Antibody responses following incident anal and penile infection with human papillomavirus in teenage men who have sex with men

Men who have sex with men (MSM) are at risk for human papillomavirus (HPV)-related anal cancer. Few data exist on antibody responses following incident anogenital infection with HPV in teenage MSM. A cohort of 200 MSM aged 16-20 years from Melbourne, Australia were assessed at baseline, 3, 6 and 12 months. At each visit anal and penile swabs were collected for HPV DNA and serum for HPV antibodies for genotypes 6, 11, 16 and 18 (Merck's Multiplex Assays using Luminex). The main outcome, seroconversion, was defined as the detection of HPV antibodies following a negative antibody result for the same HPV type at baseline. The seroincidence rates for HPV types 6, 11, 16 and 18 were: 19 (95% CI 12-26), 7 (3-12), 4 (1-8) and 6 (3-11) per 100 person-years, respectively. Men who experienced incident anal HPV infections from types 6/11 were significantly more likely to develop serum antibodies to the same HPV type(s) than those who experienced incident anal infections from types 16/18 [73 vs. 18%, odds ratio (OR) = 15, 95% CI: 2-118]. The median time between incident anal HPV infection and seroconversion for HPV 6, 11, 16 and 18 was: 91, 38, 161 and 182 days, respectively. Antibody responses against HPV types 6/11 were significantly more likely to occur following incident anal compared with incident penile infection with HPV types 6/11 (OR = 6, 95% CI: 2-21). The likelihood of antibody responses following anogenital HPV infections depends on the HPV type and site of infection.

The performance of anal cytology as a screening test for anal HSILs in homosexual men

BACKGROUND

Studies regarding the performance of anal cytology in which both the screening test (cytology) and the diagnostic test (high-resolution anoscopy [HRA]) are performed in all members of a screening population are rare. The authors evaluated the performance of liquid-based anal cytology in a cohort of homosexual men in Sydney, New South Wales, Australia.

METHODS

The Study of the Prevention of Anal Cancer (SPANC) is a 3-year prospective study of the natural history of anal human papillomavirus infection in homosexual men aged ≥35 years. At baseline, all participants underwent a liquid-based anal cytology test and HRA at the same clinical visit. Biopsies were obtained for histological assessment if lesions suspicious for human papillomavirus infection were visible during HRA. Using any cytological abnormality as the threshold, the sensitivity, specificity, and positive and negative predictive values were calculated against histologically diagnosed high-grade squamous intraepithelial lesions (HSILs).

RESULTS

Among 617 men recruited, the median age was 49 years (range, 35-79 years) and 35.7% were positive for the human immunodeficiency virus. Overall, the sensitivity of cytology was 83.2%, the specificity was 52.6%, the positive predictive value was 45.8%, and the negative predictive value was 86.7%. Specificity improved with increasing age (P for trend =.041). Sensitivity was significantly higher in men with >1 anal octant of biopsy-confirmed HSIL (92.9% vs 77.7%; P = .010), and in those who had ≥10 metaplastic cells present on their cytology slides (87.5% vs 70.2%; P = .007).

CONCLUSIONS

Anal cytology was found to have a higher specificity in older men while maintaining sensitivity. Sensitivity was higher among those with more extensive HSILs and men with metaplastic cells present on cytology. Cancer Cytopathol 2016;124:415-24. © 2016 American Cancer Society.

High azathioprine dose and lip cancer risk in liver, heart, and lung transplant recipients: A population-based cohort study

BACKGROUND

Iatrogenic immunosuppression is a risk factor for lip cancer but the determinants are unknown.

OBJECTIVE

We sought to quantify the association between the type, dose, and duration of iatrogenic immunosuppression and lip cancer risk in solid organ transplant recipients.

METHODS

We conducted a population-based cohort study of all adult Australian liver, heart, and lung transplant recipients from 1984 to 2006 (n = 4141). We abstracted longitudinal data from medical records and ascertained incident lip cancer (n = 58) and deaths (n = 1434) by linkage with national registries. We estimated multivariable hazard ratios (HR) for lip cancer using the Fine and Gray proportional subdistribution hazards model, accounting for death as a competing risk.

RESULTS

Lip cancer risk (n = 58) increased with high mean daily dose of azathioprine (HR 2.28, 95% confidence interval [CI] 1.18-4.38), longer duration of immunosuppression (HR 9.86, 95% CI 2.10-46.3), increasing year of age at transplantation (HR 1.14, 95% CI 1.04-1.25), earlier transplantation era (HR 8.73, 95% CI 1.11-68.7), and history of smoking (HR 2.71, 95% CI 1.09-6.70).

LIMITATIONS

Data on potential confounders such as personal solar ultraviolet radiation exposure were not available.

CONCLUSION

Higher doses of azathioprine increase lip cancer risk, with implications for managing immunosuppressed populations and our understanding of the relationship between solar ultraviolet radiation and lip cancer.

Rationale and design of FORTH: a randomised controlled trial assessing the effectiveness of HIV self-testing in increasing HIV testing frequency among gay and bisexual men

BACKGROUND

Gay and bisexual men (GBM) are a major risk group for HIV acquisition, yet the majority of higher-risk GBM test for HIV less often than recommended (3-6 monthly). HIV self-testing has the potential to increase testing frequency and improve awareness of personal HIV status. HIV self-tests have been approved in some countries, however there are concerns whether self-testing would increase HIV testing frequency enough to compensate for the reduced sensitivity of self-tests in early infection. We describe here a randomised controlled trial to assess the effectiveness of self-testing in increasing HIV testing frequency among higher-risk GBM, and its acceptability.

METHODS/DESIGN

Participants are higher-risk HIV negative GBM (>5 partners or condomless anal intercourse in previous 3 months; n = 350), including 50 GBM who tested for HIV over two years ago or never tested before ('infrequent-testers'). Participants are recruited from sexual health clinics and community-based organisations, and randomised 1:1 to either self-testing or standard-care (routine clinic-based testing) arms. The trial employs a wait-list control design: participants in the standard-care arm switch to self-testing arm in the second year, and gain access to self-test kits. Participants in the self-testing arm receive four oral-fluid self-test kits at enrolment, with additional kits provided on request. Demographics, sexual behaviour and HIV testing preferences are collected at baseline, and the frequency and pattern of HIV and sexually transmissible infection (STI) testing is collected via online 3-monthly questionnaires. The acceptability of self-testing is assessed at 12 months via an online questionnaire and in-depth interviews. A 24-h telephone support is provided, with expedited follow-up of those with reactive self-test results. The primary outcome is HIV testing frequency (mean number of HIV tests per person) over 12 months, and the secondary outcomes are: mean number of STI tests (chlamydia, gonorrhoea, syphilis) per person; reasons for HIV testing; and acceptability of HIV self-testing.

DISCUSSION

This is the first trial to evaluate the use of self-testing among GBM in Australia, and the first internationally among infrequent testers. The study will provide evidence on whether self-testing increases HIV testing frequency, and its acceptability among GBM. The findings will improve our understanding of self-testing patterns, and whether GBM supplement or replace their existing testing routine.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trial Registration number: ACTRN12613001236785 , registered on November 12, 2013.

Longitudinal dose and type of immunosuppression in a national cohort of Australian liver, heart, and lung transplant recipients, 1984-2006

Unconfounded comparative data on the type and dose of immunosuppressive agents among solid organ transplant recipients are sparse, as are data on longitudinal immunosuppressive therapy since transplantation. We addressed this issue in a population-based cohort of Australian liver (n = 1895), heart (n = 1220), and lung (n = 1059) transplant recipients, 1984-2006. Data on immunosuppressive therapy were retrospectively collected at discharge, three months, and one, five, 10, and 15 yr after first transplant. We computed unadjusted and adjusted estimates for the association between the type and dose of immunosuppressive therapy and organ type. After adjustment for confounders, use of induction antibody and maintenance corticosteroids was more common in heart and lung compared to liver recipients (p < 0.001), and antibody therapy for rejection more common in liver recipients (p < 0.001). Liver recipients were more likely to receive calcineurin inhibitor monotherapy, with or without corticosteroids, compared to heart and lung recipients (p < 0.001). Liver recipients consistently received lower doses of azathioprine than heart and lung recipients (p < 0.001). These differences in immunosuppression may partly explain variations in immunosuppression-related morbidity by transplanted organ, for example, malignancy risk. Longitudinal changes in the type and the dose of immunosuppressive therapy over time since transplantation also demonstrate the need for time-dependent data in observational research.

Hospitalisation rates and associated factors in community-based cohorts of HIV-infected and -uninfected gay and bisexual men

OBJECTIVES

There is evidence that HIV-positive patients are suffering from a greater burden of morbidity as they age due to nonAIDS-related complications. To date it has been difficult to determine what part of this excess risk is due to the health effects of HIV, its treatment or to lifestyle factors common to gay and bisexual men (GBM). We calculated overall and cause-specific hospitalisation rates and risk factors for hospitalisations in HIV-negative and HIV-positive cohorts of GBM and compare these with rates in the general male population.

METHODS

We conducted a record linkage study, linking two cohorts of HIV-negative (n = 1325) and HIV-positive (n = 557) GBM recruited in Sydney, New South Wales (NSW), Australia with the NSW hospital discharge data register. We compared rates of hospitalisation in the two cohorts and risk factors for hospitalisation using random-effects Poisson regression methods. Hospitalisation rates for each cohort were further compared with those in the general male population using indirect standardisation.

RESULTS

We observed 2032 hospitalisations in the HIV-negative cohort during 13,016 person-years (PYs) [crude rate: 15.6/100 PYs (95% CI: 14.9-16.3)] and 2130 hospitalisations in the HIV-positive cohort during 5571 PYs [crude rate: 38.2/100 PYs (95% CI: 36.6-39.9)]. HIV-positive individuals had an increased risk of hospitalisation compared with the HIV-negative individuals [adjusted-IRR: 2.34 (95% CI: 1.91-2.86)] and the general population [SHR: 1.45 (95% CI: 1.33-1.59)]. Hospitalisation rates were lower in the HIV-negative cohort compared with the general population [SHR: 0.72 (95% CI: 0.67-0.78)]. The primary causes of hospitalisation differed between groups.

CONCLUSIONS

HIV-positive GBM continue to experience excess morbidity compared with HIV-negative GBM men and the general population. HIV-negative GBM had lower morbidity compared with the general male population suggesting that GBM identity does not confer excess risk.

Laser capture microdissection as a tool to evaluate human papillomavirus genotyping and methylation as biomarkers of persistence and progression of anal lesions

INTRODUCTION

Anal squamous cell carcinoma is preceded by persistent infection with high-risk human papillomavirus (HPV) and the cancer precursor, high-grade squamous intraepithelial lesion (HSIL). Detection of specific HPV genotypes and HPV-related biomarkers may be an option for primary anal screening. However, more data on the natural history of HPV-related anal lesions are required. The outcomes from this study will enhance our understanding of the clinical and biological behaviour of HPV-related anal lesions and inform the development of future HPV genotype and/or biomarker screening tests.

METHODS AND ANALYSIS

HIV-negative and HIV-positive men who have sex with men, aged 35 years and over, recruited from community-based settings in Sydney, Australia, attend 6 clinic visits over 3 years. At the first 5 visits, participants undergo a digital anorectal examination, an anal swab for HPV genotyping and anal cytology, and high-resolution anoscopy with directed biopsy of any visible abnormalities that are suggestive of any abnormality suspicious of SIL. Tissue sections from participants diagnosed with histologically confirmed HSIL at the baseline clinic visit will undergo laser capture microdissection, HPV detection and genotyping, and quantitation of CpG methylation in baseline and follow-up biopsies. Histological and cytological findings in combination with HPV genotyping data will be used to identify persistent HSIL. HSIL will be stratified as non-persistent and persistent based on their status at 12 months. The performance of HPV genotype and methylation status in predicting disease persistence at 12 months will be assessed, along with associations with HIV status and other covariates such as age.

ETHICS AND DISSEMINATION

The St Vincent's Hospital Ethics Committee granted ethics approval for the study. Written informed consent is obtained from all individuals before any study-specific procedures are performed. Findings from this study will be disseminated to participants and the community through study newsletters, and through peer-reviewed publications and international conferences.

Transmission risk behaviour at enrolment in participants in the INSIGHT Strategic Timing of AntiRetroviral Treatment (START) trial

OBJECTIVES

A proportion of HIV-positive people have condomless sex. Antiretroviral treatment (ART) reduces infectiousness, but a substantial proportion of HIV-diagnosed people are not yet on ART. We describe baseline self-reported risk behaviours in ART-naïve Strategic Timing of AntiRetroviral Treatment (START) trial participants.

METHODS

All START participants completed a risk behaviour questionnaire. Data were collected on sociodemographics, lifestyle factors, health and wellbeing status and clinical status. Recent sexual behaviour and HIV transmission beliefs in the context of ART were also assessed. The primary interest was in condomless sex with serodifferent partners (CLS-D) in the past two months.

RESULTS

A total of 4601 of 4685 HIV-positive participants (98%) completed the questionnaire [2559 men who have sex with men (MSM), 803 heterosexual men and 1239 women]. Region of recruitment was Europe/Israel, 33%; South America/Mexico, 25%; Africa, 22%; other, 21%. Median age was 36 years [interquartile range (IQR) 29, 44 years]. Forty-five per cent reported white ethnicity and 31% black ethnicity. Two per cent had HIV viral load < 50 HIV-1 RNA copies/mL. Seventeen per cent (767 of 4601) reported CLS-D; 20% of MSM compared with 10% of heterosexual men and 14% of women. MSM were also more likely to report multiple CLS-D partners. Possible risk limitation measures (reported by more than half of those who had CLS-D) were seropositioning (receptive anal CLS-D only) or withdrawal (insertive anal CLS-D always without ejaculation). CLS-D was more commonly reported by participants from South America/Mexico and North America compared with Europe; among heterosexual men and women CLS-D was also more commonly reported among participants from Africa compared with Europe. Knowledge of ART impact on transmission risk was low.

CONCLUSIONS

A substantial minority recruited to the START study reported CLS-D at baseline. CLS-D reporting was higher in MSM than heterosexuals and varied significantly according to region of recruitment. A substantial proportion of MSM reporting CLS-D appear to take transmission risk limitation measures.

"Any Condomless Anal Intercourse" is No Longer an Accurate Measure of HIV Sexual risk Behavior in Gay and Other Men Who have Sex with Men

BACKGROUND

Condomless anal intercourse (CLAI) has long been recognized as the primary mode of sexual transmission of HIV in gay and other men who have sex with men (MSM). A variety of measures of CLAI have been commonly used in behavioral surveillance for HIV risk and to forecast trends in HIV infection. However, gay and other MSM's sexual practices changed as the understanding of disease and treatment options advance. In the present paper, we argue that summary measures such as "any CLAI" do not accurately measure HIV sexual risk behavior.

METHODS

Participants were 1,427 HIV-negative men from the Health in Men cohort study run from 2001 to 2007 in Sydney, Australia, with six-monthly interviews. At each interview, detailed quantitative data on the number of episodes of insertive and receptive CLAI in the last 6 months were collected, separated by partner type (regular vs. casual) and partners' HIV status (negative, positive, and HIV status unknown).

RESULTS

A total of 228,064 episodes of CLAI were reported during the study period with a mean of 44 episodes per year per participant (median: 14). The great majority of CLAI episodes were with a regular partner (92.6%), most of them with HIV-negative regular partners (84.8%). Participants were more likely to engage in insertive CLAI with casual than with regular partners (66.7 vs. 55.3% of all acts of CLAI with each partner type, p < 0.001). Men were more likely to report CLAI in the receptive position with HIV-negative and HIV status unknown partners than with HIV-positive partners (p < 0.001 for both regular and casual partners).

CONCLUSION

Gay and other MSM engaging in CLAI demonstrate clear patterns of HIV risk reduction behavior. As HIV prevention enters the era of antiretroviral-based biomedical approach, using all forms of CLAI indiscriminately as a measure of HIV behavioral risk is not helpful in understanding the current drivers of HIV transmission in the community.

Corrigendum to: Heterosexual experience and recent heterosexual encounters among Australian adults: The Second Australian Study of Health and Relationships

Background Current information about numbers of other-sex partners, experiences of different heterosexual behaviours and the recent heterosexual experiences among a representative sample of Australian adults is needed. It is not known whether these practices have changed between 2001–02 and 2012–13. Methods: Computer-assisted telephone interviews were completed by a representative sample of 9963 men and 10 131 women aged 16–69 years from all states and territories. The overall participation rate among eligible people was 66.2%. Results: Men reported more sexual partners than women, although the lifetime number of heterosexual partners reported by women increased significantly between 2001–02 and 2012–13. In 2012–13, 14.7% of men and 8.6% of women reported two or more sexual partners in the last year. Reporting multiple partners was significantly associated with being younger, being bisexual, living in major cities, having a lower income, having a blue-collar occupation and not being married. The proportion of respondents reporting ever having had oral sex or anal intercourse increased significantly since the last survey. At the last heterosexual encounter, 91.9% of men and 66.2% of women had an orgasm, oral sex was reported in only approximately one in four encounters and anal intercourse was uncommon. Conclusion: There were increases between 2001–02 and 2012–13 in partner numbers among women and in the lifetime experience of oral and anal sex. The patterns of heterosexual experience in Australia are similar to those found in studies of representative samples in other countries.

Corrigendum to: Knowledge about and experience of sexually transmissible infections in a representative sample of adults: the Second Australian Study of Health and Relationships

Background Sexually transmissible infections (STIs) present a substantial public health burden, and are related to modifiable sexual behaviours. Methods: Computer-assisted telephone interviews were completed by a population-representative sample of 20 094 men and women aged 16–69 years. The overall participation rate among eligible people was 66.2%. Respondents were asked questions regarding their knowledge about, self-reported history of, and testing for STIs. Results: STI knowledge was better in women, the young, people of higher socioeconomic status, those with a variety of indicators of being at high STI risk and those with a history of receiving sex education in school. Approximately one in six men and women reported a lifetime history of an STI. A history of STI testing in the last year was reported by ~one in six (17%) women and one in eight men (13%) and higher rates of testing in women were reported in most high-risk groups. The highest rates of STI testing (61%) and HIV testing (89%) were reported in homosexual men. Conclusion: Knowledge of STI-related health consequences and transmission is improving in Australians, and rates of STI testing were relatively high but were higher in women than in men. Further increases in testing rates in both sexes will be required to facilitate the early diagnosis and treatment of STIs, which is a cornerstone of STI control.

The epidemiology of cancers in human immunodeficiency virus infection and after organ transplantation

The authors provide an update on the association between immune deficiency and cancer risk in people with human immunodeficiency virus (HIV) and in solid organ transplant recipients. Over the past decade, it has become clear that a wider range of about 20 mostly infection-related cancers occur at increased rates in people with immune deficiency. The human herpes virus 8 (HHV8) and Epstein Barr Virus (EBV)-related cancers of Kaposi sarcoma (KS) and non-Hodgkin lymphoma (NHL) are most closely related to level of immune deficiency. Transplant recipients also have a greatly increased risk of squamous cell carcinoma (SCC) of the skin, related to direct carcinogenic effects of the pharmaceuticals used for immune suppression. For those three cancer types, the increased cancer risk is largely reversed when immune deficiency is decreased by treatment of HIV or by reduction of iatrogenic immune suppression. Other infection-related cancers also occur at increased rates, but it is not clear whether reduction of immune deficiency reduces cancer risk. Prostate and breast cancer do not occur at increased rates, providing strong evidence that these cancers are unlikely to be related to infection. Epidemiological and clinical trends in these two populations have led to substantial recent changes in cancer occurrence.

Site-specific human papillomavirus infection in adolescent men who have sex with men (HYPER): an observational cohort study

BACKGROUND

Men who have sex with men (MSM) have an increased risk of anogenital human papilomavirus (HPV) infection, which can lead to HPV-related anogenital lesions such as warts, anal intraepithelial neoplasia, and anal cancer. Some of these HPV types are preventable with vaccines. We aimed to describe the incidence of anal, penile, and oral HPV infection, and to estimate the site-specific transmission probability per partner, for teenage MSM.

METHODS

In our observational cohort study, we enrolled teenage MSM (aged 16-20 years) with low sexual exposure and a low prevalence of HPV in Melbourne (VIC, Australia). At baseline, 3, 6, and 12 months, we took a swab from the anal canal, and participants self-collected a swab from the penis and an oral rinse. Our primary outcome was definite and probable incident HPV infection of the anus, penis, or mouth at any time in the 12 months from baseline, assessed through the presence of HPV DNA. We defined definite incident HPV infection as the same HPV type detected more than once from the same site in men who had a negative HPV test at baseline. We defined probable incident HPV infection as only one positive test. We estimated the probability of HPV transmission per partner using HPV prevalence in MSM with a similar age to partners of men in our cohort. This study is registered at the Australian New Zealand Clinical Trials Registry and ClinicalTrials.gov, numbers ACTRN12611000857909 and NCT01422356.

FINDINGS

We enrolled 200 MSM aged 16-20 years (median 19 years [IRQ 18-20; range 16-20]) between Sept 20, 2010, and Aug 24, 2012. Over the 12 month follow-up period, we detected 48 definite (107 possible) HPV infections in the anus, ten definite (34 possible) HPV infections on the penis, and no definite (six possible) infections in the mouth. Definite incidence rate per 100 person-years for any anal HPV infection was 57 (95% CI 46-68), and for any anal HPV type in the quadrivalent vaccine was 33 (23-44). Definite incidence rate per 100 person-years for any penile HPV was 12 (6-21) and for any HPV type in the quadrivalent vaccine was 5 (1-12). Estimated probabilities of HPV transmission from the penis to the anus were significantly higher than were those from the anus to the penis (p<0·05 for all HPV types in the quadrivalent vaccine).

INTERPRETATION

High incidence rates suggest that the vaccination coverage in MSM will need to be high. The transmission estimates will inform HPV modelling.

FUNDING

Merck.

The Opposites Attract Study of viral load, HIV treatment and HIV transmission in serodiscordant homosexual male couples: design and methods

BACKGROUND

Studies in heterosexual HIV serodiscordant couples have provided critical evidence on the role of HIV treatments and undetectable viral load in reducing the risk of HIV transmission. There is very limited data on the risk of transmission from anal sex in homosexual male serodiscordant couples.

METHODS/DESIGN

The Opposites Attract Study is an observational prospective longitudinal cohort study of male homosexual serodiscordant partnerships running from 2012 to 2015 and conducted in clinics throughout Australia, Brazil and Thailand. Couples attend two or more clinic visits per year. The HIV-positive partner's viral load is tested and the HIV-negative partner is tested for HIV antibodies at every clinic visit. Results from any tests for sexually transmitted infections are also collected. Detailed behavioural questionnaires are completed by both partners at the time of each visit. The primary research question is whether HIV incidence is lower in those couples where the HIV-positive partner is receiving HIV treatment compared to couples where he is not receiving treatment. A voluntary semen sub-study will examine semen plasma viral load in a subsample of HIV-positive partners in Sydney, Rio de Janeiro and Bangkok. In cases of seroconversion of the initially HIV-negative partner, phylogenetic analysis will be conducted at the end of the study on virus from stored blood samples from both partners to determine if the infection came from the HIV-positive study partner. Men in new serodiscordant relationships will specifically be targeted for recruitment.

DISCUSSION

This study will provide critical data on the reduction in HIV transmission risk associated with being on HIV treatment in homosexual male serodiscordant couples in different regions of the world. Data from men in new relationships will be particularly valuable given that the highest transmission risk is in the first year of serodiscordant relationships. Furthermore, the detailed behavioural and attitudinal data from the participant questionnaires will allow exploration of many contextual factors associated with HIV risk, condom use and the negotiation of sexual practice within couples.

Effects of HIV antiretroviral therapy on sexual and injecting risk-taking behavior: a systematic review and meta-analysis

BACKGROUND

Increased global access and use of antiretroviral therapy (ART) for human immunodeficiency virus (HIV) has been postulated to undermine HIV prevention efforts by changing individual risk-taking behavior. This review aims to determine whether ART use is associated with changes in sexual or injecting risk-taking behavior or diagnosis of sexually transmitted infections (STIs).

METHODS

A systematic review and meta-analysis was conducted of HIV-seropositive participants receiving ART compared with no ART use in experimental or observational studies. Primary outcomes included (1) any unprotected sexual intercourse, (2) STI diagnoses, and (3) any unsafe injecting behavior.

RESULTS

Fifty-eight studies met the selection criteria. Fifty-six studies containing 32 857 participants reported unprotected sex; 11 studies containing 16 138 participants reported STI diagnoses; and 4 studies containing 1600 participants reported unsafe injecting behavior. All included studies were observational. Unprotected sex was lower in participants receiving ART than in those not receiving ART (odds ratio [OR], 0.73; 95% confidence interval [CI], .64-.83; P < .001; heterogeneity I(2) = 79%) in both high-income (n = 38) and low-/middle-income country (n = 18) settings, without any evidence of publication bias. STI diagnoses were also lower among individuals on ART (OR, 0.58; 95% CI, .33-1.01; P = .053; I(2) = 92%); however, there was no difference in injecting risk-taking behavior with antiretroviral use (OR, 0.90; 95% CI, .60-1.35; P = .6; I(2) = 0%).

CONCLUSIONS

Despite concerns that use of ART might increase sexual or injecting risk-taking, available research suggests that unprotected sex is reduced among HIV-infected individuals on treatment. The reasons for this are not yet clear, although self-selection and mutually reinforcing effects of HIV treatment and prevention messages among people on ART are likely.

Regional and national guideline recommendations for digital ano-rectal examination as a means for anal cancer screening in HIV positive men who have sex with men: a systematic review

Background

Although anal cancer is common in HIV positive men who have sex with men, few centres offer systematic screening. Regular digital ano-rectal examination (DARE) is a type of screening that has been recommended by some experts. How widely this forms part of HIV management guidelines is unclear.

Methods

The protocol was registered prospectively (CRD42013005188; http://www.crd.york.ac.uk/PROSPERO/). We systematically reviewed 121 regional and national HIV guidelines and searched for guidelines from http://hivinsite.ucsf.edu/global?page=cr-00-04#SauguidelineX, PubMed and Web of Science databases up to 5^th August 2013 for recommendations of DARE as a means of anal cancer screening in HIV positive MSM. Guidelines were examined in detail if they were clinical guidelines, including both prevention and treatment protocols and were in English. Guidelines were excluded if they were restricted to limited areas (e.g. antiretroviral therapy only, children or pregnant women, strategies for prevention/testing). Information was extracted regarding recommendation of DARE as a screening method, the frequency of DARE recommended, target population for screening and the strength of evidence supporting this.

Results

30 regional and national guidelines were included and examined in detail. Only 2 recommended DARE. The ‘European AIDS Clinical Society Guidelines’ recommends DARE every 1–3 years for HIV positive MSM whilst the ‘US Guideline for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents’ recommends an annual DARE for the HIV + population in general. None of these guidelines specify the age of commencing screening. In each case, the highest level of evidence supporting these two recommendations was expert opinion.

Conclusions

Few HIV guidelines discuss or recommend DARE as a means of anal cancer screening. Studies of the efficacy, acceptability and cost-effectiveness of DARE are needed to assess its role in anal cancer screening.

Sexual behaviors and risk for sexually transmitted infections among teenage men who have sex with men

OBJECTIVES

To report on sexual behaviors and sexually transmitted infections (STIs) among men who have sex with men (MSM) in their teens, when many MSM engage in their first sexual experiences.

METHODS

MSM aged 16 to 20 years were recruited via community and other sources. Men completed a questionnaire about their sexual behaviors and were screened for gonorrhea, chlamydia, syphilis, and HIV.

RESULTS

Two hundred men were included. The median age was 19 years. The median age at first insertive or receptive anal intercourse was 17 years. Half of men reported sex with mainly older men: these men were more likely to engage in receptive anal intercourse (48% vs. 25%, p < .001) than other men. Most men had engaged in insertive (87%) and receptive (85%) anal intercourse in the prior 12 months with 60% and 53% reporting inconsistent condom use with insertive and receptive anal intercourse partners, respectively. The median number of insertive anal intercourse partners was 3 and 1.5 (p < .001) among men reporting inconsistent and consistent condom use with insertive anal intercourse over the prior 12 months. The median number of receptive anal intercourse partners was 3 and 2 (p = .006) among men reporting inconsistent and consistent condom use with receptive anal intercourse over the prior 12 months. Pharyngeal gonorrhea, rectal gonorrhea, urethral chlamydia, rectal chlamydia, and syphilis were detected in 3.0%, 5.5%, 3.0%, 4%, and 2.0% of men, respectively. All men were HIV negative.

CONCLUSION

Many of the teenage MSM in this study were at risk for STI. Preventative messages and STI screening interventions that are age appropriate need to be developed to reduce HIV and STI risk in this under-recognized group.

High chlamydia positivity rates in Indigenous people attending Australian sexual health services

OBJECTIVE

To assess the clinical epidemiology of chlamydia among Aboriginal and Torres Strait Islander (Indigenous) people attending sexual health services around Australia.

DESIGN

Retrospective analysis of routine demographic, behavioural and clinical data, between 1 January 2006 and 31 December 2011.

SETTING

18 sexual health services in major cities and regional centres in five jurisdictions.

MAIN OUTCOME MEASURES

Attendance, chlamydia testing and positivity rates in patients visiting for the first time, and factors associated with chlamydia positivity.

RESULTS

Of 168 729 new patients, 7103 (4.2%) identified as Indigenous, of whom 74.3% were tested for chlamydia. Chlamydia positivity was 17.0% in Indigenous women (23.3% in 15-19-year-olds and 18.9% in 20-24-year-olds) and 17.3% in Indigenous men (20.2% in 15-19-year-olds and 24.2% in 20-24-year-olds). There was an increasing trend in chlamydia positivity in Indigenous women from 2006 to 2011 (P for trend = 0.001), but not in Indigenous men. In Indigenous women, factors independently associated with positivity were: younger age, being heterosexual, living in Queensland and attending the service in 2010. In Indigenous men, independent factors associated with chlamydia positivity were younger age, being heterosexual, having sex only in Australia and living in a regional area.

CONCLUSION

The high and increasing chlamydia positivity rates highlight the need for enhanced prevention and screening programs for Indigenous people.