In the oldest age decade, the H+/D− group had the highest positive psychological factors, suggesting an important relationship between these positive psychological factors and being able to live a relatively long, non-depressed life as a person living with HIV. Hence, positive psychological factors may be protective for PLWH. Individuals’ subjective health ratings may provide valuable insight to their overall well-being, as previous studies have shown an association between reported worse health ratings and an increased risk of mortality . This finding may also reflect a potential “survivor effect” given that these older individuals have had HIV for longer and as long-term survivors, may view living with HIV more positively compared to prior expectations. This study has strengths in its multi-cohort design methodology that allows us to examine the combined effects of HIV and depression on HRQoL across age cohorts; there are also some limitations, however. For example, we were not able to address questions regarding the onset of depressive symptoms in relation to HRQoL or the positive psychological factors. For instance, depression may lead to less resilience and grit or vice versa. Like prior studies , we found a higher proportion of elevated depressive symptoms among PLWH, and individuals with elevated depressive symptoms reported lower HRQoL and positive psychological factors. There may be other factors related to depression and acquiring HIV not captured by our present variables that may account for the difference in depressive symptoms by HIV status. Another limitation is the small sample size per group, especially within the H−/D+ group. Furthermore, the sample, particularly the within the PLWH groups, was predominantly male and these results may not be generalizable to females. However, within the United Sates the majority of middle-aged to older PLWH are male; thus, our study cohort is similar to the broader characteristics of PLWH in the U.S. . Given the negative consequences of depression in PLWH, it is important to identify those in greatest need of treatment.

Prior work has highlighted the usefulness of cognitive behavioral therapy for depression treatment among PLWH,rolling grow benches even in those with advanced HIV disease . Furthermore, meta-analytic work has shown psychotherapeutic interventions reduce depressive symptoms in PLWH, which in turn may lead to improved psychiatric and medical outcomes . With this said, older PLWH are less likely to be engaged in behavioral health treatment for depression than younger PLWH, highlighting the need to address underlying factors contributing to the lack of adequate mental health treatment among older PLWH . However, increasing or improving positive psychological factors may provide one potential avenue to mitigate depressive symptoms.Neisseria gonorrhoeae and Chlamydia trachomatis are the two most common bacterial sexually transmitted infections worldwide, estimated to have caused 87 and 127 million infections, respectively, in 2016. Men who have sex with men are disproportionately affected by STIs, including N. gonorrhoeae and C. trachomatis. Infections by N. gonorrhoeae and C. trachomatis can increase the risk of HIV transmission and acquisition, mediated through ulceration and mucosal inflammation. Extragenital chlamydia and gonorrhea infections are common among MSM and are of public health importance. Recent rectal gonorrhea or chlamydia infections have been associated with increased risk for HIV acquisition. Pharyngeal N. gonorrhoeae infections are also important, as they can serve as a reservoir for antimicrobial resistance. Extragenital infections are commonly asymptomatic and screening is necessary to make a diagnosis. The U.S. Centers for Disease Control and Prevention recommends at least annual screening for rectal and pharyngeal infections among sexually-active MSM. The World Health Organization guidelines also support periodic screening for rectal and urethral infections among MSM. Data regarding extragenital N. gonorrhoeae and C. trachomatis infections are primarily from high-resource settings. A recent meta-analysis of STIs in PrEP users found nearly one in four had chlamydia, gonorrhea, or syphilis at PrEP initiation. However, few reports from low resource settings were included in that meta-analysis, highlighting the need for additional data from these settings. In low-resource settings, there are significant infrastructure and cost barriers that limit the widespread availability of diagnostic tests needed to screen for extragenital N. gonorrhoeae and C. trachomatis.

Understanding the burden of gonorrhea and chlamydia in low-resource settings is also important for HIV prevention, as it can often be an entry point into HIV pre-exposure prophylaxis programs that are being scaled up worldwide. In Vietnam, the 2013 HIV/STI Integrated Biological and Behavioral Surveillance sampled 1587 MSM across the country and found a 5% prevalence of urethral chlamydia and <3% of urethral gonorrhea. That report found a 10% prevalence of rectal chlamydia and <3% of rectal gonorrhea, but oropharyngeal testing was not performed. Aside from that report, data regarding the prevalence and risk factors for extragenital chlamydia and gonorrhea infections among MSM in Vietnam are scarce. A better understanding of the prevalence and correlates of N. gonorrhoeae and C. trachomatis infections among MSM in Vietnam is needed to effectively plan for STI screening, diagnosis, and prevention programs in the setting of limited resources, especially in the context of the rapid scale-up of HIV PrEP programs. The objectives of this study were to determine the baseline prevalence of urethral, rectal, and pharyngeal N. gonorrhoeae and C. trachomatis infections within a cohort of HIVnegative MSM in Hanoi, the capital and second-largest city in Vietnam, and to examine the factors associated with N. gonorrhoeae and C. trachomatis infections. Between July 2017 and April 2019, MSM were recruited to participate in the Health in Men -Hanoi study, a prospective, observational cohort designed to investigate the prevalence and incidence of HIV and STIs, as well as the social and behavioral characteristics within this population. Participants were recruited from concurrent HIV and STI surveys among MSM that utilized time-location sampling, respondent-driven sampling, and internet-based sampling methods. Recruited individuals presented to the Sexual Health Promotion Clinic at Hanoi Medical University where informed consent and study enrollment were completed. Cohort inclusion criteria were: assigned male sex at birth, aged ≥ 16 years, having oral or anal sex with another man or transgender woman in the prior 12 months, living in Hanoi continuously for the prior 3 months and without a plan to move in the next two years, and serologically confirmed to be HIV-negative at baseline. At the time of the study, no participants were enrolled in a PrEP program, as PrEP was not available in Vietnam. Data collected at baseline in the sub-sample of HIV-negative MSM were used for this study.

Socio-demographics, substance use, sexual practices, history of STIs, and history pertaining to HIV counseling, testing, treatment, and care services, were collected through audio computer-assisted self-administered interviewing . Group sex was defined as more than one partner in a sexual encounter in the prior six months. Participants were asked about any rectal and genitourinary symptoms in the prior 6 months. Rectal symptoms were classified as any of the following: dyschezia, pruritis, bleeding, discharge, or ulcers. Genitourinary symptoms were classified as any of the following: dysuria, discharge, bleeding, pruritis, or ulcers. All participants received client-centered HIV and STI risk-reduction counseling. Urine samples, rectal swabs, and pharyngeal swabs were collected using cobas PCR urine sample kits and cobas PCR female swab collection kits and were tested for N. gonorrhoeae and C. trachomatis by NAAT on the cobas 4800 CT/NG v2.0 system . Blood was collected for HIV testing and was performed on the ARCHITECT HIV Ag/Ab Combo . Serologic testing for syphilis was done using the Architect Syphilis TP assay , with positive samples undergoing rapid plasma reagin testing and Treponema pallidum hemagglutination , as indicated . All participants with a positive NAAT for C. trachomatis or N. gonorrhoeae were considered to have an infection. Test results for C. trachomatis or N. gonorrhoeae were classified as missing if a specimen was not available for testing or if the testing had inconclusive results. Those with a positive T. pallidum-specific antibody and a measurable RPR were considered to have a syphilis infection. Descriptive statistics were applied to socio-demographic, behavioral,drying cannabis and clinical data. Predictive logistic regression modeling was used to evaluate factors associated with N. gonorrhoeae and C. trachomatis infections separately and the combined outcome of having either infection. Variables for consideration were selected a priori using an approach that included variables based on biologic basis, as well as known risk factors and confounders. The variables included in the bivariate analyses were: age, education, income, ATS use for sex, group sex, meeting sexual partners via mobile apps, prior diagnosis of STIs, and genitourinary orrectal symptoms. Symptom status was dichotomized for the logistic regression models. All variables in the bivariate analyses were also included in the multivariate analysis, with the exception of any substance use in the prior 3 months and amphetamine-type stimulantuse in the prior 3 months, which were excluded from the multivariate analysis due to high collinearity with ATS use to enhance sexual performance in the prior 6 months. Records with missing variable data were excluded from the logistic regression models. All data analyses were done using R version 3.61. There were 1498 participants in the baseline survey. Nine did not have any samples for N. gonorrhoeae and C. trachomatis testing and were excluded from the analysis. Among the remaining 1489 participants, the median age was 22 years . Income in the prior month was less than 5 million VND for 40.5% of participants and 30.8% had completed university education. Substance use in the prior 3 months was reported by 8.3% of participants and 6.5% reported using ATS to enhance sexual performance in prior 6 months. Among those reporting anal sex in the prior 6 months, 32.1% had insertive sex, 30.0% had receptive sex, and 29.5% had both.

Condomless anal intercourse in the prior 6 months was reported by 57.6% of participants. Anal sex with two or more partners in the prior month was reported by 31.8% of participants. Group sex in the prior 6 months was reported by 24.9% of participants. Over half of participants reported meeting sexual partners via websites or mobile apps in the prior 6 months. There were 841 participants who did not have genitourinary or rectal symptoms in the prior 6 months. There were 235 participants with a prior diagnosis of chlamydia, gonorrhea, or syphilis. The prevalence of syphilis was 18.3% . There were 1378 participants included in the analyses of factors associated with N. gonorrhoeae, C. trachomatis, or either N. gonorrhoeae or C. trachomatis infection, excluding those with missing variable data . In the multi-variable analysis of the combined N. gonorrhoeae or C. trachomatis outcome, those aged 25-34 years had lower odds of infection compared to those with ages 16-24 years . This was largely contributed to by C. trachomatis infection . Other independent factors associated with having either N. gonorrhoeae or C. trachomatis infections included having two or more recent sex partners , condomless anal intercourse in the prior six months , which was driven by C. trachomatis , and meeting sexual partners via mobile apps or the internet , which was driven by N. gonorrhoeae . Genitourinary or rectal symptoms in the prior 6months and group sex were associated with infections in bivariate analysis, but not in the multivariate model. A prior STI diagnosis and ATS use to enhance sexual performance were not associated with any infections in the multi-variable models. .In this study of young, HIV-negative MSM in Hanoi, Vietnam, we found a high prevalence of N. gonorrhoeaeand C. trachomatisinfections with more than one in four participants having one of these infections at baseline. Rectal infections occurred in 73.9% of those with chlamydia and 70.5% of gonorrhea infections occurred in the oropharynx. Limiting testing to the urethral site would have missed nearly three-quarters of C.trachomatis or N. gonorrhoeae infections within this cohort, as 27.4% of infections occurred in the urethra. Half of all persons with chlamydia or gonorrhea were asymptomatic, and reporting genitourinary or rectal symptoms were not associated with infections, highlighting the need for routine screening in this population. Prior surveys of urethral chlamydia or gonorrhea in Vietnam found a similar prevalence of C. trachomatisand N. gonorrhoeae , compared to the overall urethral prevalence of 7.1% and 1.3%, respectively, we reported here. While data on extragenital chlamydia and gonorrhea within Vietnam are very limited, surveys from Ho Chi Minh City, Hanoi, and Nha Trang including urethral, rectal, and pharyngeal testing among HIVnegative male sex workers, many of whom are MSM, found a high overall prevalence of N. gonorrhoeae, up to 29%, and up to 17% for C. trachomatis, although data stratified by anatomical site were not reported.