Summary: Background: Data on transgender women and travestis (TGW) concerning oral and anal detection of Treponema pallidum (TP) DNA are lacking. We aimed to estimate the prevalence of oral and anal TP DNA detection and the frequency of azithromycin resistance-associated mutations among TGW with high-titre syphilis in Brazil. Methods: We conducted a nested cross-sectional study as part of the TransOdara study among TGW in five Brazilian cities. Participants with high-titre syphilis (reactive treponemal test and VDRL titre ≥1:8) and an analysable oral or anal specimen underwent quantitative PCR targeting the tpp47 and polA genes to detect TP DNA. TP DNA-positive specimens were further analysed using nested PCR and Sanger sequencing to identify mutations associated with azithromycin resistance. Findings: Among the 249 participants with high-titre serological syphilis and analysable sample, TP DNA was detected in 25 (10.0%, 95% CI 6.6–14.5): 14 (5.6%) from the oral site only, 6 (2.4%) from the anal site only, and 5 (2.0%) from both sites. Participants in whom TP DNA was detected were younger and more frequently reported STI symptoms and anogenital ulcers during the preceding six months. The detection rate increased with VDRL titre (odds ratio 2.44, 95% CI 1.74–3.41 per doubling of titre for any oral or anal detection). Mutations associated with azithromycin resistance were observed in 76% (19/25, 95% CI 54.9–90.6) of participants in whom TP was detected. Interpretation: TP DNA was detected in 10% of participants with high-titre serological syphilis. Detection increased with higher VDRL titres, supporting an association between higher non-treponemal titres and mucosal TP DNA detection. These findings support continued epidemiological and molecular surveillance of syphilis and of azithromycin resistance in transgender populations. They do not support site-specific PCR screening: syphilis diagnosis remains serological, and benzathine benzylpenicillin G remains the treatment of choice. Funding: French National Agency for Research on AIDS, Viral Hepatitis, and Emerging Infectious Diseases (ANRS/MIE).
Background Data on transgender women and travestis (TGW) concerning oral and anal detection of Treponema pallidum (TP) DNA are lacking. We aimed to estimate the prevalence of oral and anal TP DNA detection and the frequency of azithromycin resistance-associated mutations among TGW with high-titre syphilis in Brazil. Methods We conducted a nested cross-sectional study as part of the TransOdara study among TGW in five Brazilian cities. Participants with high-titre syphilis (reactive treponemal test and VDRL titre ≥1:8) and an analysable oral or anal specimen underwent quantitative PCR targeting the tpp47 and polA genes to detect TP DNA. TP DNA-positive specimens were further analysed using nested PCR and Sanger sequencing to identify mutations associated with azithromycin resistance. Findings Among the 249 participants with high-titre serological syphilis and analysable sample, TP DNA was detected in 25 (10.0%, 95% CI 6.6–14.5): 14 (5.6%) from the oral site only, 6 (2.4%) from the anal site only, and 5 (2.0%) from both sites. Participants in whom TP DNA was detected were younger and more frequently reported STI symptoms and anogenital ulcers during the preceding six months. The detection rate increased with VDRL titre (odds ratio 2.44, 95% CI 1.74–3.41 per doubling of titre for any oral or anal detection). Mutations associated with azithromycin resistance were observed in 76% (19/25, 95% CI 54.9–90.6) of participants in whom TP was detected. Interpretation TP DNA was detected in 10% of participants with high-titre serological syphilis. Detection increased with higher VDRL titres, supporting an association between higher non-treponemal titres and mucosal TP DNA detection. These findings support continued epidemiological and molecular surveillance of syphilis and of azithromycin resistance in transgender populations. They do not support site-specific PCR screening: syphilis diagnosis remains serological, and benzathine benzylpenicillin G remains the treatment of choice. Funding French National Agency for Research on AIDS, Viral Hepatitis, and Emerging Infectious Diseases (ANRS/MIE).
Despite the scientific and technical capacity for precision oncology in North America (Canada, the United States, and Mexico), its implementation is deeply uneven across the region. Our narrative synthesis of precision oncology implementation found that delivery consistently fails at four operational steps: biomarker testing, molecular interpretation, reimbursement, and access to matched standard-of-care therapy or clinical trial. These failures arise along disparity axes that differ by country but converge on a single outcome: patients whose cancers harbor actionable biomarkers do not receive precision oncology-based care. We conclude that precision oncology must be treated as essential cancer-care infrastructure rather than an optional research-based service and propose a tri-national implementation agenda. Acting now is particularly urgent given the rapid emergence of artificial intelligence (AI) models trained on precision oncology-derived datasets, which risk entrenching existing inequities into clinical decision-making before implementation reform can catch up.
Summary: Background: Cervical cancer is largely preventable, yet major gaps persist in detection and timely management of cervical precancer, particularly in low- and middle-income countries. Using data from the ESTAMPA multicentric study, we derived stratified absolute risk estimates for cervical precancer and cancer based on HPV testing, cervical cytology, and colposcopic impression. Methods: ESTAMPA is a multicenter cervical cancer screening study (NCT01881659) that recruited women aged 30–64 years across 12 centres, comprising primary and secondary care facilities, hospitals, laboratories, and universities, across nine Latin American countries: Argentina, Bolivia, Colombia, Costa Rica, Honduras, Mexico, Paraguay, Peru, and Uruguay. The aims of the study were (1) to investigate the performance of emerging cervical cancer screening and triage techniques among women 30 years and older and (2) to evaluate the feasibility of different approaches for implementation of organised HPV-based screening programmes. Women were screened with HPV testing and cervical cytology. Those with positive screening results were referred to colposcopy using a standardised protocol including colposcopic impression, directed biopsies, and treatment as indicated. Women with normal colposcopy or histology less than CIN2 were recalled after 18 months for repeat HPV testing and colposcopy if HPV-positive. Absolute risks of histologically confirmed CIN3+ detected at baseline or follow-up were estimated integrating HPV testing, cytology, and colposcopic impression. Findings: Between December 12, 2012, and August 31, 2022, 44,135 women with a valid HPV test were included, of whom 6236 (14.1%) were HPV-positive. Overall, 764 CIN3+ lesions were detected (1.73%; 95% CI 1.61–1.86). CIN3+ risk was 12.0% (747/6236; 95% CI 11.2–12.8) among HPV-positive women compared with 0.04% (17/37,899; 95% CI 0.03–0.07) among HPV-negative women. Among HPV-positive women, risk increased with cervical cytological severity, reaching 62.9% (95% CI 57.1–68.5) for HSIL+, 22.4% (95% CI 18.4–26.8) for LSIL, and 19.1% (95% CI 15.1–23.6) for ASC-US; a positive colposcopic impression further increased CIN3+ risk to 70.2% (95% CI 64.1–75.9), 28.5% (95% CI 23.5–34.0), and 24.5% (95% CI 19.4–30.2), respectively. Among HPV16/18-positive women, CIN3+ risk was 32.8% (95% CI 28.9–37.0) increasing to 46.2% (95% CI 40.8–51.6) when abnormal colposcopy was present. Interpretation: We confirmed a high underlying risk of CIN3+ in the Latin American population, with risk strongly stratified by HPV positivity, increasing cervical cytological severity, and positive colposcopic impression. These estimates may support WHO-aligned cervical screening and risk-based management strategies in LMICs and contribute to accelerating cervical cancer elimination. Funding: International Agency for Research on Cancer (IARC/WHO); UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP/WHO); Pan American Health Organization (PAHO); US National Cancer Institute (NCI); NCI Center for Global Health; National Agency for the Promotion of Research, Technological Development and Innovation and National Cancer Institute of Argentina; National Cancer Institute of Colombia; Costa Rican Social Security Fund (CCSS); National Council for Science and Technology (CONACYT), Paraguay; and other local funders.
