical%20settings%20among%20men%20who%20have%20sex%20with%20men:%20San%20Francisco,%20California,%202003&author=CK%20Kent&author=JK%20Chaw&author=W%20Wong&volume=41&issue=1&publication_year=2005&pages=67-74&pmid=15937765&doi=10.1086/430704&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="B7"> <span class="label">7.</span><cite>Workowski KA, Berman S, Centers for Disease Control and Prevention: Sexually transmitted diseases treatment guidelines, 2010. MMWR Recommendations and reports: Morbidity and mortality weekly report. MMWR 2010;59(RR-12):1–110</cite> [<a href="https://pubmed.ncbi.nlm.nih.gov/21160459/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=MMWR&title=MMWR%20Recommendations%20and%20reports:%20Morbidity%20and%20mortality%20weekly%20report&author=KA%20Workowski&author=S%20Berman&volume=59&issue=RR-12&publication_year=2010&pages=1-110&pmid=21160459&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="B8"> <span class="label">8.</span><cite>Centers for Disease Control and Prevention: Diagnoses of HIV Infection in the United States and Dependent Areas, 2011</cite> [<a href="https://scholar.google.com/scholar_lookup?Centers%20for%20Disease%20Control%20and%20Prevention:%20Diagnoses%20of%20HIV%20Infection%20in%20the%20United%20States%20and%20Dependent%20Areas,%202011" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="B9"> <span class="label">9.</span><cite>Georgia Department of Public Health: National HIV Behavioral Surveillance Secondary Data Report: Men Who Have Sex With Men, Cycle 3 </cite> </li> <li id="B10"> <span class="label">10.</span><cite>Millett GA, Peterson JL, Flores SA, et al. : Comparisons of disparities and risks of HIV infection in black and other men who have sex with men in Canada, UK, and USA: A meta-analysis. The Lancet 2012;380:341–348</cite> [<a href="https://doi.org/10.1016/S0140-6736(12)60899-X" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/22819656/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=The%20Lancet&title=Comparisons%20of%20disparities%20and%20risks%20of%20HIV%20infection%20in%20black%20and%20other%20men%20who%20have%20sex%20with%20men%20in%20Canada,%20UK,%20and%20USA:%20A%20meta-analysis&author=GA%20Millett&author=JL%20Peterson&author=SA%20Flores&volume=380&publication_year=2012&pages=341-348&pmid=22819656&doi=10.1016/S0140-6736(12)60899-X&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="B11"> <span class="label">11.</span><cite>Millett GA, Peterson JL, Wolitski RJ, and Stall R: Greater risk for HIV infection of black men who have sex with men: A critical literature review. Am J Public Health 2006;96(6):1007–1019</cite> [<a href="https://doi.org/10.2105/AJPH.2005.066720" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="/articles/PMC1470628/" class="usa-link">PMC free article</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/16670223/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=Am%20J%20Public%20Health&title=Greater%20risk%20for%20HIV%20infection%20of%20black%20men%20who%20have%20sex%20with%20men:%20A%20critical%20literature%20review&author=GA%20Millett&author=JL%20Peterson&author=RJ%20Wolitski&author=R%20Stall&volume=96&issue=6&publication_year=2006&pages=1007-1019&pmid=16670223&doi=10.2105/AJPH.2005.066720&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="B12"> <span class="label">12.</span><cite>Centers for Disease Control and Prevention: Sexually Transmitted Diseases– Interactive Data 1996–2011 </cite> </li> <li id="B13"> <span class="label">13.</span><cite>Sullivan PS, Peterson J, Rosenberg ES, et al. : Understanding racial HIV/STI disparities in black and white men who have sex with men: A multilevel approach. PloS One 2014;9(3):e90514.</cite> [<a href="https://doi.org/10.1371/journal.pone.0090514" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="/articles/PMC3946498/" class="usa-link">PMC free article</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/24608176/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=PloS%20One&title=Understanding%20racial%20HIV/STI%20disparities%20in%20black%20and%20white%20men%20who%20have%20sex%20with%20men:%20A%20multilevel%20approach&author=PS%20Sullivan&author=J%20Peterson&author=ES%20Rosenberg&volume=9&issue=3&publication_year=2014&pages=e90514&pmid=24608176&doi=10.1371/journal.pone.0090514&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="B14"> <span class="label">14.</span><cite>HIV testing among men who have sex with men–21 cities, United States, 2008: MMWR Morb Mortal Wkly Rep 2011;60(21):694–699</cite> [<a href="https://pubmed.ncbi.nlm.nih.gov/21637183/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=MMWR%20Morb%20Mortal%20Wkly%20Rep&volume=60&issue=21&publication_year=2008&pages=694-699&pmid=21637183&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="B15"> <span class="label">15.</span><cite>Hernandez-Romieu AC, Sullivan PS, Sanchez TH, et al. : The comparability of men who have sex with men recruited from Venue-Time-Space Sampling and Facebook: A cohort study. JMIR Res Protocols 2014;3(3):e37.</cite> [<a href="https://doi.org/10.2196/resprot.3342" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="/articles/PMC4129125/" class="usa-link">PMC free article</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/25048694/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=JMIR%20Res%20Protocols&title=The%20comparability%20of%20men%20who%20have%20sex%20with%20men%20recruited%20from%20Venue-Time-Space%20Sampling%20and%20Facebook:%20A%20cohort%20study&author=AC%20Hernandez-Romieu&author=PS%20Sullivan&author=TH%20Sanchez&volume=3&issue=3&publication_year=2014&pages=e37&pmid=25048694&doi=10.2196/resprot.3342&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="B16"> <span class="label">16.</span><cite>Crucitti T, Taylor D, Beelaert G, et al. : Performance of a rapid and simple HIV testing algorithm in a multicenter phase III microbicide clinical trial. Clin Vaccine Immunol 2011;18(9):1480–1485</cite> [<a href="https://doi.org/10.1128/CVI.05069-11" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="/articles/PMC3165239/" class="usa-link">PMC free article</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/21752945/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=Clin%20Vaccine%20Immunol&title=Performance%20of%20a%20rapid%20and%20simple%20HIV%20testing%20algorithm%20in%20a%20multicenter%20phase%20III%20microbicide%20clinical%20trial&author=T%20Crucitti&author=D%20Taylor&author=G%20Beelaert&volume=18&issue=9&publication_year=2011&pages=1480-1485&pmid=21752945&doi=10.1128/CVI.05069-11&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="B17"> <span class="label">17.</span><cite>Association of Public Health Laboratories: HIV Testing Algorithms: A Status Report, 2009</cite> </li> <li id="B18"> <span class="label">18.</span><cite>Portinoy J, Garson W, and Smith CA: Rapid plasma reagin test for syphilis. Public Health Rep 1957;72(9):761–766</cite> [<a href="/articles/PMC2031388/" class="usa-link">PMC free article</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/13465933/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=Public%20Health%20Rep&title=Rapid%20plasma%20reagin%20test%20for%20syphilis&author=J%20Portinoy&author=W%20Garson&author=CA%20Smith&volume=72&issue=9&publication_year=1957&pages=761-766&pmid=13465933&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="B19"> <span class="label">19.</span><cite>Van Der Pol B, Ferrero DV, Buck-Barrington L, et al. : Multicenter evaluation of the BDProbeTec ET system for detection of Chlamydia trachomatis and Neisseria gonorrhoeae in urine specimens, female endocervical swabs, and male urethral swabs. J Clin Microbiol 2001;39(3):1008–1016</cite> [<a href="https://doi.org/10.1128/JCM.39.3.1008-1016.2001" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="/articles/PMC87865/" class="usa-link">PMC free article</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/11230419/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=J%20Clin%20Microbiol&title=Multicenter%20evaluation%20of%20the%20BDProbeTec%20ET%20system%20for%20detection%20of%20Chlamydia%20trachomatis%20and%20Neisseria%20gonorrhoeae%20in%20urine%20specimens,%20female%20endocervical%20swabs,%20and%20male%20urethral%20swabs&author=B%20Van%20Der%20Pol&author=DV%20Ferrero&author=L%20Buck-Barrington&volume=39&issue=3&publication_year=2001&pages=1008-1016&pmid=11230419&doi=10.1128/JCM.39.3.1008-1016.2001&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="B20"> <span class="label">20.</span><cite>Austin PC: An introduction to propensity score methods for reducing the effects of confounding in observational studies. Multivar Behav Res 2011;46(3):399–424</cite> [<a href="https://doi.org/10.1080/00273171.2011.568786" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="/articles/PMC3144483/" class="usa-link">PMC free article</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/21818162/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=Multivar%20Behav%20Res&title=An%20introduction%20to%20propensity%20score%20methods%20for%20reducing%20the%20effects%20of%20confounding%20in%20observational%20studies&author=PC%20Austin&volume=46&issue=3&publication_year=2011&pages=399-424&pmid=21818162&doi=10.1080/00273171.2011.568786&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="B21"> <span class="label">21.</span><cite>Hernan MA. and Robins JM: Estimating causal effects from epidemiological data. J Epidemiol Comm Health 2006;60(7):578–586</cite> [<a href="https://doi.org/10.1136/jech.2004.029496" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="/articles/PMC2652882/" class="usa-link">PMC free article</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/16790829/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=J%20Epidemiol%20Comm%20Health&title=Estimating%20causal%20effects%20from%20epidemiological%20data&author=MA%20Hernan&author=JM%20Robins&volume=60&issue=7&publication_year=2006&pages=578-586&pmid=16790829&doi=10.1136/jech.2004.029496&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="B22"> <span class="label">22.</span><cite>Ho DE IK, King G, and Stuart E: Matching as nonparametric preprocessing for reducing model dependence in parametric causal inference. Polit Anal 2006;15(3):199–236</cite> [<a href="https://scholar.google.com/scholar_lookup?journal=Polit%20Anal&title=Matching%20as%20nonparametric%20preprocessing%20for%20reducing%20model%20dependence%20in%20parametric%20causal%20inference&author=IK%20Ho%20DE&author=G%20King&author=E%20Stuart&volume=15&issue=3&publication_year=2006&pages=199-236&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="B23"> <span class="label">23.</span><cite>Oehlert GW: A note on the delta method. Am Statist 1992;46(1):27–29</cite> [<a href="https://scholar.google.com/scholar_lookup?journal=Am%20Statist&title=A%20note%20on%20the%20delta%20method&author=GW%20Oehlert&volume=46&issue=1&publication_year=1992&pages=27-29&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="B24"> <span class="label">24.</span><cite>Rosenberg ES, Sullivan PS, Kelley CF, et al. :. Race and age disparities in HIV incidence and prevalence among MSM in Atlanta GA. Abstract presented at the 2014 Conference on Retroviruses and Opportunistic Infections, Boston, MA</cite> [<a href="https://scholar.google.com/scholar_lookup?Rosenberg%20ES,%20Sullivan%20PS,%20Kelley%20CF,%20et%20al.%20:.%20Race%20and%20age%20disparities%20in%20HIV%20incidence%20and%20prevalence%20among%20MSM%20in%20Atlanta%20GA.%20Abstract%20presented%20at%20the%202014%20Conference%20on%20Retroviruses%20and%20Opportunistic%20Infections,%20Boston,%20MA" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="B25"> <span class="label">25.</span><cite>Patton ME, Su JR, Nelson R, Weinstock H, Centers for Disease Control and Prevention: Primary and secondary syphilis–United States, 2005–2013. MMWR Morb Mortal Wkly Rep 2014;63(18):402–406</cite> [<a href="/articles/PMC5779405/" class="usa-link">PMC free article</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/24807239/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=MMWR%20Morb%20Mortal%20Wkly%20Rep&title=Primary%20and%20secondary%20syphilis%E2%80%93United%20States,%202005%E2%80%932013&author=ME%20Patton&author=JR%20Su&author=R%20Nelson&author=H%20Weinstock&volume=63&issue=18&publication_year=2014&pages=402-406&pmid=24807239&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="B26"> <span class="label">26.</span><cite>Bernstein KT, Marcus JL, Nieri G, et al. : Rectal gonorrhea and Chlamydia reinfection is associated with increased risk of HIV seroconversion. J Acquir Immune Defic Syndr 2010;53(4):537–543</cite> [<a href="https://doi.org/10.1097/QAI.0b013e3181c3ef29" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/19935075/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=J%20Acquir%20Immune%20Defic%20Syndr&title=Rectal%20gonorrhea%20and%20Chlamydia%20reinfection%20is%20associated%20with%20increased%20risk%20of%20HIV%20seroconversion&author=KT%20Bernstein&author=JL%20Marcus&author=G%20Nieri&volume=53&issue=4&publication_year=2010&pages=537-543&pmid=19935075&doi=10.1097/QAI.0b013e3181c3ef29&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="B27"> <span class="label">27.</span><cite>Pathela P, Braunstein SL, Blank S, and Schillinger JA: HIV incidence among men with and those without sexually transmitted rectal infections: Estimates from matching against an HIV case registry. Clin Infect Dis 2013;57(8):1203–1209</cite> [<a href="https://doi.org/10.1093/cid/cit437" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/23800942/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=Clin%20Infect%20Dis&title=HIV%20incidence%20among%20men%20with%20and%20those%20without%20sexually%20transmitted%20rectal%20infections:%20Estimates%20from%20matching%20against%20an%20HIV%20case%20registry&author=P%20Pathela&author=SL%20Braunstein&author=S%20Blank&author=JA%20Schillinger&volume=57&issue=8&publication_year=2013&pages=1203-1209&pmid=23800942&doi=10.1093/cid/cit437&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="B28"> <span class="label">28.</span><cite>Jin F, Prestage GP, Imrie J, et al. : Anal sexually transmitted infections and risk of HIV infection in homosexual men. J Acquir Immune Defic Syndr 2010;53(1):144–149</cite> [<a href="https://doi.org/10.1097/QAI.0b013e3181b48f33" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/19734801/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=J%20Acquir%20Immune%20Defic%20Syndr&title=Anal%20sexually%20transmitted%20infections%20and%20risk%20of%20HIV%20infection%20in%20homosexual%20men&author=F%20Jin&author=GP%20Prestage&author=J%20Imrie&volume=53&issue=1&publication_year=2010&pages=144-149&pmid=19734801&doi=10.1097/QAI.0b013e3181b48f33&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="B29"> <span class="label">29.</span><cite>Buchbinder SP, Glidden DV, Liu AY, et al. : HIV pre-exposure prophylaxis in men who have sex with men and transgender women: A secondary analysis of a phase 3 randomised controlled efficacy trial. Lancet Infect Dis 2014;14(6):468–475</cite> [<a href="https://doi.org/10.1016/S1473-3099(14)70025-8" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="/articles/PMC4133171/" class="usa-link">PMC free article</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/24613084/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=Lancet%20Infect%20Dis&title=HIV%20pre-exposure%20prophylaxis%20in%20men%20who%20have%20sex%20with%20men%20and%20transgender%20women:%20A%20secondary%20analysis%20of%20a%20phase%203%20randomised%20controlled%20efficacy%20trial&author=SP%20Buchbinder&author=DV%20Glidden&author=AY%20Liu&volume=14&issue=6&publication_year=2014&pages=468-475&pmid=24613084&doi=10.1016/S1473-3099(14)70025-8&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="B30"> <span class="label">30.</span><cite>Ng BE, Butler LM, Horvath T, and Rutherford GW: Population-based biomedical sexually transmitted infection control interventions for reducing HIV infection. Cochrane Database Syst Rev 2011;(3):CD001220.</cite> [<a href="https://doi.org/10.1002/14651858.CD001220.pub3" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/21412869/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=Cochrane%20Database%20Syst%20Rev&title=Population-based%20biomedical%20sexually%20transmitted%20infection%20control%20interventions%20for%20reducing%20HIV%20infection&author=BE%20Ng&author=LM%20Butler&author=T%20Horvath&author=GW%20Rutherford&issue=3&publication_year=2011&pages=CD001220&pmid=21412869&doi=10.1002/14651858.CD001220.pub3&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="B31"> <span class="label">31.</span><cite>Grosskurth H, Gray R, Hayes R, et al. : Control of sexually transmitted diseases for HIV-1 prevention: Understanding the implications of the Mwanza and Rakai trials. Lancet 2000;355(9219):1981–1987</cite> [<a href="https://doi.org/10.1016/S0140-6736(00)02336-9" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/10859054/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=Lancet&title=Control%20of%20sexually%20transmitted%20diseases%20for%20HIV-1%20prevention:%20Understanding%20the%20implications%20of%20the%20Mwanza%20and%20Rakai%20trials&author=H%20Grosskurth&author=R%20Gray&author=R%20Hayes&volume=355&issue=9219&publication_year=2000&pages=1981-1987&pmid=10859054&doi=10.1016/S0140-6736(00)02336-9&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="B32"> <span class="label">32.</span><cite>Korenromp EL, White RG, Orroth KK, et al. : Determinants of the impact of sexually transmitted infection treatment on prevention of HIV infection: A synthesis of evidence from the Mwanza, Rakai, and Masaka intervention trials. J Infect Dis 2005;191(Suppl 1):S168–178</cite> [<a href="https://doi.org/10.1086/425274" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/15627227/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=J%20Infect%20Dis&title=Determinants%20of%20the%20impact%20of%20sexually%20transmitted%20infection%20treatment%20on%20prevention%20of%20HIV%20infection:%20A%20synthesis%20of%20evidence%20from%20the%20Mwanza,%20Rakai,%20and%20Masaka%20intervention%20trials&author=EL%20Korenromp&author=RG%20White&author=KK%20Orroth&volume=191&issue=Suppl%201&publication_year=2005&pages=S168-178&pmid=15627227&doi=10.1086/425274&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> <li id="B33"> <span class="label">33.</span><cite>Solomon MM, Mayer KH, Glidden DV, et al. : Syphilis predicts HIV incidence among men and transgender women who have sex with men in a pre-exposure prophylaxis trial. Clin Infect Dis 2014;59(7):1020–1026</cite> [<a href="https://doi.org/10.1093/cid/ciu450" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">DOI</a>] [<a href="/articles/PMC4166980/" class="usa-link">PMC free article</a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/24928295/" class="usa-link">PubMed</a>] [<a href="https://scholar.google.com/scholar_lookup?journal=Clin%20Infect%20Dis&title=Syphilis%20predicts%20HIV%20incidence%20among%20men%20and%20transgender%20women%20who%20have%20sex%20with%20men%20in%20a%20pre-exposure%20prophylaxis%20trial&author=MM%20Solomon&author=KH%20Mayer&author=DV%20Glidden&volume=59&issue=7&publication_year=2014&pages=1020-1026&pmid=24928295&doi=10.1093/cid/ciu450&" class="usa-link usa-link--external" data-ga-action="click_feat_suppl" target="_blank" rel="noopener noreferrer">Google Scholar</a>]</li> </ul></section></section></section><footer class="p courtesy-note font-secondary font-sm text-center"><hr class="headless"> <p>Articles from AIDS Research and Human Retroviruses are provided here courtesy of <strong>Mary Ann Liebert, Inc.</strong></p></footer></section></article> </main> </div> </div> </div>  <div class="pmc-sidenav desktop:grid-col-4 display-flex"> <section class="pmc-sidenav__container" aria-label="Article resources and navigation"> <button type="button" class="usa-button pmc-sidenav__container__close usa-button--unstyled"> <img src="/static/img/usa-icons/close.svg" role="img" alt="Close" /> </button> <div class="display-none desktop:display-block"> <section class="margin-top-4 desktop:margin-top-0"> <h2 class="margin-top-0">ACTIONS</h2> <ul class="usa-list usa-list--unstyled usa-list--actions"> <li> <a href="https://doi.org/10.1089/aid.2015.0013" class="usa-button usa-button--outline width-24 font-xs display-inline-flex flex-align-center flex-justify-start padding-left-1" target="_blank" rel="noreferrer noopener" data-ga-category="actions" data-ga-action="click" data-ga-label="publisher_link_desktop" > <svg class="usa-icon width-3 height-3" aria-hidden="true" focusable="false" role="img" hidden> <use xlink:href="/static/img/sprite.svg#launch"></use> </svg> <span class="display-inline-flex flex-justify-center flex-1 padding-right-2">View on publisher site</span> </a> </li> <li> <a href="pdf/aid.2015.0013.pdf" class="usa-button usa-button--outline width-24 display-inline-flex flex-align-center flex-justify-start padding-left-1" data-ga-category="actions" data-ga-action="click" data-ga-label="pdf_download_desktop" > <svg class="usa-icon width-3 height-3" aria-hidden="true" focusable="false" role="img" hidden> <use xlink:href="/static/img/sprite.svg#file_download"></use> </svg> <span class="display-inline-flex flex-justify-center flex-1">PDF (122.6 KB)</span> </a> </li> <li> <button role="button" class="usa-button width-24 citation-dialog-trigger display-inline-flex flex-align-center flex-justify-start padding-left-1" aria-label="Open dialog with citation text in different styles" data-ga-category="actions" data-ga-action="open" data-ga-label="cite_desktop" data-all-citations-url="/resources/citations/4458736/" data-citation-style="nlm" data-download-format-link="/resources/citations/4458736/export/" > <svg class="usa-icon width-3 height-3" aria-hidden="true" focusable="false" role="img" hidden> <use xlink:href="/static/img/sprite.svg#format_quote"></use> </svg> <span class="display-inline-flex flex-justify-center flex-1 button-label">Cite</span> </button> </li> <li> <button class="usa-button width-24 collections-dialog-trigger collections-button display-inline-flex flex-align-center flex-justify-start padding-left-1 collections-button-empty" aria-label="Save article in MyNCBI collections." data-ga-category="actions" data-ga-action="click" data-ga-label="collections_button_desktop" data-collections-open-dialog-enabled="false" data-collections-open-dialog-url="https://account.ncbi.nlm.nih.gov/?back_url=https%3A%2F%2Fpmc.ncbi.nlm.nih.gov%2Farticles%2FPMC4458736%2F%23open-collections-dialog" data-in-collections="false"> <svg class="usa-icon width-3 height-3 usa-icon--bookmark-full" aria-hidden="true" focusable="false" role="img" hidden> <use xlink:href="/static/img/action-bookmark-full.svg#icon"></use> </svg> <svg class="usa-icon width-3 height-3 usa-icon--bookmark-empty" aria-hidden="true" focusable="false" role="img" hidden> <use xlink:href="/static/img/action-bookmark-empty.svg#icon"></use> </svg> <span class="display-inline-flex flex-justify-center flex-1">Collections</span> </button> </li> <li class="pmc-permalink"> <button type="button" class="usa-button width-24 display-inline-flex flex-align-center flex-justify padding-left-1 shadow-none" aria-label="Show article permalink" aria-expanded="false" aria-haspopup="true" data-ga-category="actions" data-ga-action="open" data-ga-label="permalink_desktop" > <svg class="usa-icon width-3 height-3" aria-hidden="true" focusable="false" role="img" hidden> <use xlink:href="/static/img/sprite.svg#share"></use> </svg> <span class="display-inline-flex flex-justify-center flex-1 button-label">Permalink</span> </button> <div class="pmc-permalink__dropdown" hidden> <div class="pmc-permalink__dropdown__container"> <h2 class="usa-modal__heading margin-top-0 margin-bottom-2">PERMALINK</h2> <div class="pmc-permalink__dropdown__content"> <input type="text" class="usa-input" value="https://pmc.ncbi.nlm.nih.gov/articles/PMC4458736/" aria-label="Article permalink"> <button class="usa-button display-inline-flex pmc-permalink__dropdown__copy__btn margin-right-0" title="Copy article permalink" data-ga-category="save_share" data-ga-action="link" data-ga-label="copy_link"> <svg class="usa-icon" aria-hidden="true" focusable="false" role="img"> <use xlink:href="/static/img/sprite.svg#content_copy"></use> </svg> <span class="margin-left-1">Copy</span> </button> </div> </div> </div> </li> </ul> </section> </div> <section class="pmc-resources margin-top-6 desktop:margin-top-4" data-page-path="/articles/PMC4458736/"> <h2 class="margin-top-0">RESOURCES</h2> <div class="usa-accordion usa-accordion--multiselectable" data-allow-multiple> <h3 class="usa-accordion__heading"> <button type="button" class="usa-accordion__button" aria-expanded="false" aria-controls="resources-similar-articles" data-ga-category="resources_accordion" data-ga-action="open_similar_articles" data-ga-label="/articles/PMC4458736/" data-action-open="open_similar_articles" data-action-close="close_similar_articles" > Similar articles </button> </h3> <div id="resources-similar-articles" class="usa-accordion__content usa-prose" data-source-url="/resources/similar-article-links/25719950/" > </div> <h3 class="usa-accordion__heading"> <button type="button" class="usa-accordion__button" aria-expanded="false" aria-controls="resources-cited-by-other-articles" data-ga-category="resources_accordion" data-ga-action="open_cited_by" data-ga-label="/articles/PMC4458736/" data-action-open="open_cited_by" data-action-close="close_cited_by" > Cited by other articles </button> </h3> <div id="resources-cited-by-other-articles" class="usa-accordion__content usa-prose" data-source-url="/resources/cited-by-links/25719950/" > </div> <h3 class="usa-accordion__heading"> <button type="button" class="usa-accordion__button" aria-expanded="false" aria-controls="resources-links-to-ncbi-databases" data-ga-category="resources_accordion" data-ga-action="open_NCBI_links" data-ga-label="/articles/PMC4458736/" data-action-open="open_NCBI_links" data-action-close="close_NCBI_link" > Links to NCBI Databases </button> </h3> <div id="resources-links-to-ncbi-databases" class="usa-accordion__content usa-prose" data-source-url="/resources/db-links/4458736/" > </div> </div> </section> <section class="usa-in-page-nav usa-in-page-nav--wide margin-top-6 desktop:margin-top-4" data-title-text="On this page" data-title-heading-level="h2" data-scroll-offset="0" data-root-margin="-10% 0px -80% 0px" data-main-content-selector="main" data-threshold="1" hidden ></section> </section> </div> <div class="overlay" role="dialog" aria-label="Citation Dialog" hidden> <div class="dialog citation-dialog" aria-hidden="true"> <div class="display-inline-flex flex-align-center flex-justify width-full margin-bottom-2"> <h2 class="usa-modal__heading margin-0">Cite</h2> <button type="button" class="usa-button usa-button--unstyled close-overlay text-black width-auto" tabindex="1"> <svg class="usa-icon width-3 height-3" aria-hidden="true" focusable="false" role="img"> <use xlink:href="/static/img/sprite.svg#close"></use> </svg> </button> </div> <div class="citation-text-block"> <div class="citation-text margin-bottom-2"></div> <ul class="usa-list usa-list--unstyled display-inline-flex flex-justify width-full flex-align-center"> <li> <button class="usa-button usa-button--unstyled text-no-underline display-flex flex-align-center copy-button dialog-focus" data-ga-category="save_share" data-ga-action="cite" data-ga-label="copy" tabindex="2"> <svg class="usa-icon width-3 height-3" aria-hidden="true" focusable="false" role="img"> <use xlink:href="/static/img/sprite.svg#content_copy"></use> </svg> <span>Copy</span> </button> </li> <li> <a href="#" role="button" class="usa-button usa-button--unstyled text-no-underline display-flex flex-align-center export-button" data-ga-category="save_share" data-ga-action="cite" data-ga-label="download" title="Download a file for external citation management software" tabindex="3"> <svg class="usa-icon width-3 height-3" aria-hidden="true" focusable="false" role="img"> <use xlink:href="/static/img/sprite.svg#file_download"></use> </svg> <span class="display-none mobile-lg:display-inline">Download .nbib</span> <span class="display-inline mobile-lg:display-none">.nbib</span> </a> </li> <li> <div class="display-inline-flex flex-align-center"> <label class="usa-label margin-top-0">Format:</label> <select aria-label="Format" class="usa-select citation-style-selector padding-1 margin-top-0 border-0 padding-right-4" tabindex="4" > <option data-style-url-name="ama" value="AMA" > AMA </option> <option data-style-url-name="apa" value="APA" > APA </option> <option data-style-url-name="mla" value="MLA" > MLA </option> <option data-style-url-name="nlm" value="NLM" selected="selected"> NLM </option> </select> </div> </li> </ul> </div> </div> </div> <div class="overlay" role="dialog" hidden> <div id="collections-action-dialog" class="dialog collections-dialog" aria-hidden="true"> <div class="display-inline-flex flex-align-center flex-justify width-full margin-bottom-2"> <h2 class="usa-modal__heading margin-0">Add to Collections</h2> </div> <div class="collections-action-panel action-panel"> <form id="collections-action-dialog-form" class="usa-form maxw-full collections-action-panel-form action-panel-content action-form action-panel-smaller-selectors" data-existing-collections-url="/list-existing-collections/" data-add-to-existing-collection-url="/add-to-existing-collection/" data-create-and-add-to-new-collection-url="/create-and-add-to-new-collection/" data-myncbi-max-collection-name-length="100" data-collections-root-url="https://www.ncbi.nlm.nih.gov/myncbi/collections/"> <input type="hidden" name="csrfmiddlewaretoken" value="O8y2IwKyajmNFB13AnSO0WgjJgudApUTbyCIMOgmxh1AmNFAIwSV31yYsD8W9guh"> <fieldset class="usa-fieldset margin-bottom-2"> <div class="usa-radio"> <input type="radio" id="collections-action-dialog-new" class="usa-radio__input usa-radio__input--tile collections-new margin-top-0" name="collections" value="new" data-ga-category="collections_button" data-ga-action="click" data-ga-label="collections_radio_new" /> <label class="usa-radio__label" for="collections-action-dialog-new">Create a new collection</label> </div> <div class="usa-radio"> <input type="radio" id="collections-action-dialog-existing" class="usa-radio__input usa-radio__input--tile collections-existing" name="collections" value="existing" checked="true" data-ga-category="collections_button" data-ga-action="click" data-ga-label="collections_radio_existing" /> <label class="usa-radio__label" for="collections-action-dialog-existing">Add to an existing collection</label> </div> </fieldset> <fieldset class="usa-fieldset margin-bottom-2"> <div class="action-panel-control-wrap new-collections-controls"> <label for="collections-action-dialog-add-to-new" class="usa-label margin-top-0"> Name your collection <abbr title="required" class="usa-hint usa-hint--required text-no-underline">*</abbr> </label> <input type="text" name="add-to-new-collection" id="collections-action-dialog-add-to-new" class="usa-input collections-action-add-to-new" pattern="[^"&=<>/]*" title="The following characters are not allowed in the Name field: "&=<>/" maxlength="" data-ga-category="collections_button" data-ga-action="create_collection" data-ga-label="non_favorties_collection" required /> </div> <div class="action-panel-control-wrap existing-collections-controls"> <label for="collections-action-dialog-add-to-existing" class="usa-label margin-top-0"> Choose a collection </label> <select id="collections-action-dialog-add-to-existing" class="usa-select collections-action-add-to-existing" data-ga-category="collections_button" data-ga-action="select_collection" data-ga-label="($('.collections-action-add-to-existing').val() === 'Favorites') ? 'Favorites' : 'non_favorites_collection'"> </select> <div class="collections-retry-load-on-error usa-input-error-message selection-validation-message"> Unable to load your collection due to an error<br> <a href="#">Please try again</a> </div> </div> </fieldset> <div class="display-inline-flex"> <button class="usa-button margin-top-0 action-panel-submit" type="submit" data-loading-label="Adding..." data-pinger-ignore data-ga-category="collections_button" data-ga-action="click" data-ga-label="add"> Add </button> <button class="usa-button usa-button--outline margin-top-0 action-panel-cancel" aria-label="Close 'Add to Collections' panel" ref="linksrc=close_collections_panel" data-ga-category="collections_button" data-ga-action="click" data-ga-label="cancel"> Cancel </button> </div> </form> </div> </div> </div> </div> </div> </div> <footer class="ncbi-footer ncbi-dark-background " > <div class="ncbi-footer__icon-section"> <div class="ncbi-footer__social-header"> Follow NCBI </div> <div class="grid-container ncbi-footer__ncbi-social-icons-container"> <a href="https://twitter.com/ncbi" class="ncbi-footer__social-icon ncbi-footer__social-icon--gray" target="_blank" rel="noreferrer noopener"> <svg width="40" height="40" viewBox="0 0 40 40" fill="none" xmlns="http://www.w3.org/2000/svg" focusable="false" aria-hidden="true"> <path d="m6.067 8 10.81 13.9L6 33.2h4.2l8.4-9.1 7.068 9.1H34L22.8 18.5 31.9 8h-3.5l-7.7 8.4L14.401 8H6.067Zm3.6 1.734h3.266l16.8 21.732H26.57L9.668 9.734Z"> </path> </svg> <span class="usa-sr-only">NCBI on X (formerly known as Twitter)</span> </a> <a href="https://www.facebook.com/ncbi.nlm" class="ncbi-footer__social-icon ncbi-footer__social-icon--gray" target="_blank" rel="noreferrer noopener"> <svg width="16" height="29" focusable="false" aria-hidden="true" viewBox="0 0 16 29" fill="none" xmlns="http://www.w3.org/2000/svg"> <path d="M3.8809 21.4002C3.8809 19.0932 3.8809 16.7876 3.8809 14.478C3.8809 14.2117 3.80103 14.1452 3.54278 14.1492C2.53372 14.1638 1.52334 14.1492 0.514288 14.1598C0.302626 14.1598 0.248047 14.0972 0.248047 13.8936C0.256034 12.4585 0.256034 11.0239 0.248047 9.58978C0.248047 9.37013 0.302626 9.30224 0.528931 9.3049C1.53798 9.31688 2.54837 9.3049 3.55742 9.31555C3.80103 9.31555 3.8809 9.26097 3.87957 9.00272C3.87158 8.00565 3.85428 7.00592 3.90753 6.00884C3.97142 4.83339 4.31487 3.73115 5.04437 2.78467C5.93095 1.63318 7.15699 1.09005 8.56141 0.967577C10.5582 0.79319 12.555 0.982221 14.5518 0.927641C14.7102 0.927641 14.7462 0.99287 14.7449 1.13664C14.7449 2.581 14.7449 4.02668 14.7449 5.47104C14.7449 5.67604 14.6517 5.68669 14.4946 5.68669C13.4523 5.68669 12.4113 5.68669 11.3703 5.68669C10.3506 5.68669 9.92057 6.10868 9.90593 7.13904C9.89661 7.7647 9.91525 8.39303 9.89794 9.01869C9.88995 9.26364 9.96583 9.31822 10.2015 9.31688C11.7204 9.30623 13.2393 9.31688 14.7595 9.3049C15.0257 9.3049 15.0723 9.3728 15.0444 9.62439C14.89 10.9849 14.7515 12.3467 14.6144 13.7085C14.5691 14.1571 14.5785 14.1585 14.1458 14.1585C12.8386 14.1585 11.5313 14.1665 10.2254 14.1518C9.95119 14.1518 9.89794 14.2317 9.89794 14.4899C9.90593 19.0799 9.89794 23.6752 9.91125 28.2612C9.91125 28.5674 9.8407 28.646 9.53186 28.6433C7.77866 28.6273 6.02414 28.6366 4.27094 28.634C3.82499 28.634 3.87158 28.6992 3.87158 28.22C3.87602 25.9472 3.87913 23.6739 3.8809 21.4002Z"> </path> </svg> <span class="usa-sr-only">NCBI on Facebook</span> </a> <a href="https://www.linkedin.com/company/ncbinlm" class="ncbi-footer__social-icon ncbi-footer__social-icon--gray" target="_blank" rel="noreferrer noopener"> <svg width="25" height="23" viewBox="0 0 26 24" fill="none" xmlns="http://www.w3.org/2000/svg" focusable="false" aria-hidden="true"> <path d="M14.6983 9.98423C15.6302 9.24808 16.5926 8.74754 17.6762 8.51991C19.673 8.09126 21.554 8.30824 23.1262 9.7526C24.2351 10.7723 24.7529 12.1115 25.0165 13.5612C25.1486 14.3363 25.2105 15.1218 25.2015 15.9081C25.2015 18.3043 25.2015 20.6898 25.2082 23.0806C25.2082 23.3468 25.1549 23.444 24.8621 23.4414C23.1297 23.4272 21.3992 23.4272 19.6704 23.4414C19.4041 23.4414 19.3429 23.3588 19.3442 23.1019C19.3535 20.5194 19.3442 17.9368 19.3442 15.3543C19.3442 14.0005 18.3258 12.9448 17.0266 12.9488C15.7273 12.9528 14.6983 14.0071 14.6983 15.361C14.6983 17.9328 14.6917 20.5047 14.6983 23.0753C14.6983 23.3708 14.6198 23.444 14.3296 23.4427C12.6185 23.4294 10.9079 23.4294 9.19779 23.4427C8.93155 23.4427 8.86099 23.3735 8.86232 23.1086C8.8783 19.7619 8.88628 16.4144 8.88628 13.066C8.88628 11.5688 8.87874 10.0708 8.86365 8.57182C8.86365 8.3575 8.90758 8.27896 9.14054 8.28029C10.9048 8.29094 12.6687 8.29094 14.4321 8.28029C14.6464 8.28029 14.6983 8.34818 14.6983 8.54653C14.6903 9.00047 14.6983 9.45441 14.6983 9.98423Z"> </path> <path d="M6.55316 15.8443C6.55316 18.2564 6.55316 20.6699 6.55316 23.082C6.55316 23.3629 6.48127 23.4388 6.19906 23.4374C4.47737 23.4241 2.75568 23.4241 1.03399 23.4374C0.767751 23.4374 0.69986 23.3629 0.701191 23.1006C0.709178 18.2648 0.709178 13.4281 0.701191 8.59053C0.701191 8.34026 0.765089 8.27237 1.01669 8.2737C2.74991 8.28435 4.48048 8.28435 6.20838 8.2737C6.47462 8.2737 6.5465 8.33627 6.54517 8.6065C6.54783 11.0186 6.55316 13.4308 6.55316 15.8443Z"> </path> <path d="M3.65878 0.243898C5.36804 0.243898 6.58743 1.45529 6.58743 3.1406C6.58743 4.75801 5.32145 5.95742 3.60819 5.96807C3.22177 5.97614 2.83768 5.90639 2.47877 5.76299C2.11985 5.61959 1.79344 5.40546 1.51897 5.13334C1.24449 4.86123 1.02755 4.53668 0.881058 4.17902C0.734563 3.82136 0.661505 3.43788 0.666231 3.05141C0.67555 1.42601 1.9362 0.242566 3.65878 0.243898Z"> </path> </svg> <span class="usa-sr-only">NCBI on LinkedIn</span> </a> <a href="https://github.com/ncbi" class="ncbi-footer__social-icon ncbi-footer__social-icon--gray" target="_blank" rel="noreferrer noopener"> <svg width="28" height="27" viewBox="0 0 28 28" fill="none" xmlns="http://www.w3.org/2000/svg" focusable="false" aria-hidden="true"> <path d="M16.7228 20.6334C17.5057 20.5527 18.2786 20.3944 19.0301 20.1608C21.3108 19.4193 22.5822 17.8259 22.963 15.4909C23.1228 14.5112 23.1814 13.5287 22.9883 12.5437C22.8106 11.6423 22.4013 10.8028 21.8007 10.1076C21.7526 10.0605 21.7197 10 21.7064 9.934C21.6931 9.86799 21.7 9.79952 21.7262 9.73748C22.0856 8.6206 21.9711 7.51969 21.601 6.42677C21.582 6.3497 21.5345 6.2827 21.468 6.23923C21.4016 6.19577 21.3211 6.17906 21.2429 6.19248C20.7329 6.21649 20.2313 6.33051 19.7611 6.52928C19.1103 6.7908 18.4899 7.12198 17.9104 7.51703C17.84 7.56996 17.7581 7.60551 17.6713 7.62078C17.5846 7.63605 17.4954 7.6306 17.4112 7.60489C15.2596 7.05882 13.0054 7.06203 10.8554 7.61421C10.7806 7.63586 10.7018 7.63967 10.6253 7.62534C10.5487 7.611 10.4766 7.57892 10.4148 7.53167C9.64788 7.03247 8.85171 6.58918 7.96368 6.33359C7.65781 6.24338 7.34123 6.19458 7.02239 6.18849C6.94879 6.17986 6.87462 6.19893 6.81432 6.242C6.75402 6.28507 6.71191 6.34904 6.69621 6.42145C6.32342 7.51437 6.2209 8.61527 6.56307 9.73348C6.59635 9.84264 6.64694 9.93316 6.54177 10.0516C5.47666 11.2604 5.09988 12.6834 5.19574 14.2676C5.2663 15.4244 5.46201 16.5466 6.01454 17.5769C6.84399 19.1171 8.21664 19.9119 9.85158 20.3352C10.3938 20.4706 10.9444 20.5698 11.4998 20.632C11.5384 20.7492 11.4506 20.7798 11.408 20.8291C11.1734 21.1179 10.9894 21.4441 10.8634 21.7942C10.7622 22.0458 10.8315 22.4039 10.6065 22.5516C10.263 22.7766 9.83827 22.8485 9.42421 22.8871C8.17936 23.0056 7.26471 22.4877 6.6283 21.4348C6.25552 20.8184 5.76956 20.3325 5.08523 20.0663C4.76981 19.9325 4.42139 19.8967 4.08537 19.9638C3.7898 20.029 3.73788 20.1901 3.93891 20.4111C4.03639 20.5234 4.14989 20.6207 4.27575 20.6999C4.9796 21.1318 5.51717 21.7884 5.80152 22.5636C6.37002 23.9973 7.48039 24.5697 8.93825 24.6323C9.43741 24.6575 9.93768 24.615 10.4254 24.5058C10.5892 24.4672 10.6531 24.4872 10.6517 24.6762C10.6451 25.4936 10.6637 26.3123 10.6517 27.131C10.6517 27.6635 10.1684 27.9297 9.58663 27.7393C8.17396 27.2671 6.84977 26.5631 5.66838 25.656C2.59555 23.2891 0.720966 20.1861 0.217704 16.3376C-0.357453 11.9127 0.911353 8.00824 3.98551 4.73881C6.11909 2.42656 8.99932 0.939975 12.1203 0.540191C16.5351 -0.0601815 20.4347 1.14323 23.7232 4.16373C26.2449 6.47869 27.724 9.37672 28.1048 12.7726C28.5828 17.0325 27.3686 20.7945 24.4768 23.9827C22.9762 25.6323 21.0956 26.8908 18.9982 27.6488C18.8783 27.6927 18.7585 27.738 18.636 27.7726C18.0356 27.9404 17.6189 27.6395 17.6189 27.0098C17.6189 25.7452 17.6308 24.4806 17.6295 23.2159C17.6329 22.9506 17.6128 22.6856 17.5696 22.4238C17.4325 21.6664 17.3419 21.484 16.7228 20.6334Z"> </path> </svg> <span class="usa-sr-only">NCBI on GitHub</span> </a> <a href="https://ncbiinsights.ncbi.nlm.nih.gov/" class="ncbi-footer__social-icon ncbi-footer__social-icon--gray" target="_blank" rel="noreferrer noopener"> <svg width="26" height="26" viewBox="0 0 27 27" fill="none" xmlns="http://www.w3.org/2000/svg" focusable="false" aria-hidden="true"> <path d="M23.7778 26.4574C23.1354 26.3913 22.0856 26.8024 21.636 26.3087C21.212 25.8444 21.4359 24.8111 21.324 24.0347C19.9933 14.8323 14.8727 8.80132 6.09057 5.85008C4.37689 5.28406 2.58381 4.99533 0.779072 4.99481C0.202773 4.99481 -0.0229751 4.83146 0.00455514 4.21479C0.0660406 3.08627 0.0660406 1.95525 0.00455514 0.826734C-0.0413285 0.0815827 0.259669 -0.0193618 0.896534 0.00266238C6.96236 0.222904 12.3693 2.24179 16.9889 6.16209C22.9794 11.2478 26.1271 17.7688 26.4372 25.648C26.4629 26.294 26.3179 26.5271 25.6609 26.4684C25.0827 26.417 24.4991 26.4574 23.7778 26.4574Z"> </path> <path d="M14.8265 26.441C14.0924 26.441 13.2371 26.6795 12.6626 26.3786C12.0092 26.0372 12.3781 25.0644 12.246 24.378C11.1154 18.5324 6.6849 14.5497 0.74755 14.1001C0.217135 14.0615 -0.0104482 13.9422 0.0134113 13.3659C0.0519536 12.1454 0.0482829 10.9213 0.0134113 9.69524C-0.00127145 9.14464 0.196946 9.03268 0.703502 9.04736C9.21217 9.27128 16.5994 16.2511 17.2804 24.7231C17.418 26.4446 17.418 26.4446 15.6579 26.4446H14.832L14.8265 26.441Z"> </path> <path d="M3.58928 26.4555C2.64447 26.4618 1.73584 26.0925 1.06329 25.4289C0.39073 24.7653 0.00933763 23.8617 0.0030097 22.9169C-0.00331824 21.9721 0.365937 21.0635 1.02954 20.3909C1.69315 19.7184 2.59675 19.337 3.54156 19.3306C4.48637 19.3243 5.39499 19.6936 6.06755 20.3572C6.7401 21.0208 7.1215 21.9244 7.12782 22.8692C7.13415 23.814 6.7649 24.7226 6.10129 25.3952C5.43768 26.0677 4.53409 26.4491 3.58928 26.4555Z"> </path> </svg> <span class="usa-sr-only">NCBI RSS feed</span> </a> </div> </div> <div data-testid="gridContainer" class="grid-container ncbi-footer__container"> <div class="grid-row ncbi-footer__main-content-container" data-testid="grid"> <div class="ncbi-footer__column"> <p class="ncbi-footer__circled-icons-heading"> Connect with NLM </p> <div class="ncbi-footer__circled-icons-list"> <a href=https://twitter.com/nlm_nih class="ncbi-footer__social-icon ncbi-footer__social-icon--circled" target="_blank" rel="noreferrer noopener"> <svg width="32" height="32" viewBox="0 0 40 40" fill="none" xmlns="http://www.w3.org/2000/svg" focusable="false" aria-hidden="true"> <path d="m6.067 8 10.81 13.9L6 33.2h4.2l8.4-9.1 7.068 9.1H34L22.8 18.5 31.9 8h-3.5l-7.7 8.4L14.401 8H6.067Zm3.6 1.734h3.266l16.8 21.732H26.57L9.668 9.734Z"> </path> </svg> <span class="usa-sr-only">NLM on X (formerly known as Twitter)</span> </a> <a href=https://www.facebook.com/nationallibraryofmedicine class="ncbi-footer__social-icon ncbi-footer__social-icon--circled" target="_blank" rel="noreferrer noopener"> <svg width="13" height="24" viewBox="0 0 13 24" fill="none" xmlns="http://www.w3.org/2000/svg" focusable="false" aria-hidden="true"> <path d="M4.11371 23.1369C4.11371 23.082 4.11371 23.0294 4.11371 22.9745V12.9411H0.817305C0.6709 12.9411 0.670898 12.9411 0.670898 12.8016C0.670898 11.564 0.670898 10.3287 0.670898 9.09341C0.670898 8.97903 0.705213 8.95158 0.815017 8.95158C1.8673 8.95158 2.91959 8.95158 3.97417 8.95158H4.12057V8.83263C4.12057 7.8055 4.12057 6.7738 4.12057 5.74897C4.1264 4.92595 4.31387 4.11437 4.66959 3.37217C5.12916 2.38246 5.94651 1.60353 6.95717 1.1921C7.64827 0.905008 8.3913 0.764035 9.13953 0.778051C10.0019 0.791777 10.8644 0.830666 11.7268 0.860404C11.8869 0.860404 12.047 0.894717 12.2072 0.90158C12.2964 0.90158 12.3261 0.940469 12.3261 1.02968C12.3261 1.5421 12.3261 2.05452 12.3261 2.56465C12.3261 3.16857 12.3261 3.7725 12.3261 4.37642C12.3261 4.48165 12.2964 4.51367 12.1912 4.51138C11.5369 4.51138 10.8804 4.51138 10.2261 4.51138C9.92772 4.51814 9.63058 4.5526 9.33855 4.61433C9.08125 4.6617 8.84537 4.78881 8.66431 4.97766C8.48326 5.16652 8.3662 5.40755 8.32972 5.66661C8.28476 5.89271 8.26027 6.1224 8.25652 6.35289C8.25652 7.19014 8.25652 8.02969 8.25652 8.86923C8.25652 8.89439 8.25652 8.91955 8.25652 8.95615H12.0219C12.1797 8.95615 12.182 8.95616 12.1614 9.10714C12.0768 9.76596 11.9876 10.4248 11.9029 11.0813C11.8312 11.6319 11.7626 12.1824 11.697 12.733C11.6719 12.9434 11.6787 12.9434 11.4683 12.9434H8.26338V22.899C8.26338 22.979 8.26338 23.0591 8.26338 23.1392L4.11371 23.1369Z"> </path> </svg> <span class="usa-sr-only">NLM on Facebook</span> </a> <a href=https://www.youtube.com/user/NLMNIH class="ncbi-footer__social-icon ncbi-footer__social-icon--circled" target="_blank" rel="noreferrer noopener"> <svg width="21" height="15" viewBox="0 0 21 15" fill="none" xmlns="http://www.w3.org/2000/svg" focusable="false" aria-hidden="true"> <path d="M19.2561 1.47914C18.9016 1.15888 18.5699 0.957569 17.2271 0.834039C15.5503 0.678484 13.2787 0.655608 11.563 0.65332H9.43556C7.71987 0.65332 5.4483 0.678484 3.77151 0.834039C2.43098 0.957569 2.097 1.15888 1.74242 1.47914C0.813665 2.32097 0.619221 4.62685 0.598633 6.89384C0.598633 7.31781 0.598633 7.74101 0.598633 8.16345C0.626084 10.4121 0.827391 12.686 1.74242 13.521C2.097 13.8412 2.4287 14.0425 3.77151 14.1661C5.4483 14.3216 7.71987 14.3445 9.43556 14.3468H11.563C13.2787 14.3468 15.5503 14.3216 17.2271 14.1661C18.5676 14.0425 18.9016 13.8412 19.2561 13.521C20.1712 12.6929 20.3725 10.451 20.3999 8.22064C20.3999 7.74025 20.3999 7.25986 20.3999 6.77946C20.3725 4.54907 20.1689 2.30724 19.2561 1.47914ZM8.55942 10.5311V4.65201L13.5601 7.50005L8.55942 10.5311Z" fill="white" /> </svg> <span class="usa-sr-only">NLM on YouTube</span> </a> </div> </div> <address class="ncbi-footer__address ncbi-footer__column"> <p> <a class="usa-link usa-link--external" href="https://www.google.com/maps/place/8600+Rockville+Pike,+Bethesda,+MD+20894/%4038.9959508, -77.101021,17z/data%3D!3m1!4b1!4m5!3m4!1s0x89b7c95e25765ddb%3A0x19156f88b27635b8!8m2!3d38.9959508! 4d-77.0988323" rel="noopener noreferrer" target="_blank">National Library of Medicine <br/> 8600 Rockville Pike<br/> Bethesda, MD 20894</a> </p> </address> <ul class="usa-list usa-list--unstyled ncbi-footer__vertical-list ncbi-footer__column"> <li class="ncbi-footer__vertical-list-item"> <a href="https://www.nlm.nih.gov/web_policies.html" class="usa-link usa-link--alt ncbi-footer__link" > Web Policies </a> </li> <li class="ncbi-footer__vertical-list-item"> <a href="https://www.nih.gov/institutes-nih/nih-office-director/office-communications-public-liaison/freedom-information-act-office" class="usa-link usa-link--alt ncbi-footer__link" > FOIA </a> </li> <li class="ncbi-footer__vertical-list-item"> <a href="https://www.hhs.gov/vulnerability-disclosure-policy/index.html" class="usa-link usa-link--external usa-link--alt ncbi-footer__link" rel="noreferrer noopener" target='_blank' > HHS Vulnerability Disclosure </a> </li> </ul> <ul class="usa-list usa-list--unstyled ncbi-footer__vertical-list ncbi-footer__column"> <li class="ncbi-footer__vertical-list-item"> <a href="https://support.nlm.nih.gov/" class="usa-link usa-link--alt ncbi-footer__link" > Help </a> </li> <li class="ncbi-footer__vertical-list-item"> <a href="https://www.nlm.nih.gov/accessibility.html" class="usa-link usa-link--alt ncbi-footer__link" > Accessibility </a> </li> <li class="ncbi-footer__vertical-list-item"> <a href="https://www.nlm.nih.gov/careers/careers.html" class="usa-link usa-link--alt ncbi-footer__link" > Careers </a> </li> </ul> </div> <div class="grid-row grid-col-12" data-testid="grid"> <ul class="ncbi-footer__bottom-links-list"> <li class="ncbi-footer__bottom-list-item"> <a href="https://www.nlm.nih.gov/" class="usa-link usa-link--alt ncbi-footer__link" > NLM </a> </li> <li class="ncbi-footer__bottom-list-item"> <a href="https://www.nih.gov/" class="usa-link usa-link--alt ncbi-footer__link" > NIH </a> </li> <li class="ncbi-footer__bottom-list-item"> <a href="https://www.hhs.gov/" class="usa-link usa-link--external usa-link--alt ncbi-footer__link" rel="noreferrer noopener" target='_blank' > HHS </a> </li> <li class="ncbi-footer__bottom-list-item"> <a href="https://www.usa.gov/" class="usa-link usa-link--external usa-link--alt ncbi-footer__link" rel="noreferrer noopener" target='_blank' > USA.gov </a> </li> </ul> </div> </div> </footer> <script type="text/javascript" src="https://cdn.ncbi.nlm.nih.gov/core/pinger/pinger.js"> </script> <button class="back-to-top" data-ga-category="pagination" data-ga-action="back_to_top"> <label>Back to Top</label> <svg class="usa-icon order-0" aria-hidden="true" focusable="false" role="img"> <use xlink:href="/static/img/sprite.svg#arrow_upward"></use> </svg> </button> <script type="application/javascript"> window.ncbi = window.ncbi || {}; window.ncbi.pmc = window.ncbi.pmc || {}; window.ncbi.pmc.options = { logLevel: 'INFO', staticEndpoint: '/static/', citeCookieName: 'pmc-cf', }; </script> <script type="module" crossorigin="" src="/static/assets/base-6f05ef93.js"></script> <script type="text/javascript" src="https://cdn.ncbi.nlm.nih.gov/core/jquery/jquery-3.6.0.min.js"> </script> <script type="text/javascript"> jQuery.getScript("https://cdn.ncbi.nlm.nih.gov/core/alerts/alerts.js", function () { galert(['div.nav_and_browser', 'div.header', '#universal_header', '.usa-banner', 'body > *:nth-child(1)']) }); </script> <script type="text/javascript">var exports = {};</script> <script src="/static/CACHE/js/output.13b077bc3ffd.js"></script> <script type="module" crossorigin="" src="/static/assets/article-69f9d1ae.js"></script> </body> </html>

CINXE.COM

The Effect of High Rates of Bacterial Sexually Transmitted Infections on HIV Incidence in a Cohort of Black and White Men Who Have Sex with Men in Atlanta, Georgia - PMC