About

Lisa E. Manhart is a Professor in the Department of Epidemiology and an Adjunct Professor in Global Health at the University of Washington. She holds a PhD in Epidemiology from the University of Washington, an MPH in International Health & Development from Tulane University, and a BA in French from Indiana University. Her research focuses on sexually transmitted infections (STI) and human immunodeficiency virus (HIV), with a primary emphasis on defining the clinical epidemiology of emerging STI pathogens, particularly Mycoplasma genitalium. She led the MEGA trial evaluating the efficacy of standard therapies against M. genitalium and is currently leading cohort studies of men with urethritis to explore the role of the male urethral microbiome in genital tract disease. Her work also includes studies on the psychosocial implications of STI and HIV infection, such as stigma and mental health, as well as the social context of STI risk.

Research topics

• Internal medicine
• Microbiology
• Gynecology
• Virology
• Biology
• Medicine

Selected publications

• The Natural History of <i>Mycoplasma genitalium</i> in the Pharynx and Rectum in a Cohort of Men Who Have Sex With Men: Prevalence, Incidence, Duration, and Symptoms

  The Journal of Infectious Diseases · 2026-03-18 · 1 citations

  articleSenior author

  BACKGROUND: Little is known about Mycoplasma genitalium's (MG) natural history in the throat and the rectum. Methods: Men who have sex with men (MSM) enrolled in a longitudinal cohort study on the natural history of extragenital gonorrhea and chlamydia. Men self-collected pharyngeal and rectal specimens weekly and completed electronic symptom and sexual behavior diaries for 48 weeks. Prevalent infections were detected on the first week of testing; incident infections were ≥2 consecutive weeks of positive specimens after a negative test. We calculated duration using Kaplan-Meier analysis. RESULTS: Of 140 enrolled MSM, 112 participated and 108 submitted samples on week one. Ten (9.3%) had prevalent rectal MG; there were fifteen incident rectal MG infections (incidence 19.8 per 100 person years (py), 95% CI:11.5-34.1 per 100 py). Rectal MG had a median duration of 42 weeks (95% CI: 7.3 weeks - undefined); most infections (60%) were entirely asymptomatic. Four (3.7%) participants had prevalent pharyngeal infections. Fourteen incident pharyngeal infections arose (incidence 17.5 per 100 person years, 95% CI: 9.9-30.8 per 100 py). Pharyngeal MG had a median duration of 12 weeks (95% CI: 6.3 weeks - undefined); symptoms were rare (6%). CONCLUSIONS: Rectal and pharyngeal MG was common in this cohort. Half of the rectal MG infections persisted for nearly a year; many remained positive on week 48 suggesting persistence beyond one year. Pharyngeal infection persisted three months. The absence of symptoms or other morbidity in most infections suggests testing for MG at these sites would have uncertain individual benefit.

  PublisherDOI

• Prevalence, Duration, and Severity of Rectal Symptoms Among Men Who Have Sex With Men With Rectal Sexually Transmitted Infections

  Open Forum Infectious Diseases · 2026-04-28

  articleOpen access

  Abstract Background Rectal sexually transmitted infections (STIs) are commonly diagnosed among men who have sex with men (MSM), but limited prospective data exist on the rectal symptomatology associated with these infections. Method In 2016–2018, we enrolled 140 MSM in a 48-week cohort study in Seattle, Washington. Participants self-collected weekly rectal specimens that were tested at the end of the study for Chlamydia trachomatis (CT), Neisseria gonorrhoeae (GC), and Mycoplasma genitalium (MG) using nucleic acid amplification tests. Participants reported rectal symptoms (rectal discharge, pain, itching, blood in stool, and pain on defecation) in a weekly survey. We calculated the adjusted relative risk (aRR) of the association between incident rectal STIs and rectal symptoms. Results Participants reported rectal symptoms during 12 (38%) of 32 incident rectal CT infections, 6 (30%) of 20 incident rectal GC infections, and 9 (60%) of 15 incident rectal MG infections. Rectal symptoms were significantly more likely to be reported during weeks when participants tested positive for CT, GC, or MG (8.1% [44/544]) compared to weeks when specimens tested negative for all 3 (3.9% [97/2456]) (aRR = 3.01; 95% CI = 1.77–5.13). Rectal itching was the most common symptom during weeks when participants tested either positive (4.6%) or negative (1.7%); rectal discharge was rare (&amp;lt;1% of weeks). The median duration of symptoms was 1 week for CT and GC and 3 weeks for MG. Conclusions Rectal symptoms are common among persons with rectal GC, CT, and MG infections but are typically mild and of short duration.

  PublisherDOI

• Dynamics of Gender Identity With STI Diagnoses and Behavioral Outcomes Among Seattle Sexual Health Clinic Attendees, 2016–2023

  Sexually Transmitted Diseases · 2025-11-04

  article

  BACKGROUND: Nonbinary/genderqueer (NB/GQ) individuals represent a distinct population with unique sexual health care needs. We characterize trends in clinic attendance, sociodemographics, sexually transmitted infection (STI), and drug use among NB/GQ patients at an urban sexual health clinic (SHC). METHODS: We analyzed Public Health, Seattle & King County, Seattle (PHSKC) SHC visit data collected between January 2016 and October 2023. We used the Cochran-Armitage trend test to identify trends in reported gender identity and χ 2 tests to identify sociodemographic characteristics associated with cisgender, transgender, and NB/GQ. We evaluated the associations between gender identity and the prevalence of syphilis, urogenital gonorrhea, rectal chlamydia infection, methamphetamine, and nonprescribed injection drug use using generalized estimating equations. RESULTS: Of 82,384 visits, 1672 (2.0%), 867 (1.1%), and 79,845 (96.9%) were NB/GQ, transgender, and cisgender patients, respectively. From 2016 to 2023, the proportion of visits among NB/GQ and transgender patients increased from 0.7% to 3.5% and 0.7% to 1.7%, respectively ( p trend<0.001). NB/GQ identity was more common among patients assigned female versus male sex at birth (3.2% vs 1.8%, P < 0.001), younger vs older patients (14-25 years: 3.1% vs >46: 0.2%, P < 0.001), and white versus black patients (2.3% vs 1.0%, P < 0.001). Compared with MSM, NB/GQ patients had significantly lower odds of urogenital gonorrhea (adjusted odds ratio [aOR], 0.50; 95% confidence interval [CI], 0.32-0.80). The differences in rectal chlamydia (aOR, 0.78; 95% CI, 0.59-1.02) and syphilis (aOR, 0.96; 95% CI, 0.87-1.06) were not statistically significant. There were no significant differences between the NB/GQ and transgender visits. CONCLUSIONS: Gender diversity among SHC attendees increased significantly over the 8 years. Continued monitoring is essential for tailoring STI/HIV prevention strategies.

  PublisherDOI

• HIV Pre-exposure Prophylaxis (PrEP) Uptake and Persistence in Wartime Ukraine: Analysis of Data from a Scaled PrEP Program

  AIDS and Behavior · 2025-06-11

  articleOpen access

  Russia's invasion of Ukraine and the ongoing war have had devastating effects on health programs. This observational study assessed uptake and persistent use of HIV pre-exposure prophylaxis (PrEP) during wartime. The study included newly-initiating daily PrEP users from 94 clinics who enrolled on PrEP from October 2022 through September 2023. PrEP persistence was defined as returning for a PrEP refill no later than 7 days after the expected refill date. We used Kaplan-Meier curves and sex-stratified Cox regression to explore PrEP discontinuation by sex, key population group, age group, and wartime location. 4537 clients initiated daily PrEP, with 31.9% being men who have sex with men (MSM), 29.7% based in a frontline location, and 16.7% aged 18-25. Six-month persistence was 37.3% overall. It was lower among MSM (28.6%), young adults aged 18-25 (17.2%), and frontline residents (15.6%), and higher among sex workers (SW) (81.5%). In adjusted analysis among women, SW had a lower risk of discontinuing PrEP compared with discordant couples (adjusted hazard ratio [aHR]: 0.22, 95% confidence interval [CI] 0.14-0.34). In both sexes, clients aged 18-25 had a higher risk of discontinuing PrEP (aHR: 1.43, 95% CI 1.25-1.65 for men; aHR: 1.60, 95% CI 1.16-2.20 for women), as did those based in frontline locations (aHR: 2.19, 95% CI 1.99-2.41 for men; aHR: 1.26, 95% CI 1.04-1.53 for women). The findings highlight the resilience of Ukraine's PrEP program and the need to support PrEP persistence among younger and frontline populations.

  PublisherOA PDFDOI

• Study Design Matters: Using a Rigorous Analytic Design to Examine the Association Between Rectal Douching and Incident Rectal Gonorrhea and Chlamydia

  Sexually Transmitted Diseases · 2025-07-22

  article

  BACKGROUND: Prior studies have identified an association between rectal douching and prevalent rectal Neisseria gonorrhoeae (GC) and Chlamydia trachomatis (CT), but few studies have examined associations with incident infections. METHODS: We used data from ExGen, a 48-week cohort study conducted in Seattle, Washington, 2016 to 2018. Each week, participants completed a survey and self-collected rectal specimens, which were tested for CT/GC at the end of the study. Our primary analysis was a case-crossover analysis. We identified individuals with incident rectal GC or CT and included 1 case-week (the first week of the incident rectal infection) and 2 randomly selected control-weeks (weeks where the participant tested negative for rectal GC/CT). We used multivariate conditional logistic regression to estimate the association between douching and rectal GC/CT. In an exploratory analysis, we created a "synthetic" cross-sectional study of the longitudinal data to mirror the design of other studies. RESULTS: There were 140 individuals in ExGen. Our case-crossover sample comprised 17 GC case-weeks and 34 matched GC control-weeks, and 22 CT case-weeks and 44 matched CT control-weeks. Participants reported douching during 64.7% of GC case-weeks and 70.6% control-weeks (adjusted odds ratio, 0.47; 95% confidence interval, 0.07-3.10). Douching was reported at a similar frequency among CT case-weeks (45.5%) versus control weeks (47.7%; adjusted odds ratio, 1.16; 95% confidence interval, 0.26-5.07). In our exploratory synthetic cross-sectional study, rectal douching was significantly associated with rectal GC but not CT. CONCLUSIONS: Douching was not associated with rectal GC/CT in this methodologically rigorous analysis. A better understanding of the mechanisms of douching products and impact of long-term use may be warranted.

  PublisherDOI

• High Incidence and Duration of Antibiotic Use Among a Cohort of Men Who Have Sex With Men in Seattle, Washington

  Open Forum Infectious Diseases · 2025-01-30 · 3 citations

  articleOpen access

  Background: Doxycycline postexposure prophylaxis (doxy-PEP) effectively prevents bacterial sexually transmitted infections (STIs) but may increase antibiotic pressure. Little is known about longitudinal antibiotic use among men who have sex with men (MSM), a key population for doxy-PEP. Methods: We analyzed data from a prospective cohort of MSM in Seattle, Washington, from 2016 to 2018, prior to the introduction of doxy-PEP. Antibiotic use and reason for prescription were self-reported in weekly surveys and extracted from medical records. We characterized antibiotic use across 49 weeks of follow-up, stratified by specific antibiotics of interest and reasons for prescription. Incidence rates (IRs) were calculated for the number of incident events of antibiotic initiation per 100 person-years (PY) at risk. We assessed factors associated with antibiotic initiation using negative binomial regression to estimate adjusted incidence rate ratios (IRRs). Results: Among 140 participants, 68.6% (n = 96) received at least 1 antibiotic during follow-up, resulting in an overall IR of 264.5 events of antibiotic initiation per 100 PY and 1696 total days of antibiotic use. STI treatment was the most common reason for antibiotic initiation (IR, 153.5 events per 100 PY; 462 days); however, treatment for other conditions contributed most to overall days of antibiotic use (IR, 42.6 events per 100 PY; 947 days). An age of 25-39 years (IRR, 1.54 [95% confidence interval {CI}, 1.02-2.32]) and a history of bacterial STIs <12 months prior to enrollment (IRR, 1.81 [95% CI, 1.12-2.93]) were significantly associated with higher incidence of antibiotic initiation. Conclusions: Antibiotic consumption among this population was very high. Our analysis provides a necessary foundation for assessing the potential impacts of doxy-PEP.

  PublisherDOI

• Trends in Chlamydia trachomatis Treatment Prescribing Practices in King County, Washington, 2010–2018

  Sexually Transmitted Diseases · 2024-01-26 · 1 citations

  articleOpen access

  BACKGROUND: In 2021, national Chlamydia trachomatis (CT) treatment guidelines changed from recommending either azithromycin (1 g; single dose) or doxycycline (100 mg twice daily for 7 days) to recommending only doxycycline as first-line treatment. The distribution and trends in CT prescribing practices before the guidelines change is largely unknown. METHODS: We conducted a trends analysis using Washington STD surveillance data. We included all female cases of urogenital CT 15 years or older who resided in King County and were diagnosed between 2010 and 2018. Surveillance data included information on demographics, sexual history, clinical features, diagnosing facility (eg, emergency department, family planning), and treatment regimen. We conducted descriptive analyses to examine trends in prescribing practices over time and by facility type. We used Poisson regression to examine the association between CT case characteristics and receipt of receipt of azithromycin. RESULTS: There were 36,830 cases of female urogenital CT during the study period. The percent of cases receiving azithromycin increased significantly from 86% in 2010 to 94% in 2018; the percent receiving doxycycline decreased from 13% to 5%. Five of the 8 facility types prescribed azithromycin to >95% of CT cases by 2018. Cases who were younger or cases of color were more likely to receive azithromycin (versus doxycycline) compared with older and White cases, respectively. CONCLUSIONS: A substantial shift in CT prescribing practices will be needed to adhere to new CT treatment guidelines. Our findings highlight the need for targeted provider education and training to encourage the transition to doxycycline use.

  PublisherOA PDFDOI

• Uptake and Persistent Use of HIV Preexposure Prophylaxis Among Key Populations: Results From Ukraine's Scaled National Preexposure Prophylaxis Program

  JAIDS Journal of Acquired Immune Deficiency Syndromes · 2024-04-15 · 4 citations

  articleOpen access

  BACKGROUND: Ukraine has implemented ambitious HIV-prevention programs since 1999 and began offering preexposure prophylaxis (PrEP) in 2017. Little is known about PrEP uptake and persistence in this setting. SETTING: We analyzed data from 40 facilities providing PrEP in 11 oblasts (regions) of Ukraine between October 2020 and February 2022. METHODS: We estimated the time between PrEP visits and conducted Kaplan-Meier analyses to estimate retention on PrEP stratified by sex, age, and key populations (KPs): men who have sex with men (MSM), people who inject drugs (PWID), sex workers (SW), discordant couples, and others vulnerable to HIV acquisition (DC/other). We used Cox regression to estimate the risk of PrEP discontinuation by KP group and sex, adjusting for age. RESULTS: Overall, 2033 clients initiated PrEP across regions; the majority (51%) were DC/other, 22% were MSM, 22% were PWID, and 5% were SW. The overall 3-month persistence was 52.3% (95% confidence interval [CI]: 49.9% to 54.8%) and was lowest among MSM (46.7%; 95% CI: 41.9% to 52.2%) and SW (25.9%; 95% CI: 18.2% to 36.9%) (P < 0.05 for differences by KP group). After adjusting for age, PrEP discontinuation was not statistically significantly different across groups, although female PWID tended to have the lowest discontinuation risk (adjusted hazard ratio [aHR] 0.59; 95% CI: 0.31 to 1.11) while male SW tended to have the highest risk (aHR 1.87, 95% CI: 0.57 to 6.11) compared with females in the DC/other group. CONCLUSION: Three-month PrEP persistence was low across KP groups, especially in SW. Further research examining the barriers and enablers of persistence by KPs is needed.

  PublisherDOI

• Systematic Review and Meta-analysis of the Association Between <i>Mycoplasma genitalium</i> and Pelvic Inflammatory Disease (PID)

  Clinical Infectious Diseases · 2024-06-06 · 23 citations

  articleOpen access

  BACKGROUND: Differences in opinion concerning the contribution of Mycoplasma genitalium to pelvic inflammatory disease (PID) has resulted in inconsistencies across global testing and treatment guidelines. We conducted a systematic review and meta-analysis to determine the association between M. genitalium and PID and M. genitalium positivity within PID cases to provide a contemporary evidence base to inform clinical practice (PROSPERO registration: CRD42022382156). METHODS: PubMed, Embase, Medline, and Web of Science were searched to 1 December 2023 for studies that assessed women for PID using established clinical criteria and used nucleic acid amplification tests to detect M. genitalium. We calculated summary estimates of the (1) association of M. genitalium with PID (pooled odds ratio [OR]) and 2) proportion of PID cases with M. genitalium detected (pooled M. genitalium positivity in PID), using random-effects meta-analyses, with 95% confidence intervals (CI). RESULTS: Nineteen studies were included: 10 estimated M. genitalium association with PID, and 19 estimated M. genitalium positivity in PID. M. genitalium infection was significantly associated with PID (pooled OR = 1.67 [95% CI: 1.24-2.24]). The pooled positivity of M. genitalium in PID was 10.3% [95% CI: 5.63-15.99]. Subgroup and meta-regression analyses showed that M. genitalium positivity in PID was highest in the Americas, in studies conducted in both inpatient and outpatient clinic settings, and in populations at high risk of sexually transmitted infections. CONCLUSIONS: M. genitalium was associated with a 67% increase in odds of PID and was detected in about 1 of 10 clinical diagnoses of PID. These data support testing women for M. genitalium at initial PID diagnosis.

  PublisherOA PDFDOI

• The Relationship Between Insertive Oral and Anal Sex and Select Measures of the Composition of the Urethral Microbiota Among Men Who Have Sex With Men

  Sexually Transmitted Diseases · 2024-02-23 · 1 citations

  articleOpen accessCorresponding

  BACKGROUND: Sexual behavior may influence the composition of the male urethral microbiota, but this hypothesis has not been tested in longitudinal studies of men who have sex with men (MSM). METHODS: From December 2014 to July 2018, we enrolled MSM with nongonococcal urethritis (NGU) attending a sexual health clinic. Men attended 5 in-clinic visits at 3-week intervals, collected weekly urine specimens at home, and reported daily antibiotics and sexual activity on weekly diaries. We applied broad-range 16S rRNA gene sequencing to urine. We used generalized estimating equations to estimate the association between urethral sexual exposures in the prior 7 days (insertive oral sex [IOS] only, condomless insertive anal intercourse [CIAI] only, IOS with CIAI [IOS + CIAI], or none) and Shannon index, number of species (observed, oral indicator, and rectal indicator), and specific taxa, adjusting for recent antibiotics, age, race/ethnicity, HIV, and preexposure prophylaxis. RESULTS: Ninety-six of 108 MSM with NGU attended ≥1 follow-up visit. They contributed 1140 person-weeks of behavioral data and 1006 urine specimens. Compared with those with no urethral sexual exposures, those with IOS only had higher Shannon index ( P = 0.03 ) but similar number of species and presence of specific taxa considered, adjusting for confounders; the exception was an association with Haemophilus parainfluenzae . CIAI only was not associated with measured aspects of the urethral microbiota. IOS + CIAI was only associated with presence of H. parainfluenzae and Haemophilus . CONCLUSIONS: Among MSM after NGU, IOS and CIAI did not seem to have a substantial influence on measured aspects of the composition of the urethral microbiota.

  PublisherOA PDFDOI

Recent grants

• NIH Grant R01AI072728

  NIH · $1.4M · 2012

• NIH Grant R21AI091970

  NIH · $480k · 2014

• NIH Grant R01AI110666

  NIH · $3.9M · 2021

• NIH Grant R21NR011279

  NIH · $364k · 2013

• NIH Grant U19AI113173

  NIH · $29.9M · 2020

Frequent coauthors

• Matthew R. Golden

  AIDS United

  248 shared

• Julia C. Dombrowski

  Public Health – Seattle & King County

  135 shared

• Lindley A. Barbee

  University of Washington

  135 shared

• David A. Katz

  University of Washington

  117 shared

• Roxanne P. Kerani

  University of Washington

  106 shared

• James P. Hughes

  University of Washington

  104 shared

• Fred Swanson

  Cape Peninsula University of Technology

  100 shared

• Christine M. Khosropour

  University of Washington

  78 shared