Position statement of the German STI Society on the prophylactic use of doxycycline to prevent STIs (Doxy-PEP, Doxy-PrEP)

Over the past two decades, there has been a rise in the incidence of syphilis, particularly among men who have sex with men (MSM). This has sparked interest in studying the prophylactic use of doxycycline to prevent syphilis and other sexually transmitted infections (STIs), commonly referred to as Doxycycline Pre- or Post-Exposure Prophylaxis (Doxy-PrEP, Doxy-PEP). At the same time, demand from potential users for this preventive measure is increasing. Several randomized controlled trials have demonstrated that the prophylactic use of doxycycline in MSM and trans women using HIV pre-exposure prophylaxis (HIV-PrEP) or living with an HIV infection effectively reduces the risk of syphilis and chlamydia infections. At present, however, unresolved questions remain, particularly regarding implications of a broad implementation of prophylactic doxycycline to prevent STIs on tetracycline and other antimicrobial resistance in bacterial STIs, non-STI-related bacterial pathogens, and the microbiome. In response to the increasing demand and the challenge of balancing effectiveness, safety, and the risk of promoting antibiotic resistance, the German STI Society (DSTIG) has issued a position statement, providing specific recommendations regarding potential indications, criteria, and occasions for the use of doxycycline in STI prevention. These recommendations are based on current evidence and expert opinion.

Stellungnahme der Deutschen STI-Gesellschaft zur antibiotischen STI-Prophylaxe mit Doxycyclin (Doxy-PEP, Doxy-PrEP): Position Statement of the German STI Society on the Prophylactic Use of Doxycycline to Prevent STIs (Doxy-PEP, Doxy-PrEP)

Seit etwa zwei Jahrzehnten ist eine Zunahme der Syphilisinzidenz zu beobachten, insbesondere unter Männern, die Sex mit Männern haben (MSM). Diese Entwicklung hat zu einem wachsenden Interesse an Studien zur prophylaktischen Anwendung des Antibiotikums Doxycyclin zur Vermeidung von Syphilisinfektionen und anderen sexuell übertragbaren Infektionen (STI), international meist als Doxycyclin‐Prä‐ beziehungsweise Post‐Expositionsprophylaxe (Doxy‐PrEP, Doxy‐PEP) bezeichnet, geführt. Zugleich steigt die Nachfrage seitens potenzieller Nutzer nach dieser präventiven Maßnahme.

Mehrere randomisierte kontrollierte Studien haben gezeigt, dass die prophylaktische Anwendung von Doxycyclin bei MSM und Trans‐Frauen mit HIV‐PrEP‐Gebrauch oder bekannter HIV‐Infektion das Risiko einer Syphilis‐ und Chlamydien‐Infektion wirksam reduziert. Zum gegenwärtigen Zeitpunkt bestehen jedoch noch offene Fragen, insbesondere hinsichtlich der möglichen Auswirkungen einer breiten Anwendung der antibiotischen STI‐Prophylaxe mit Doxycyclin auf Tetrazyklin‐ und andere antimikrobielle Resistenzen bei bakteriellen STI, anderen bakteriellen Pathogenen und Bakterien des Mikrobioms.

Angesichts der steigenden Nachfrage und der Herausforderung, eine Abwägung zwischen Wirksamkeit, Sicherheit und dem Risiko der Förderung von Antibiotikaresistenzen vorzunehmen, hat die Deutsche STI‐Gesellschaft (DSTIG) die vorliegende Stellungnahme erarbeitet. Diese enthält spezifische Empfehlungen zu potenziellen Indikationen, Kriterien und Anlässen für den Einsatz von Doxycyclin zur Prävention von STI. Die Empfehlungen basieren auf aktuellen Studienergebnissen und der Meinung von Fachpersonen.

Free HIV self-test for identification and linkage to care of previously undetected HIV infection in men who have sex with men in England and Wales (SELPHI): an open-label, internet-based, randomised controlled trial

BACKGROUND

High levels of HIV testing in men who have sex with men remain key to reducing the incidence of HIV. We aimed to assess whether the offer of a single, free HIV self-testing kit led to increased HIV diagnoses with linkage to care.

METHODS

SELPHI was an internet-based, open-label, randomised controlled trial that recruited participants via sexual and social networking sites. Eligibility criteria included being a man or trans woman (although trans women are reported separately); being resident in England or Wales, UK; being aged 16 years or older; having had anal intercourse with a man; not having a positive HIV diagnosis; and being willing to provide name, email address, date of birth, and consent to link to national HIV databases. Participants were randomly allocated (3:2) by computer-generated number sequence to receive a free HIV self-test kit (BT group) or to not receive this free kit (nBT group). Online surveys collected data at baseline, 2 weeks after enrolment (BT group only), 3 months after enrolment, and at the end of the study. The primary outcome was confirmed (linked to care) new HIV diagnosis within 3 months of enrolment, analysed by intention to treat. Those assessing the primary outcome were masked to allocation. This study is registered with the ISRCTN Clinical Trials Register, number ISRCTN20312003.

FINDINGS

10 111 participants (6049 in BT group and 4062 in nBT group) enrolled between Feb 16, 2017, and March 1, 2018. The median age of participants was 33 years (IQR 26-44 years); 9000 (89%) participants were White; 8118 (80%) participants were born in the UK; 81 (1%) participants were transgender men; 4706 (47%) participants were university educated; 1537 (15%) participants had never been tested for HIV; and 389 (4%) participants were taking pre-exposure prophylaxis. At enrolment, 7282 (72%) participants reported condomless anal sex with at least one male partner in the previous 3 months. In the BT group, of the 4511 participants for whom HIV testing information was available, 4263 (95%) reported having used the free HIV self-test kit within 3 months.Within 3 months of enrolment there were 19 confirmed new HIV diagnoses (0·31%) in 6049 participants in the BT group and 15 (0·37%) of 4062 in the nBT group (p=0·64).

INTERPRETATION

The offer of a single, free HIV self-test did not lead to increased rates of new HIV diagnoses, which could reflect decreasing HIV incidence rates in the UK. Nonetheless, the offer of a free HIV self-testing kit resulted in high HIV testing rates, indicating that self-testing is an attractive testing option for a large group of men who have sex with men.

FUNDING

UK National Institute for Health and Care Research.

Kissing, fellatio, and analingus as risk factors for oropharyngeal gonorrhoea in men who have sex with men: A cross-sectional study

BACKGROUND

Our aim was to determine whether exposure to the anatomical sites (oropharynx, penis, or anus) of male partners of men who have sex with men (MSM) were independent risk factors for oropharyngeal gonorrhoea after adjusting for exposures to these sites.

METHODS

In this cross-sectional study, we invited MSM who attended the Melbourne Sexual Health Centre (MSHC) in Victoria, Australia between 26-November 2018 and 31-December 2020 to complete a survey of their sexual practices in the past three months. We collected data on the number of male partners with whom men engaged in sexual activities that exposed their oropharynx to their partners' oropharynx (kissing), penis (fellatio), and anus (rimming or analingus). Only men who were aged ≥16 years, tested for oropharyngeal gonorrhoea and did not have indeterminate or invalid results were included in the final analysis. We conducted univariable and multivariable logistic regression analyses to investigate associations between oropharyngeal gonorrhoea and the three exposures to the oropharynx.

FINDINGS

The median age of the 2,322 men who completed the survey was 31 years (IQR: 26-40), and 5·2% (n = 120) were diagnosed with oropharyngeal gonorrhoea. Our univariate analysis showed that oropharyngeal gonorrhoea was significantly associated with increasing number of kissing (p _trend<0·0001), rimming (p _trend<0·0001) and fellatio (p _trend<0·0001) partners. After adjusting for all three exposures, oropharyngeal gonorrhoea was associated with increasing number of kissing (p _{trend =}0·014) and rimming partners (p _trend = 0·037) but not fellatio (p _trend = 0·61).

INTERPRETATION

Our data suggest kissing and rimming are important practices in oropharyngeal gonorrhoea transmission in MSM Novel interventions which target the oropharynx are required for gonorrohoea prevention.

FUNDING

Australian National Health and Medical Research Council.

Systematic Development of an Intervention to Promote Self-Sampling for HIV and Sexually Transmitted Infections for Men Who Have Sex With Men: An Intervention Mapping Approach

Sexual healthcare aims to reduce HIV and sexually transmitted infections (STIs) by promoting testing and prevention. To better reach men who have sex with men (MSM), additional strategies are needed. Here, we describe development of an intervention, which is part of a broader HIV/STI home-care program, targeted to reach MSM and motivate them to use self-sampling tests. Self-sampling includes blood sampling (finger prick) for HIV, hepatitis B, and syphilis, and a urine sample and oral and anorectal swab samples for chlamydia and gonorrhea. Intervention mapping, a systematic six-step approach, was used to guide the development process: (1) needs assessment including interviews with MSM, (2) create a matrix of change, (3) selection of theory-based methods and practical strategies, (4) intervention development, (5) implementation plan, and (6) evaluation (not included in this paper). Stakeholders were involved to increase program support and feasibility. The needs assessment revealed that testing barriers among MSM related to stigma, time, and privacy concerns. Barriers among healthcare providers related to time, competing priorities, lack of expertise, and guideline restrictions. Included intervention components are designed to overcome these barriers, e.g., engaging role models, with a website with a role model story, and providing tailored information. Methods to reach MSM were a variety of information channels (posters, flyers, and audio-visual displays) and delivery modes, such as advertisements on websites and invitational cards (online and paper) distributed by healthcare providers and MSM themselves (social network testing/peer testing). Our intervention aims to encourage MSM to engage in testing, re-testing, and providing a test to peer MSM. Evidence-based methods to overcome barriers were included to reach and motivate an increased number of MSM. Using intervention mapping stimulated systematic evidence-based decision making and adapting the intervention to the target audience and setting. The next step (step 6) is to implement and evaluate the intervention.

Increased targeted HIV testing and reduced undiagnosed HIV infections among gay and bisexual men

OBJECTIVES

To evaluate the impact of government HIV strategies that aimed to increase HIV testing uptake and frequency among gay and bisexual men (GBM) in New South Wales (NSW), Australia.

DESIGN

We analysed HIV testing data from existing passive and sentinel surveillance systems between 2010 and 2018.

METHODS

Six indicators were measured: (1) state-wide total HIV laboratory tests; (2) number of GBM attending publicly-funded clinics; (3) 12-monthly testing uptake; (4) annual testing frequency; (5) HIV testing with a STI diagnosis; and (6) HIV positivity. Mathematical modelling was used to estimate (7) the proportion of men with undiagnosed HIV. Indicators were stratified by Australian vs. overseas-born.

RESULTS

Overall, 43,560 GBM attended participating clinics (22,662 Australian-born, 20,834 overseas-born) from 2010-2018. Attendees increased from 5,186 in 2010 to 16,507 in 2018. There were increasing trends (p<0.001 for all) in testing uptake (83.9% to 95.1%); testing with a STI diagnosis (68.7% to 94.0%); annual HIV testing frequency (1.4 to 2.7); and a decreasing trend (p<0.01) in HIV positivity (1.7% to 0.9%).Increases in testing were similar in Australian-born and overseas-born GBM. However, there were decreasing trends in the estimated undiagnosed HIV proportion overall (9.5% to 7.7%) and in Australian-born GBM (7.1% to 2.8%), but an increasing trend in overseas-born GBM (15.3% to 16.9%) (p<0.001 for all).

Sustained, Low Prevalence of Undiagnosed HIV Among Gay and Bisexual Men in Sydney, Australia Coincident With Increased Testing and Pre-exposure Prophylaxis Use: Results From Repeated, Bio-Behavioral Studies 2014-2018

BACKGROUND

Gay and bisexual men with undiagnosed HIV contribute disproportionately to HIV transmission in Australia.

METHODS

In 2014 and 2018, we recruited men at gay venues and events in Sydney. Participants self-completed surveys and provided oral fluid samples for HIV testing. We calculated the prevalence of HIV and undiagnosed infection, and assessed changes in behavior, HIV testing, and the use of pre-exposure prophylaxis. We weighted the samples to adjust for differences in where participants were recruited between rounds. Two-sample tests of proportion were used to compare prevalence estimates and χ tests to assess differences between the samples.

RESULTS

In 2014, 944 men were recruited, and 890 men were recruited in 2018. In 2014, the weighted estimate of HIV prevalence was 6.1% [95% confidence intervals (CI): 4.6 to 7.6], of which 13.8% (95% CI: 5.0 to 22.7) was undiagnosed. In 2018, weighted HIV prevalence was 6.4% (95% CI: 4.8 to 8.0), of which 5.3% (95% CI: 0.5 to 11.1) was undiagnosed. Between 2014 and 2018 among all participants, men reporting at least 10 recent casual partners increased from 22.3% to 27.7% (P = 0.008), condomless anal intercourse with casual partners in the previous 6 months increased from 23.9% to 37.3% (P < 0.001), and sexually transmitted infection diagnoses in the previous year increased from 14.4% to 27.5% (P < 0.001). HIV testing and the use of pre-exposure prophylaxis in the previous 6 months increased from 49.6% to 56.3% (P = 0.004) and 2.0%-21.0% (P < 0.001), respectively.

CONCLUSIONS

Repeated, bio-behavioral surveillance suggests the prevalence of undiagnosed HIV remains low in Sydney, despite gay and bisexual men reporting more casual sex partners, condomless sex, and sexually transmitted infections.

Cross-sectional study of sexual behaviour and health of gay and bisexual men in suburban Sydney, New South Wales, Australia: contrasts between sex venue and clinic attendees

Background In Australia, men-who-have-sex-with-men (MSM) have higher rates of sexually transmissible infections (STIs) and HIV compared with heterosexual men. We compared demographics, behaviour and HIV/STI prevalence for MSM attending a sex-on-premises-venue (SOPV) or the local sexual health clinic (SHC) to determine key differences.

METHODS

Men attending a SOPV during onsite HIV/STI screening from November 2015 for 12 months were compared with MSM attending a local SHC for screening. Each group completed a self-administered questionnaire and STI/HIV testing. Data analysis was performed using SPSS.

RESULTS

Compared with SHC participants (n = 108), SOPV participants (n = 84) had a higher median age (47 years [range, 22-88] vs 33 years [range, 19-71]; P < 0.001) and less likely to report previous HIV testing (73% vs 89%; P < 0.01), STI testing (60% vs 90%; P < 0.001) or be vaccinated for hepatitis A (32% vs 65%; P < 0.001) or hepatitis B (35% vs 73%; P < 0.001). SOPV participants were more likely to be married, widowed or have a long-term female partner (39% vs 7%; P < 0.001) and have a higher prevalence of urethral and rectal chlamydia (7% vs 1%; P = 0.02 and 8% vs 2%; P = 0.03, respectively). There was no significant difference between the groups for detection of syphilis (4% vs 9%), gonorrhoea (5% vs 9%) or HIV (1% vs 0%).

CONCLUSION

MSM attending the SOPV had higher anogenital chlamydial prevalence compared with those attending the SHC. They reported higher rates of sex with female partners, which may facilitate STI/HIV transmission to heterosexual populations. Our findings have implications for HIV/STI service provision, contact tracing and local health promotion initiatives.

Trends and differences in sexual practices and sexually transmitted infections in men who have sex with men only (MSMO) and men who have sex with men and women (MSMW): a repeated cross-sectional study in Melbourne, Australia

OBJECTIVES

In the 2010s, there has been an increase in sexually transmitted infections (STI) in men who have sex with men (MSM) in Australia, and since 2015 also in urban heterosexuals. Men who have sex with both men and women (MSMW) have characteristics that may differ from both men who have sex with men only (MSMO) and heterosexual men. We aimed to compare the sexual practices and the trends in HIV/STI positivity between MSMO and MSMW.

DESIGN

Repeated cross-sectional study.

SETTING

A sexual health centre in Melbourne, Australia.

PARTICIPANTS

MSM aged 18 years and above who attended the Melbourne Sexual Health Centre for the first time between 2011 and 2018. This includes 12 795 MSMO and 1979 MSMW.

PRIMARY OUTCOME MEASURES

Demographic characterics, sexual practices and HIV/STI positivity.

RESULTS

Compared with MSMW, MSMO were more likely to practice anal sex and to have condomless receptive anal sex with casual male partners, and less likely to have a current regular relationship. Over the 8-year period, there was an increase in condomless receptive anal sex with casual male partners for both groups (MSMO: from 46.2% to 63.3%, ptrend <0.001; MSMW: from 41.3% to 57.9%, ptrend=0.011). Syphilis positivity increased in MSMO (from 5.5% to 7.9%, ptrend=0.012) and MSMW (from 0.9% to 6.4%, ptrend=0.004) and HIV remained stable. Gonorrhoea increased among MSMO from 2011 to 2014 (from 6.7% to 9.6%, ptrend=0.002), and remained stable from 2015 to 2018. MSMO had higher odds of testing positive for gonorrhoea (adjusted OR (aOR) 1.36, 95% CI 1.13 to 1.64), chlamydia (aOR 1.39, 95% CI 1.16 to 1.67), syphilis (aOR 1.74, 95% CI 1.37 to 2.22) and HIV (aOR 4.60, 95% CI 2.43 to 8.70) than MSMW.

CONCLUSIONS

MSMW have overall lower condomless sex and lower HIV/STI positivity. In the last years, changes in sexual practices in MSM have affected both MSMW and MSMO leading to an increased STI risk.

Gonorrhoea gone wild: rising incidence of gonorrhoea and associated risk factors among gay and bisexual men attending Australian sexual health clinics

Background Gonorrhoea notifications continue to rise among gay and bisexual men in Australia and around the world. More information is needed on infection trends, accounting for testing and complimented by demographics and risk practices.

METHODS

A retrospective cohort analysis was undertaken using repeat gonorrhoea testing data among gay and bisexual men from 2010 to 2017, which was extracted from a network of 47 sexual health clinics across Australia. Poisson and Cox regression analyses were used to determine temporal trends in gonorrhoea incidence rates, as well as associated demographic and behavioural factors.

RESULTS

The present analysis included 46904 gay and bisexual men. Gonorrhoea incidence at any anatomical site increased from 14.1/100 person years (PY) in 2010 to 24.6/100 PY in 2017 (P<0.001), with the greatest increase in infections of the pharynx (5.6-15.9/100 PY, P<0.001) and rectum (6.6-14.8/100 PY, P<0.001). After adjusting for symptomatic and contact-driven presentations, the strongest predictors of infection were having more than 20 sexual partners in a year (hazard ratio (HR)=1.9, 95% confidence interval (CI): 1.7-2.2), using injecting drugs (HR=1.7, 95%CI: 1.4-2.0), being HIV positive (HR=1.4, 95%CI: 1.2-1.6) and being aged less than 30 years old (HR=1.4, 95%CI: 1.2-1.6).

CONCLUSIONS

Gonorrhoea has increased dramatically among gay and bisexual men in Australia. Enhanced prevention efforts, as well as more detailed, network-driven research are required to combat gonorrhoea among young men, those with HIV and those who use injecting drugs.

Providing competent, comprehensive and inclusive sexual health services for men who have sex with men in low- and middle-income countries: a scoping review

Although men who have sex with men (MSM) are disproportionately affected by HIV and other sexually transmissible infections, sexual health services for MSM in low- and middle-income countries (LMIC) remain under-resourced and are poorly understood. A scoping review of literature on MSM sexual health in LMIC was conducted in order to identify key clinical services and gaps in knowledge. Three databases were searched, in addition to hand-reviewing key journals and bulletins, to identify literature with a focus on MSM sexual health. Key services related to providing care to MSM in LMIC that emerged from our review are described. These services include creation of safe and confidential clinic environments, HIV testing services, behavioural interventions, HIV pre-exposure prophylaxis (PrEP), rapid antiretroviral therapy (ART) initiation and STI services. Compared with high-income settings, major differences in LMIC include lack of diagnostic technology, unfavourable legal environments and lack of funding for MSM health. Innovative approaches to healthcare delivery, such as harnessing mobile technology, self-testing and crowdsourcing interventions, can improve health services among MSM in LMIC. There are gaps in the evidence about how best to provide sexual health services for MSM in LMIC settings. Implementation research and scale-up of existing biomedical and behavioural interventions, such as HIV/STI testing services, PrEP and early antiretroviral initiation are urgently needed in LMIC.

Increases in HIV Testing Frequency in Australian Gay and Bisexual Men are Concentrated Among PrEP Users: An Analysis of Australian Behavioural Surveillance Data, 2013-2018

Increasing HIV testing frequency in gay and bisexual men (GBM) is critical to reducing the time between HIV infection and diagnosis. Using anonymous national behavioural surveillance data (2013-2018) from 43,753 surveys of Australian GBM, we examined HIV testing frequency trends and factors differentiating PrEP-users, non-PrEP-users reporting two or more tests in the previous year, and non-PrEP-users reporting less frequent testing. The proportion tested at least annually increased from 64.4% in 2013 to 70.8% in 2018 (p-trend < 0.001), and from 73.9% to 84.6% among the 51.6% of men classified as higher-risk. Among higher-risk men, having two or more tests in the previous year increased from 48.0% to 69.3% (p-trend < 0.001). Among higher-risk non-PrEP-users, it increased from 47.2% to 54.8% (p-trend < 0.001), however, there was a decrease since 2016 (p-trend < 0.001). Among PrEP-users, it increased from 82.1% in 2013 to 97.3% in 2018 (p-trend < 0.001). Non-PrEP-using higher-risk men having less frequent tests reported lower risk than PrEP-users and non-PrEP-using men reporting two or more tests in the previous year. However, recent risk behaviour was not uncommon: nearly half reported condomless sex; one-fifth reported receptive condomless sex with ejaculation; over half reported group sex; one-quarter used drugs for the purposes of sex; and one-fifth had more than ten sex partners. Efforts are needed to encourage frequent testing and PrEP use among non-PrEP-users who are at higher-risk.

Prevalence of Mycoplasma genitalium by anatomical site in men who have sex with men: a systematic review and meta-analysis

OBJECTIVE

To systematically review and appraise published data, to determine the prevalence of Mycoplasma genitalium (MG) in men who have sex with men (MSM) tested at each anatomical site, that is, at the urethra, rectum and/or pharynx.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Ovid Medline, PubMed, Embase were searched for articles from 1st January 1981 (the year MG was first identified) to 1st June 2018.

REVIEW METHODS

Studies were eligible for inclusion if they reported MG prevalence in MSM tested at the urethra, rectum and/or pharynx, in at least 50 MSM, using nucleic acid amplification testing. Data were extracted by anatomical site, symptom and HIV status. Summary estimates (95% CIs) were calculated using random-effects meta-analysis. Subgroup analyses were performed to assess heterogeneity between studies.

RESULTS

Forty-six studies met inclusion criteria, with 34 reporting estimates of MG prevalence at the urethra (13 753 samples), 25 at the rectum (8629 samples) and 7 at the pharynx (1871 samples). MG prevalence was 5.0% (95% CI 3.5 to 6.8; I²=94.0) at the urethra; 6.2% (95% CI 4.6 to 8.1; I²=88.1) at the rectum and 1.0% (95% CI 0.0 to 5.1; I²=96.0) at the pharynx. The prevalence of MG was significantly higher at urethral and rectal sites in symptomatic versus asymptomatic MSM (7.1% vs 2.2%, p<0.001; and 16.1% vs 7.5%, p=0.039, respectively). MG prevalence at the urethra was significantly higher in HIV-positive compared with HIV-negative MSM (7.0% vs 3.4%, p=0.006).

CONCLUSION

MG was common in MSM, particularly at urethral and rectal sites (5% to 6%). MG was more commonly detected in symptomatic men at both sites, and more common in HIV-positive men at the urethra. MG was uncommonly detected in the pharynx. Site-specific estimates are similar to those for chlamydia and will be helpful in informing testing practices in MSM.

PROSPERO REGISTRATION NUMBER

CRD42017058326.

The resurgence of syphilis in high-income countries in the 2000s: a focus on Europe

Syphilis can cause severe complications and sequelae. Following a decrease in reported cases in European Union/European Economic Area (EU/EEA) and other high-income countries in the 1980s and 1990s as a result of the HIV epidemic and ensuing changes in sexual behaviour, trends started to increase in the 2000s in a number of EU/EEA Member States with higher rates among men and a large proportion of cases reported among men who have sex with men (MSM), particularly HIV-positive MSM. Trends in EU/EEA Member States vary however with some countries continuing to report decreases in the number of reported cases (mostly in the Eastern part of EU/EEA) whereas many Western European countries report increasing numbers of cases. Increasing rates among women, although still relatively low, have been observed in a number of countries leading to concerns around mother-to-child transmission of syphilis and congenital syphilis. Similar overall trends are observed in other high-income countries with the exception of Japan where rates among heterosexual men and women have been rising at alarming levels. Control of syphilis requires use of comprehensive, evidence-based strategies which take into account lessons learned from previous control efforts as well as consideration of biomedical interventions.

Facilitators and Barriers Associated with Uptake of HIV Self-Testing among Men Who Have Sex with Men in Chongqing, China: A Cross-Sectional Survey

While studies on human immunodeficiency virus self-testing (HIVST) continue to accumulate after the World Health Organization’s recommendation of HIVST as an additional approach to HIV testing services in 2016, few studies have focused on men who have sex with men (MSM) in Chinese cities. A cross-sectional study was conducted to describe the HIVST status of MSM in Chongqing, China. MSM participants were recruited by random sampling, and qualified interviewers collected data, using confidential self-administered questionnaires. Blood specimens were collected for HIV antibody detection. The survey evaluated the uptake and accuracy of HIVST kits and identified factors that may be associated with HIVST. The proportion of HIVST uptake was 15.6%. The sensitivity and specificity of HIVST were 74.2% (95% confidence interval [CI] 66.6%–80.7%) and 99.0% (95% CI 96.9%–99.7%), respectively. The consistency between the HIVST kit and antibody detection results was 90.5% (95% CI 87.5%–93.0%), and the Kappa value was 0.777 (p < 0.001). The positive predictive value of self-testing kits is 80.9% and the negative predictive value is 17.7%. Having been tested ≥2 times in the last year, higher educational levels, and higher scores of basic HIV/AIDS knowledge facilitated higher uptake of HIVST. Self-reported existing barriers for HIVST uptake included older age, marital status, and having resided in Chongqing for more than two years.

Which Gay and Bisexual Men Attend Community-Based HIV Testing Services in Australia? An Analysis of Cross-Sectional National Behavioural Surveillance Data

In Australia, HIV testing services have become increasingly available in non-traditional settings such as peer-led, community-based services to expand access and increase uptake of HIV testing among gay and bisexual men (GBM). This study aimed to compare the socio-demographic and behavioural characteristics of GBM whose last HIV test was conducted at a community-based service to GBM whose last test was at a traditional clinical setting. We analysed behavioural surveillance data collected from 5988 participants in seven states and territories in the period 2016-2017. We found that non-HIV-positive GBM who attended community-based services were largely similar to men attending clinic-based settings, particularly in terms of sexual practice and risk of HIV. However, non-HIV-positive GBM who were younger, born in Asia, more socially engaged with other gay men but who had not recently used PrEP were more likely to attend community-based services for their last HIV test. This study points to the successful establishment of community-based HIV testing services in Australia as a way to attract subgroups of GBM at potentially higher risk of HIV.

Prevalence of rectal Mycoplasma genitalium and macrolide resistance in men who have sex with men attending Sydney Sexual Health Centre

Background Sexually transmissible infections (STIs) have been increasing in men who have sex with men (MSM) in recent years; however, few studies have investigated the prevalence or antimicrobial resistance in rectal Mycoplasma genitalium in this group. This study aimed to determine the prevalence and predictors of rectal M. genitalium in MSM attending an urban sexual health service in Sydney, Australia, namely the Sydney Sexual Health Centre (SSHC), as well as estimate the rate of macrolide resistance.

METHODS

A prospective cross-sectional analysis was conducted of rectally asymptomatic MSM having a rectal swab collected as part of their routine care. Participants self-collected a rectal swab to be tested for M. genitalium and completed a 14-item questionnaire that provided information on behavioural risk factors. The prevalence of rectal M. genitalium was determined and multivariate analysis was performed to assess the associations for this infection. Positive specimens then underwent testing for macrolide-resistant mutations (MRMs) using the ResistancePlus MG assay (SpeeDx, Eveleigh, NSW, Australia).

RESULTS

In all, 742 patients were consecutively enrolled in the study. The median age was 31 years (interquartile range 27-39 years), with 43.0% born in Australia. Overall, 19.0% of men were bisexual, 22.9% were taking pre-exposure prophylaxis (PrEP) and 4.3% were HIV positive. The prevalence of rectal M. genitalium was 7.0% (95% confidence interval (CI) 5.3-9.1) overall and 11.8% in those taking PrEP. On multivariate analysis, PrEP use was significantly associated with having rectal M. genitalium (odds ratio 2.01; 95% CI 1.09-3.73; P = 0.01). MRMs were detected in 75.0% (36/48; 95% CI 60.4-86.4%) of infections.

CONCLUSION

Rates of rectal M. genitalium infection were high among asymptomatic MSM attending SSHC and MRMs were detected in 75% of infections. PrEP use was found to be significantly associated with rectal M. genitalium infection. These data contribute to the evidence base for screening guidelines in MSM.

Prevalence of sexually transmissible infections and HIV in men attending sex-on-premises venues in Australia: a systematic review and meta-analysis of observational studies

Background In Australia, men who have sex with men (MSM) have high rates sexually transmissible infections (STIs) and sex-on-premises venue (SOPV) patrons are at risk. This paper assesses Neisseria gonorrhoeae (NG), Chlamydia trachomatis (CT), syphilis and HIV prevalence in men tested at Australian SOPVs and describes testing services.

METHODS

EMBASE, Medline, PubMed and international conference proceedings were searched for articles reporting on-site SOPV testing between 1 January 2000 and 31 January 2017. Meta-analysis calculated pooled prevalence estimates of STIs by anatomical site.

RESULTS

Twelve cross-sectional studies were identified. Most (8/12) were local sexual health clinics (SHC) outreach services. Participants' mean age was 41.1 years (95% confidence interval (CI) 37.0-43.3; range 17 to 84 years). Testing included CT and NG (9/12), HIV (8/12) and syphilis (5/12). CT and NG prevalence overall summary estimates were 3.4% (95% CI 1.9-5.2%, I2 = 88.7%, P < 0.01) and 1.3% (95% CI 0.7-2.2%, I2 = 75.5%, P < 0.01) respectively. CT and NG prevalence was highest in the ano-rectum and oro-pharynx respectively. The HIV and syphilis pooled estimates were 2.3% (95% CI 1.6-2.9%, I2 = 93.1%, P < 0.01) and 3.2% (95% CI 1.8-4.6%, I2 = 72.8%, P < 0.01) respectively. Participation rate varied.

CONCLUSION

This review examines HIV and STI testing in Australian SOPVs before HIV pre-exposure prophylaxis (PrEP). Findings indicate a high prevalence of STIs. PrEP use and resultant condomless sex may influence STI prevalence. Further research is required to determine the effect of PrEP on the STI prevalence among SOPV patrons.

Epidemiology of lymphogranuloma venereum in New South Wales, 2006-2015

Aim

To describe the epidemiology of lymphogranuloma venereum (LGV) in New South Wales (NSW) from 2006 to 2015.

Methods

LGV notification data between 2006 and 2015 from New South Wales were analysed to describe time trends in counts and rates by gender, age group and area of residence, as well as anatomical sites of infection. A positivity ratio was calculated using the number of LGV notifications per 100 anorectal chlamydia notifications per year. Data linkage was used to ascertain the proportion of LGV cases that were co-infected with HIV.

Results

There were 208 notifications of LGV in NSW from 2006 to 2015; all were among men, with a median age of 42 years, and half were residents of inner-city Sydney. Annual notifications peaked at 57 (1.6 per 100,000 males) in 2010, declined to 16 (0.4 per 100,000 males) in 2014, and then increased to 34 (0.9 per 100,000 males) in 2015. Just under half (47.4%) of LGV cases were determined to be co-infected with HIV.

Conclusion

The number of LGV notifications each year has not returned to the low levels seen prior to the peak in 2010. Continued public health surveillance is important for the management and control of LGV.

Factors associated with declining to report the number of sexual partners using computer-assisted self-interviewing: a cross-sectional study among individuals attending a sexual health centre in Melbourne, Australia

Background The number of sexual partners is one of the most important risk factors for sexually transmissible infections (STIs), including HIV. The aim of the present study was to examine the association between declining to report the number of partners using computer-assisted self-interviewing (CASI) and HIV or STI positivity at a public sexual health centre in Melbourne, Australia, in 2016.

METHODS

Individuals were categorised into three risk populations: women, men who have sex with women only (MSW) and men who have sex with men (MSM). Logistic regression analysis was used to examine the association between declining to report the number of sexual partners in the past 12 months and HIV or STI positivity for women and MSW, with generalised estimating equations (GEE) used for estimation in MSM to address repeated-measures within individuals.

RESULTS

In all, 18085 individuals (5579 women, 6013 MSW, 6493 MSM) were included in the final analysis. There was no association between chlamydia positivity and declining to respond among women and MSW. MSM who declined to respond were more likely to be chlamydia positive (adjusted odds ratio1.21; 95% confidence interval (CI) 1.01-1.43). Known HIV-positive MSM and MSM newly diagnosed with HIV had 3.31-fold (95% CI 2.48-4.42) and 2.82-fold (95% CI 1.84-4.32) greater odds respectively of declining to respond compared with HIV-negative MSM. Gonorrhoea and syphilis positivity in MSM were not associated with declining to respond.

CONCLUSIONS

There was no association between declining to report the number of partners and chlamydia positivity among women and MSW. However, MSM who declined to report the number of partners were slightly more likely to have chlamydia and substantially more likely to be HIV positive.

Only recent sexual partners contribute to oropharyngeal gonorrhoea positivity: the number of sexual partners over different time periods as an indicator of gonorrhoea and chlamydia infection duration among men who have sex with men

Background Mathematical models have demonstrated that the majority of gonococcal transmission is from oropharynx to oropharynx (i.e. kissing) among men who have sex with men (MSM). The aim of this study is to investigate the association between the number of partners within specific time periods and gonorrhoea and chlamydia positivity.

METHODS

This was a retrospective data analysis of MSM attending the Melbourne Sexual Health Centre between 2007 and 2016. Univariable and multivariable logistic regression analyses, with generalised estimating equations (GEE), were performed to determine if the number of partners within specified time periods was associated with site-specific gonorrhoea and chlamydia positivity.

RESULTS

There were 45933 consultations which included 15197 MSM. Oropharyngeal gonorrhoea positivity was associated with the number of partners in the past 3 months, but not the number of partners 4-12 months ago; men who had ≥6 partners in the past 3 months had significantly higher odds of acquiring oropharyngeal gonorrhoea (aOR 1.93; 95% CI 1.61-2.31), but this was not the case for men who had ≥6 partners 4-12 months ago. Anorectal gonorrhoea and chlamydia and urethral chlamydia were associated with the number of partners in both time periods after adjusting for age and condom use.

CONCLUSIONS

The association of oropharyngeal gonorrhoea with the number of recent partners, but not partners from an earlier period, unlike anorectal gonorrhoea and anorectal and urethral chlamydia, could be explained by a shorter duration of oropharyngeal gonococcal infection. Annual screening for gonorrhoea may be insufficient to materially reduce oropharyngeal prevalence.

High Rates of Subsequent Asymptomatic Sexually Transmitted Infections and Risky Sexual Behavior in Patients Initially Presenting With Primary Human Immunodeficiency Virus-1 Infection

Background

Knowledge of the risk factors of individuals with an asymptomatic sexually transmitted infection (STI) is essential for implementation of targeted STI screening strategies.

Methods

Between June 2015 and January 2017, an STI screening was offered to all participants in the Zurich Primary human immunodeficiency virus (HIV)-1 Infection study. Patients were tested for gonorrhea, chlamydia, syphilis, and hepatitis C virus (HCV).

Results

Of 214 participants, 174 (81%) were screened at least once. Most patients were men who have sex with men (MSM) (87.4%). Presenting with a primary HIV infection was associated with higher odds for later risky sexual behavior, as compared with presenting in the chronic phase (odds ratio [OR], 5.58; 95% confidence interval [CI], 3.68-8.8). In total, 79 STIs were detected, reflecting a high period prevalence of 33.3% (58 of 174 patients). Sixty-six percent of patients (52 of 79) were asymptomatic. Most common STIs were chlamydia (50.6%; 40 of 79 patients), gonorrhea (25.3%; 20 of 79), and syphilis (19%; 15 of 79). In a multivariable model, engaging in insertive (OR, 6.48; 95% CI, 1.14-36.76) or both insertive and receptive (4.61; 1.01-20.96) anal intercourse, STI symptoms (3.4; 1.68-6.89), and condomless sex (2.06; 1.14-3.74) were positively correlated with a positive screening result. The hazard of an incident STI increased with the presence of STI symptoms (hazard ratio, 3.03; 95% CI, 1.17-7.84) and any recent drug use (2.63; 1-6.9).

Conclusions

A trimonthly STI screening including asymptomatic individuals should be considered in this population, particularly in MSM who report sexual risk behavior.

Clinical Trial Registration

NCT 00537966.

Increases in pharyngeal Neisseria gonorrhoeae positivity in men who have sex with men, 2011-2015: observational study

OBJECTIVES

Pharyngeal gonorrhoea disproportionately affects men who have sex with men (MSM). We explored temporal trends in pharyngeal gonorrhoea positivity among MSM compared with anorectal and urogenital positivity.

METHODS

Data (2011-2015) were extracted from 41 publicly funded sexual health clinics participating in a national surveillance network. Positivity was defined as the proportion of first-visit testing occasions where gonorrhoea was detected. Logistic regression explored trends in positivity and correlates of positive pharyngeal tests.

RESULTS

From 2011 to 2015, 24 792 MSM tested (16 710 pharyngeal, 19 810 urogenital and 15 974 anorectal first-visit tests). Pharyngeal positivity increased by 183% from 139/3509 (4.0%) in 2011 to 397/3509 (11.3%) in 2015, p-trend <0.001; urogenital positivity by 39% from 257/4615 (5.6%) to 295/3783 (7.8%), p-trend=0.006; and anorectal positivity by 87% from 160/3469 (4.6%) to 286/3334 (8.6%), p-trend <0.001. The annual temporal increase in positivity was greater in the pharynx (OR 1.33; 95% CI 1.27 to 1.38) than at urogenital (OR 1.06; 95% CI 1.02 to 1.10) and anorectal (OR 1.16; 95% CI 1.11 to 1.21) sites. Factors independently associated with pharyngeal gonorrhoea were: younger age (p<0.001), higher numbers of recent sexual partners (p-trend=0.004), contact with a person with a diagnosed STI (p<0.001), injecting drug use (p<0.001), anogenital symptoms (p<0.001) and HIV-positive status (p=0.050).

CONCLUSION

Temporal increases in gonorrhoea positivity occurred at all anatomical sites, with the greatest increase in the pharynx. Risk factors could be used to help to develop testing and prevention strategies among MSM at highest risk. Strengthening sexual health service delivery, testing and surveillance remain priorities for pharyngeal gonorrhoea control.

Is Screening for Chlamydia and Gonorrhea in Men Who Have Sex With Men Associated With Reduction of the Prevalence of these Infections? A Systematic Review of Observational Studies

BACKGROUND

Neisseria gonorrhoeae (gonorrhea) could become untreatable in the near future. Indeed, while the treatment of symptomatic gonorrhea in core groups, such men who have sex with men (MSM), is crucial for gonorrhea control programs, screening for and treating asymptomatic gonorrhea/Chlamydia trachomatis(chlamydia) in MSM may contribute to antibiotic resistance in gonorrhea. In this systematic review, we aim to assess if there is evidence that screening MSM for gonorrhea/chlamydia is associated with a decline in the prevalence of these infections.

METHODS

We conducted a systematic review in PubMed and Web of Science for relevant studies including uncontrolled observational studies and reported the results following the PRISMA guidelines. The change in estimated prevalences for chlamydia and gonorrhea across the different time points for 3 anatomical sites (oral, urethral and anal) were collected and examined.

RESULTS

Twelve studies met our entry criteria. We were able to statistically assess the change in prevalence in 10 of 12 studies. In 3 studies, there was a significant increase in chlamydia prevalence, whereas for gonorrhea, 2 studies reported a significant increase and 2 others a decrease. Our review provides little evidence that screening for gonorrhea and chlamydia in MSM has an effect on the prevalence of these infections. No evidence was found that more frequent screening reduces prevalence more effectively than annual screening.

CONCLUSIONS

Our study was not able to provide evidence that screening for chlamydia and gonorrhea lowers the prevalence of these infections in MSM. Randomized controlled trials are required to assess the risks and benefits of gonorrhea/chlamydia screening in high- and low-risk MSM.

As through a glass, darkly: the future of sexually transmissible infections among gay, bisexual and other men who have sex with men

The trajectory of sexually transmissible infection (STI) incidence among gay and other men who have sex with men (MSM) suggests that incidence will likely remain high in the near future. STIs were hyperendemic globally among MSM in the decades preceding the HIV epidemic. Significant changes among MSM as a response to the HIV epidemic, caused STI incidence to decline, reaching historical nadirs in the mid-1990s. With the advent of antiretroviral treatment (ART), HIV-related mortality and morbidity declined significantly in that decade. Concurrently, STI incidence resurged among MSM and increased in scope and geographic magnitude. By 2000, bacterial STIs were universally resurgent among MSM, reaching or exceeding pre-HIV levels. While the evidence base necessary for assessing the burden STIs among MSM, both across time and across regions, continues to be lacking, recent progress has been made in this respect. Current epidemiology indicates a continuing and increasing trajectory of STI incidence among MSM. Yet increased reported case incidence of gonorrhoea is likely confounded by additional screening and identification of an existing burden of infection. Conversely, more MSM may be diagnosed and treated in the context of HIV care or as part of routine management of pre-exposure prophylaxis (PrEP), potentially reducing transmission. Optimistically, uptake of human papillomavirus (HPV) vaccination may lead to a near-elimination of genital warts and reductions in HPV-related cancers. Moreover, structural changes are occurring with respect to sexual minorities in social and civic life that may offer new opportunities, as well as exacerbate existing challenges, for STI prevention among MSM.

Sexually transmissible infection control programs for men who have sex with men - what will they look like in 2020?

The resurgence of sexually transmissible infections among men who have sex with men is a concern for sexual health. Traditional strategies have relied on the promotion of condom use, regular testing, treatment, and partner management. Future sexually transmissible infection control programs must combine current prevention methods with novel approaches that target the providers, patients, and mechanisms of health care delivery.

Trends and predictors of recent HIV testing over 22 years among a clinic sample of men who have sex with men in South Australia

Increasing the frequency of HIV testing is crucial for effective HIV prevention and care. The aim of the present study was to determine whether there has been a change in HIV testing among men who have sex with men (MSM) at the South Australia Specialist Sexual Health (SASSH) clinic over the past two decades.

METHODS

Computerised medical records of MSM who attended the SASSH at their first visit between 1994 and 2015 were used to determine whether HIV testing had changed among MSM. First HIV tests in each calendar year and return tests within 12 months were analysed. Factors associated with recent HIV testing were also examined.

RESULTS

There were 24036 HIV tests conducted among 8163 individual MSM over the study period. The proportion of newly registered MSM who reported ever being tested for HIV declined (P_trend=0.030), the proportion who reported recent HIV testing did not change (P_trend=0.955) and the proportion who have had current HIV testing increased (P_trend=0.008). The proportion of MSM who returned to the clinic for HIV testing within 12 months did not change (P_trend >0.05), with less than 40% of MSM returning for HIV testing. Factors independently associated with recent HIV testing included MSM aged ≥20 years, (odds ratio (OR) 1.79; 95% confidence interval (CI) 1.53-2.10), higher education (OR 1.28; 95% CI 1.12-1.45), non-Caucasian (African OR 1.68; 95% CI 1.30-2.17), having multiple sex partners (OR 1.47; 95% CI 1.29-1.69), having had sex interstate (OR 1.61; 95% CI 1.42-1.82) or overseas (OR 1.53; 95% CI 1.33-1.76) and injecting drug use (OR 1.56; 95% CI 1.29-1.88).

CONCLUSIONS

HIV testing rate among MSM attending SASSH was suboptimal. New approaches are needed to increase the uptake and early detection of HIV infection among the high-priority MSM population.

HIV testing self-efficacy is associated with higher HIV testing frequency and perceived likelihood to self-test among gay and bisexual men

Background Regular testing of individuals at higher-risk of HIV is central to current prevention strategies. The aim of the present study was to examine the extent to which confidence in one's perceived ability to undertake various aspects of HIV testing and self-testing (self-efficacy) affected HIV testing outcomes. We assessed factors, including self-efficacy, associated with HIV testing frequency and the likelihood to self-test among gay and bisexual men (GBM).

METHODS

Participants were HIV-negative GBM at an increased risk of HIV (more than five partners or condomless anal intercourse in the previous 3 months) enrolled in a randomised controlled trial of HIV self-testing. The baseline questionnaire captured data regarding sociodemographic characteristics, HIV and/or sexually transmissible infection testing history, sexual behaviour, beliefs and attitudes towards HIV and eight items capturing confidence in HIV testing ability that were combined as a single broad measure of HIV testing self-efficacy (α=0.81). Factors associated with three or more HIV tests in the past year and the likelihood of self-testing in the future were determined using logistic regression.

RESULTS

Of 354 GBM, 34% reported three or more HIV tests in the past year, and 64% reported being 'very likely' to self-test. Factors independently associated with three or more HIV tests in the past year were: higher self-efficacy (adjusted odds ratio (aOR) 1.08 per unit increase; 95% confidence interval (CI) 1.02-1.14; P=0.004); >10 male partners in the past 6 months (aOR 1.79; 95% CI 1.05-3.04; P=0.031) and higher optimism regarding the effects of HIV treatments on HIV transmission (aOR 1.14; 95% CI 1.00-1.29; P=0.044). Only higher self-efficacy was independently associated with reporting a greater likelihood to self-test in the future (aOR 1.10; 95% CI 1.05-1.15; P < 0.001).

CONCLUSIONS

Improving self-efficacy by enhancing GBM's knowledge and experience may lead to higher testing frequency. The self-efficacy measure used in the present study could be useful in identifying GBM likely to face difficulties with HIV testing and self-testing.

Anal Ureaplasma spp. positivity among HIV positive men who have sex with men may be associated with high-risk-type HPV infections

OBJECTIVE

HIV positive individuals, particularly men having sex with men (MSM), are at increased risk of sexually transmitted infections (STIs) at genital and extra-genital sites. Data on anorectal Ureaplasma infections are lacking. The aim of our study was to characterize anal Ureaplasma positivity among a cohort of HIV positive MSM and evaluate possible association with papillomavirus infection at the same site.

METHODS

Anal swab samples, collected as part of routine screening for Chlamydia trachomatis and Neisseria gonorrhea, were additionally tested for HPV genotypes as well as for Ureaplasma and Mycoplasma using nucleic acid amplification method.

RESULTS

Out of a total of 222 study participants, 195 (89%, 95% CI (84.9-93.2)) were positive for HPV, approximately three quarter being high-risk genotypes. Forty three individuals (19.4%, 95% CI (14.4-24.3)) harbored Ureaplasma spp. Infection with high-risk HPV types was significantly associated with co-presence of Ureaplasma with an odds ratio (95% confidence-interval) of 2.59 (1.03-6.54), P = 0.04.

CONCLUSION

Besides a high predominance of HPV infection, asymptomatic HIV positive MSM had a high prevalence of anal Ureaplasma positivity. Concomitant infections with high-risk HPV genotypes were common and statistically significant. The role of this co-existence as a potential risk factor for anal carcinogenesis needs further elucidation.

Evaluation of the Implementation of a New Nurse-Led Express "Test-And-Go" Human Immunodeficiency Virus/Sexually Transmitted Infection Testing Service for Men Who Have Sex With Men at a Sexual Health Center in Melbourne, Australia

BACKGROUND

In August 2015, a nurse-led express human immunodeficiency virus (HIV)/sexually transmitted infection (STI) testing service "Test-And-Go" (TAG) for asymptomatic men who have sex with men (MSM) was implemented in a large public sexual health center in Melbourne, Australia. We aimed to compare the clients' characteristics between the TAG and routine walk-in service among asymptomatic MSM.

METHODS

This study was conducted at the Melbourne Sexual Health Centre, Australia, between August 5, 2015, and June 1, 2016. General estimating equation logistic regression models were constructed to examine the association between the use of TAG service and clients' demographic characteristics, sexual behaviors, and HIV/STI positivity. Clients' consultation and waiting times for both services were calculated.

RESULTS

Of the 3520 consultations, 784 (22.3%) were TAG services and 2736 (77.7%) were routine walk-in services for asymptomatic MSM. Asymptomatic MSM were more likely to use the TAG service if they were born in Australia (adjusted odds ratio, 1.29; 95% confidence interval, 1.07-1.56), and had more than 6 male partners in the last 12 months (adjusted odds ratio, 1.13; 95% confidence interval, 1.08-1.58). Age, HIV status, condomless anal sex and HIV/STI positivity did not differ between the two services. The TAG service had a shorter median waiting time (8.4 minutes vs 52.9 minutes; p < 0.001) and consultation time (8.9 minutes vs 17.6 minutes; p < 0.001) than the routine walk-in service.

CONCLUSIONS

Although country of birth and sexual behaviors differed between clients attending the 2 services, there were no differences in HIV and STI positivity. Importantly, the TAG service required less waiting and consultation time and hence created additional clinic capacity at the general clinic to see clients who are at higher risk.

Evidence for a new paradigm of gonorrhoea transmission: cross-sectional analysis of Neisseria gonorrhoeae infections by anatomical site in both partners in 60 male couples

OBJECTIVE

Gonorrhoea transmission between men is currently thought to occur primarily to and from the urethra. Transmission without urethral involvement, from throat-to-throat and throat-to-anus, is considered to be uncommon. Using gonorrhoea results from male couples, we aimed to investigate the transmission dynamics of gonorrhoea. If current medical consensus is correct, then most throat and anal infections should be explained by the partner's urethral infection.

METHODS

This is a cross-sectional analysis of gonorrhoea diagnosed by nucleic acid amplification tests in both partners in male couples who attended Melbourne Sexual Health Centre together between March 2015 and June 2017. Isolates obtained from culture-positive infections underwent whole genome sequencing to assess phylogenetic relatedness between partners.

RESULTS

In all 60 couples (120 men) at least one partner had gonorrhoea, and isolates had very high phylogenetic relatedness between partners. After excluding men with urethral gonorrhoea, among 32 men with anal gonorrhoea, 34% (95% CI 19% to 53 %) had a partner with throat gonorrhoea. After excluding couples where either man had urethral gonorrhoea, among 48 couples in which at least one man had throat gonorrhoea, in 23% (95% CI 12% to 37 %) of couples both men had throat gonorrhoea.

CONCLUSIONS

The observed gonorrhoea positivity when urethral infection is absent supports a new paradigm of gonorrhoea transmission, where the throat is a major source of gonorrhoea transmission between men, through tongue kissing, oroanal sex and saliva use as anal lubricant. Public health messages may need to address the risk of saliva exposure during sex.

Association of HIV Preexposure Prophylaxis With Incidence of Sexually Transmitted Infections Among Individuals at High Risk of HIV Infection

IMPORTANCE

Emerging evidence suggests that risk of bacterial sexually transmitted infections (STIs) increases among gay and bisexual men following initiation of HIV preexposure prophylaxis (PrEP).

OBJECTIVE

To describe STI incidence and behavioral risk factors among a cohort of predominantly gay and bisexual men who use PrEP, and to explore changes in STI incidence following PrEP commencement.

DESIGN, SETTING, AND PARTICIPANTS

The Pre-exposure Prophylaxis Expanded (PrEPX) Study, a multisite, open-label intervention study, was nested within the Australian Collaboration for Coordinated Enhanced Sentinel Surveillance (ACCESS) clinic network. A total of 4275 participants were enrolled (July 26, 2016-April 1, 2018) in Victoria, Australia. Of these, 2981 enrolled at 5 ACCESS clinics (3 primary care, 1 sexual health, and 1 community-based HIV rapid testing service), had at least 1 follow-up visit, and were monitored until April 30, 2018.

EXPOSURES

Upon enrollment, participants received daily oral tenofovir disoproxil fumurate and emtricitabine for HIV PrEP, quarterly HIV and STI testing, and clinical monitoring.

MAIN OUTCOMES AND MEASURES

The primary outcome was incidence of chlamydia, gonorrhea, or syphilis. Incidence rates and hazard ratios describing behavioral risk factors of STI diagnosis were calculated. Incidence rate ratios (IRRs), adjusted for change in testing frequency, described changes in STI incidence from 1-year preenrollment to study follow-up among participants with preenrollment testing data (n = 1378).

RESULTS

Among the 2981 individuals (median age, 34 years [interquartile range, 28-42]), 98.5% identified as gay or bisexual males, 29% used PrEP prior to enrollment, 89 (3%) withdrew and were censored at date of withdrawal, leaving 2892 (97.0%) enrolled at final follow-up. During a mean follow-up of 1.1 years (3185.0 person-years), 2928 STIs were diagnosed among 1427 (48%) participants (1434 chlamydia, 1242 gonorrhea, 252 syphilis). STI incidence was 91.9 per 100 person-years, with 736 participants (25%) accounting for 2237 (76%) of all STIs. Among 2058 participants with complete data for multivariable analysis, younger age, greater partner number, and group sex were associated with greater STI risk, but condom use was not. Among 1378 participants with preenrollment testing data, STI incidence increased from 69.5 per 100 person-years prior to enrollment to 98.4 per 100 person-years during follow-up (IRR, 1.41 [95% CI, 1.29-1.56]). After adjusting for testing frequency, the increase in incidence from 1 year preenrollment to follow-up was significant for any STI (adjusted IRR, 1.12 [95% CI, 1.02-1.23]) and for chlamydia (adjusted IRR, 1.17 [95% CI, 1.04-1.33]).

CONCLUSIONS AND RELEVANCE

Among gay and bisexual men using PrEP, STIs were highly concentrated among a subset, and receipt of PrEP after study enrollment was associated with an increased incidence of STIs compared with preenrollment. These findings highlight the importance of frequent STI testing among gay and bisexual men using PrEP.

Early initiation of antiretroviral therapy for people newly diagnosed with HIV infection in Australia: trends and predictors, 2004-2015

OBJECTIVES

To determine trends in and predictors of early treatment for people newly diagnosed with human immunodeficiency virus (HIV) infection in Australia.

DESIGN, SETTING

Retrospective cohort analysis of routinely collected longitudinal data from 44 sexual health clinics participating in the Australian Collaboration for Coordinated Enhanced Sentinel Surveillance (ACCESS) program.

PARTICIPANTS

Patients diagnosed with HIV infections, January 2004 - June 2015.

MAIN OUTCOME MEASURES

Commencement of antiretroviral therapy within 6 months of HIV diagnosis (early treatment); demographic, clinical, and risk group characteristics of patients associated with early treatment; trends in early treatment, by CD4⁺ cell count at diagnosis.

RESULTS

917 people were diagnosed with HIV infections, their median age was 34 years (interquartile range [IQR]: 27-43 years), and 841 (92%) were men; the median CD4⁺ cell count at diagnosis was 510 cells/μL (IQR, 350-674 cells/μL). The proportion of patients who received early treatment increased from 17% (15 patients) in 2004-06 to 20% (34 patients) in 2007-09, 34% (95 patients) in 2010-12, and 53% (197 patients) in 2013-15 (trend, P < 0.001). The probability of early treatment, which increased with time, was higher for patients with lower CD4⁺ cell counts and higher viral loads at diagnosis.

CONCLUSIONS

The proportion of people newly diagnosed with HIV in sexual health clinics in Australia who received treatment within 6 months of diagnosis increased from 17% to 53% during 2004-2015, reflecting changes in the CD4⁺ cell count threshold in treatment guidelines. Nevertheless, further strategies are needed to maximise the benefits of treatment to prevent viral transmission and morbidity.

Effectiveness of self-testing kits availability on improving HIV testing frequency for chinese men who have sex with men and their sexual partners: a protocol for a multicenter randomised controlled trial

INTRODUCTION

HIV epidemic is increasing among men who have sex with men (MSM) in China, yet HIV testing uptake remains low. As an emerging approach, HIV self-testing (HIVST) has the potential to promote HIV testing coverage and frequency in this population. However, evidence of the effectiveness on implementation of HIVST among Chinese MSM and their sexual partners is scarce.

METHODS AND ANALYSIS

The randomised controlled trial will be performed in Changsha, Changde, Shaoyang and Yiyang, Hunan province, China, recruiting 184 recent testers (men who had at least one HIV test within the past 2 years) and 26 non-recent testers (men who did not have HIV tests within 2 years or never had an HIV test). Eligible men will be randomly divided 1:1 into two groups: intervention (with free HIVST kits plus site-based HIV testing services) and control (site-based HIV testing services only). Participants in the intervention group will be provided with two free finger-prick-based HIVST kits, and can apply for two to four kits every 3 months for 1 year.Participants in both groups will complete questionnaires via WeChat at five separate times: baseline, third, sixth, ninth and twelfth month. The primary outcome is the mean number of HIV tests for MSM over the 12-month study period. The secondary outcome is the mean number of HIV tests for sexual partners of MSM over the 12-month study period. The tertiary outcomes are the self-reported proportion of consistent condom usage for anal sex, and the numbers of sexual partners during the 12-month study period.

ETHICS AND DISSEMINATION

The study has been approved by the Institutional Review Board of Behavioural and Nursing Research in Xiangya School of Nursing of Central South University, China (2018002). Study results will be disseminated through conferences and academic journals.

TRIAL REGISTRATION NUMBER

ChiCTR1800015584; Pre-results.

Cardiovascular disease and diabetes in HIV-positive and HIV-negative gay and bisexual men over the age of 55 years in Australia: insights from the Australian Positive & Peers Longevity Evaluation Study

OBJECTIVES

As HIV-positive people age, diagnosis and management of comorbidities associated with ageing are of increasing concern. In this study, we aimed to compare the self-reported prevalences of heart disease, stroke, thrombosis and diabetes in older Australian HIV-positive and HIV-negative gay and bisexual men (GBM).

METHODS

We analysed data from the Australian Positive & Peers Longevity Evaluation Study (APPLES), a study of a prospectively recruited cross-sectional sample of 228 (51.1%) HIV-positive and 218 (48.9%) HIV-negative GBM, aged ≥ 55 years. Regression methods were used to assess the association of HIV status with self-reported comorbidities.

RESULTS

Of 446 patients, 389 [200 (51.4%) HIV-positive] reported their disease history. The reported prevalence of comorbidities was higher in the HIV-positive group than in the HIV-negative group: heart disease, 19.5 versus 12.2%; stroke, 7.5 versus 4.2%; thrombosis, 10.5 versus 4.2%; and diabetes, 15.0 versus 9.0%, respectively. In adjusted analyses, HIV-positive GBM had significantly increased odds of reporting heart disease [adjusted odds ratio (aOR) 1.99; P = 0.03] and thrombosis (aOR 2.87; P = 0.01). In our analysis, HIV status was not significantly associated with either age at diagnosis of heart disease (median 53 years for HIV-positive GBM versus 55 years for HIV-negative GBM; P = 0.64) or 5-year cardiovascular disease (CVD) risk estimated using the Framingham risk score.

CONCLUSIONS

HIV-positive GBM more commonly reported heart disease and thrombosis compared with their HIV-negative peers. These results further highlight the need to understand the impact of HIV on age-related comorbidities in GBM, to guide optimal screening and treatment strategies to reduce the risk of these comorbidities among the HIV-positive population.

Assessing the Impacts of Integrated Decision Support Software on Sexual Orientation Recording, Comprehensive Sexual Health Testing, and Detection of Infections Among Gay and Bisexual Men Attending General Practice: Observational Study

Background

Gay and bisexual men are disproportionately affected by HIV and other sexually transmissible infections (STIs), yet opportunities for sexual health testing of this population are often missed or incomplete in general practice settings. Strategies are needed for improving the uptake and completeness of sexual health testing in this setting.

Objectives

The goal of the research was to evaluate the impact of an intervention centered around integrated decision support software and routine data feedback on the collection of sexual orientation data and sexual health testing among gay and bisexual men attending general practice.

Methods

A study using before/after and intervention/comparison methods was undertaken to assess the intervention’s impact in 7 purposively sampled Australian general practice clinics located near the urban centers of Sydney and Melbourne. The software was introduced at staggered points between April and August 2012; it used patient records to prompt clinicians to record sexual orientation and accessed pathology testing history to generate prompts when sexual health testing was overdue or incomplete. The software also had a function for querying patient management system databases in order to generate de-identified data extracts, which were used to report regularly to participating clinicians. We calculated summary rate ratios (SRRs) based on quarterly trends and used Poisson regression analyses to assess differences between the 12-month preintervention and 24-month intervention periods as well as between the intervention sites and 4 similar comparison sites that did not receive the intervention.

Results

Among 32,276 male patients attending intervention clinics, sexual orientation recording increased 19% (from 3213/6909 [46.50%] to 5136/9110 [56.38%]) during the intervention period (SRR 1.10, 95% CI 1.04-1.11, P<.001) while comprehensive sexual health testing increased by 89% (305/1159 [26.32%] to 690/1413 [48.83%]; SRR 1.38, 95% CI 1.28-1.46, P<.001). Comprehensive testing increased slightly among the 7290 gay and bisexual men attending comparison sites, but the increase was comparatively greater in clinics that received the intervention (SRR 1.12, 95% CI 1.10-1.14, P<.001). In clinics that received the intervention, there was also an increase in detection of chlamydia and gonorrhea that was not observed in the comparison sites.

Conclusions

Integrated decision support software and data feedback were associated with modest increases in sexual orientation recording, comprehensive testing among gay and bisexual men, and the detection of STIs. Tests for and detection of chlamydia and gonorrhea were the most dramatically impacted. Decision support software can be used to enhance the delivery of sexual health care in general practice.

Knowledge and awareness of HIV self-testing among Australian gay and bisexual men: a comparison of never, sub-optimal and optimal testers willingness to use

This paper explores the willingness to use and pay for HIV Self-testing (HIVST) among Australian gay and bisexual men (GBM). Bivariate and univariate multinominal logistic regression of data from an online survey was performed. Thirty-one (13%) had never HIV tested and 41.9% (88) were testing sub-optimally by Australian guidelines. Half (58.4%, 136) had never heard of HIVST, however, 56.2% (131) reported willingness to use HIVST, with sub-optimal (OR=2.13; p < 0.01) and never-testers (OR=2.01; p < 0.10) significantly more likely to do so than optimal-testers. Most were confident (51.7%, 119) or somewhat confident (29.1%, 67) accessing support following a reactive result, however, never-testers were significantly less confident compared to previous testers (OR=3.47; p< 0.05). Less than a quarter (23.6%, 57) were willing to pay for a kit with AUD$15 (R² = 0.9882) the estimated preferred price. This research confirms that HIVST is an important and accepted adjunct to established HIV testing modalities, particularly among sub-optimal and never-testers and that online (61.6%, 143) or clinic-based (61.6%, 143) dissemination are preferred. Research examining how best to disseminate HIVST in a range of safe and effective models needs to continue to ensure HIVST is part of a comprehensive strategy that facilitates usage and linkages to care.

High chlamydia and gonorrhoea repeat positivity in remote Aboriginal communities 2009-2011: longitudinal analysis of testing for re-infection at 3 months suggests the need for more frequent screening

Background Extremely high rates of diagnosis of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) have been recorded in remote communities across northern and central Australia. Re-testing at 3 months, after treatment administered, of CT or NG is recommended to detect repeat infections and prevent morbidity and ongoing transmission.

METHODS

Baseline CT and NG laboratory data (2009-2010) from 65 remote health services participating in a cluster randomised trial was used to calculate the proportion of individuals re-tested after an initial CT or NG diagnosis at <2 months (not recommended), 2-4 months (recommended) and 5-12 months and the proportion with repeat positivity on re-test. To assess if there were difference in re-testing and repeat positivity by age group and sex, t-tests were used.

RESULTS

There was a total of 2054 people diagnosed with CT and/or NG in the study period; 14.9% were re-tested at 2-4 months, 26.9% at 5-12 months, a total of 41.8% overall. Re-testing was higher in females than in males in both the 2-4-month (16.9% v. 11.5%, P<0.01) and 5-12-month (28.9% v. 23.5%, P=0.01) periods. Women aged 25-29 years had a significantly higher level of re-testing 5-12 months post-diagnosis than females aged 16-19 years (39.8% v. 25.4%, P<0.01). There was a total of 858 people re-tested at 2-12 months and repeat positivity was 26.7%. There was higher repeat NG positivity than repeat CT positivity (28.8% v. 18.1%, P<0.01).

CONCLUSIONS

Just under half the individuals diagnosed with CT or NG were re-tested at 2-12 months post-diagnosis; however, only 15% were re-tested in the recommended time period of 2-4 months. The higher NG repeat positivity compared with CT is important, as repeat NG infections have been associated with higher risk of pelvic inflammatory disease-related hospitalisation. Findings have implications for clinical practice in remote community settings and will inform ongoing sexual health quality improvement programs in remote community clinics.

What would be missed if we didn't screen men who have sex with men for oral chlamydia trachomatis? A cross-sectional study

Background This study aimed to describe oropharyngeal chlamydia (OCT) in gay and bisexually active men (GBM) attending a large urban sexual health clinic in Sydney and determine what proportion of cases would be missed if screening was not routine.

METHODS

Retrospective data were extracted for all GBM with a positive OCT result between 1 October 2012 and 31 April 2014. The control group consisted of patients who had a negative OCT result on their first visit during the study period, and each patient was only counted once.

RESULTS

A total of 74 of 2920 GBM (0.03, 95% CI: 0.02-0.03) were diagnosed with OCT. The 2920 GBM had a total of 11226 OCT tests performed, demonstrating OCT test positivity of 0.006 (95% CI: 0.005-0.008). A total of 62 sexually transmissible infections (STIs) were diagnosed at other sites: 34 rectal chlamydia (CT), 12 throat gonorrohea (GC), 7 urine CT, 7 rectal GC, 1 infectious syphilis and 1 non-gonoccal urethritis (NGU) case. Of the 74 OCT cases, 56 (0.76, 95% CI: 0.64-0.85) were treated with Azithromycin; 51 (69%) as part of standard treatment for their STI co-infection (34 rectal CT, 12 throat GC, 7 urine CT, 7 rectal GC, 1 NGU case) and a further five (7%) were treated as contacts. The remaining 18 people (0.24, 95% CI: 0.15-0.36) would not have been treated unless they were tested specifically for OCT.

CONCLUSION

Overall, two-thirds of the OCT cases received appropriate treatment and only a small number of cases would have been missed had routine screening not been performed. With an extremely low overall test positivity of 0.6%, screening for OCT at our service adds little to population level health control.

Viral suppression and HIV transmission in serodiscordant male couples: an international, prospective, observational, cohort study

BACKGROUND

Evidence on viral load and HIV transmission risk in HIV-serodiscordant male homosexual couples is limited to one published study. We calculated transmission rates in couples reporting condomless anal intercourse (CLAI), when HIV-positive partners were virally suppressed, and daily pre-exposure prophylaxis (PrEP) was not used by HIV-negative partners.

METHODS

In the Opposites Attract observational cohort study, serodiscordant male homosexual couples were recruited from 13 clinics in Australia, one in Brazil, and one in Thailand. At study visits, HIV-negative partners provided information on sexual behaviour and were tested for HIV and sexually transmitted infections; HIV-positive partners had HIV viral load tests, CD4 cell count, and sexually transmitted infection tests done. Viral suppression was defined as less than 200 copies per mL. Linked within-couple HIV transmissions were identified with phylogenetic analysis. Incidence was calculated per couple-year of follow-up, focusing on periods with CLAI, no use of daily PrEP, and viral suppression. One-sided upper 95% CI limits for HIV transmission rates were calculated with exact Poisson methods.

FINDINGS

From May 8, 2012, to March 31, 2016, in Australia, and May 7, 2014, to March 31, 2016, in Brazil and Thailand, 358 couples were enrolled. 343 couples had at least one follow-up visit and were followed up for 588·4 couple-years. 258 (75%) of 343 HIV-positive partners had viral loads consistently less than 200 copies per mL and 115 (34%) of 343 HIV-negative partners used daily PrEP during follow-up. 253 (74%) of 343 couples reported within-couple CLAI during follow-up, with a total of 16 800 CLAI acts. Three new HIV infections occurred but none were phylogenetically linked. There were 232·2 couple-years of follow-up and 12 447 CLAI acts in periods when CLAI was reported, HIV-positive partners were virally suppressed, and HIV-negative partners did not use daily PrEP, resulting in an upper CI limit of 1·59 per 100 couple-years of follow-up for transmission rate.

INTERPRETATION

HIV treatment as prevention is effective in men who have sex with men. Increasing HIV testing and linking to immediate treatment is an important strategy in HIV prevention in homosexual men.

FUNDING

National Health and Medical Research Council; amfAR, The Foundation for AIDS Research; ViiV Healthcare; and Gilead Sciences.

Increased Syphilis Testing of Men Who Have Sex With Men: Greater Detection of Asymptomatic Early Syphilis and Relative Reduction in Secondary Syphilis

Background

Syphilis rates have increased markedly among men who have sex with men (MSM) internationally. We examined trends in syphilis testing and detection of early syphilis among MSM in Australia.

Methods

Serial cross-sectional analyses on syphilis testing and diagnoses among MSM attending a national sentinel network of 46 clinics in Australia between 2007 and 2014.

Results

359313 clinic visits were included. The proportion of MSM serologically tested for syphilis annually increased in HIV-negative (48% to 91%; Ptrend < .0001) and HIV-positive MSM (42% to 77%; Ptrend < .0001). The mean number of tests per man per year increased from 1.3 to 1.6 in HIV-negative MSM (Ptrend < .0001) and from 1.6 to 2.3 in HIV-positive MSM (Ptrend < .0001). 2799 and 1032 syphilis cases were detected in HIV-negative and HIV-positive MSM, respectively. Among HIV-negative MSM, the proportion of infections that were early latent increased from 27% to 44% (Ptrend < .0001), while the proportion that were secondary decreased from 24% to 19% (Ptrend = .030). Among HIV-positive MSM, early latent infections increased from 23% to 45% (Ptrend < .0001), while secondary infections decreased from 45% to 26% (Ptrend = .0003). Among HIV-positive MSM, decreasing secondary syphilis correlated with increasing testing coverage (r = -0.87; P = .005) or frequency (r = -0.93; P = .001).

Conclusions

Increases in syphilis screening were associated with increased detection of asymptomatic infectious syphilis and relative falls in secondary syphilis for both HIV-positive and HIV-negative MSM nationally, suggesting interruption of syphilis progression.

Concordance of gonorrhoea of the rectum, pharynx and urethra in same-sex male partnerships attending a sexual health service in Melbourne, Australia

BACKGROUND

We aimed to describe anatomic site-specific concordance of gonococcal infections in partnerships of men who have sex with men (MSM).

METHODS

We conducted a cross-sectional analysis of data from MSM partnerships attending Melbourne Sexual Health Centre between March 2011 and February 2015. Logistic regression models (random effect) were used to examine the association between gonococcal infections of the urethra, rectum and pharynx. Gonococci were detected by culture at all anatomic sites.

RESULTS

The analysis included 495 partnerships. Of the men with urethral gonorrhoea, 33% (95% CI 18-52) had partners with pharyngeal gonorrhoea and 67% (95% CI 48-82) had partners with rectal gonorrhoea. The adjusted odds of having urethral gonorrhoea was 4.6 (95% CI 1.2-17.1) for a man whose partner had pharyngeal gonorrhoea, and 48.1 (95% CI 18.3-126.7) for a man whose partner had rectal gonorrhoea. Of the men with rectal gonorrhoea, 46% (95% CI 31-61) had a partner with urethral gonorrhoea and 23% (95% CI 12-37) had a partner with pharyngeal gonorrhoea. The adjusted odds of having rectal gonorrhoea was 63.9 (95% CI 24.7-165.6) for a man whose partner had urethral gonorrhoea. Of the men with pharyngeal gonorrhoea, 42% (95% CI 23-63) had a partner with rectal gonorrhoea and 23% (95% CI 9-44) had a partner with had a partner with pharyngeal gonorrhoea. The adjusted odds of having pharyngeal gonorrhoea was 8.9 (95% CI 3.2-24.6) for a man whose partner had rectal gonorrhoea. The crude odds of having pharyngeal gonorrhoea was 14.2 (95% CI 5.1-39.0) for a man whose partner had pharyngeal gonorrhoea.

CONCLUSIONS

These data provide the first estimates of concordance of anatomic site-specific gonococcal infections in MSM partnerships, and confirm that urethral gonorrhoea is contracted from both rectal and pharyngeal sites, and suggest that gonococci transmit between the rectum and pharynx. However, due to use of culture rather than NAAT, our analysis was not adequately powered to assess pharynx-to-pharynx transmission of gonococci.

Understanding the Targeting and Uptake of HIV Testing Among Gay and Bisexual Men Attending Sexual Health Clinics

We assessed trends in HIV testing outcomes during a period of clinic-based initiatives introduced to increase HIV testing among gay and bisexual men (GBM) attending sexual health clinics (SHCs) in New South Wales (NSW). A cohort of 25,487 HIV-negative GBM attending 32 SHCs in NSW (2009-2015) was classified into six sub-groups each year based on client-type (new/existing), risk-status (low/high-risk), and any recent HIV testing. Poisson regression methods were used to assess HIV testing outcomes in sub-groups of GBM. HIV testing outcomes and the sub-groups with greatest statistically significant annual increases were: individuals attending (26% in high-risk existing clients with recent testing); testing uptake (4% in low-risk existing clients with no recent testing); testing frequency (6% in low-risk existing clients with no recent testing and 5% in high-risk existing clients with recent testing); and total tests (31% in high-risk existing clients with recent testing). High-risk existing clients with recent testing had a 13% annual increase in the proportional contribution to total tests. Our findings show improved targeting of testing to high-risk GBM at NSW SHCs. The clinic-based initiatives should be considered for translation to other similar settings.

Risk factors for oropharyngeal gonorrhoea in men who have sex with men: an age-matched case-control study

OBJECTIVES

Oropharyngeal gonorrhoea is common among men who have sex with men (MSM). We aimed to clarify which oral sex practices were independent risk factors for oropharyngeal gonorrhoea: tongue kissing, receptive oro-penile sex (fellatio) or insertive oro-anal sex (rimming), and whether daily use of mouthwash and recent antibiotic use was protective.

METHODS

In 2015, we conducted an age-matched case-control study of MSM who attended the Melbourne Sexual Health Centre. Cases had tested positive for oropharyngeal gonorrhoea by nucleic acid amplification testing, and controls had tested negative. Questionnaire items included tongue kissing, oral sex practices, condom use, recent antibiotic use, mouthwash use and alcohol consumption.

RESULTS

We identified 177 cases, age matched to 354 controls. In univariable analyses, cases were 1.90 times (95% CI 1.13 to 3.20) more likely than controls to have had casual sexual partners (CSP) in the preceding 3 months, were 2.17 times (95% CI 1.31 to 3.59) more likely to have kissed CSP and were 2.04 times (95% CI 1.26 to 3.30) more likely to have had receptive oro-penile sex with CSP. Oropharyngeal gonorrhoea was not associated with insertive oro-anal sex or mouthwash use. The number of CSP for tongue kissing and receptive oral sex and total CSP were highly correlated, and in multivariable analysis neither kissing nor receptive oro-penile sex was significantly associated with having oropharyngeal gonorrhoea, after adjusting for total number of CSP.

CONCLUSIONS

The finding that oropharyngeal gonorrhoea was associated with a higher number of sexual partners but not specific sexual practices highlights the need for further research in the area of gonorrhoea transmission to define the probability of transmission from specific sex acts.

2016 United Kingdom national guideline on the sexual health care of men who have sex with men

This guideline is intended for use in UK Genitourinary medicine clinics and sexual health services but is likely to be of relevance in all sexual health settings, including general practice and Contraception and Sexual Health (CASH) services, where men who have sex with men (MSM) seek sexual health care or where addressing the sexual health needs of MSM may have public health benefits. For the purposes of this document, MSM includes all gay, bisexual and all other males who have sex with other males and both cis and trans men. This document does not provide guidance on the treatment of particular conditions where this is covered in other British Association for Sexual Health and HIV (BASHH) Guidelines but outlines best practice in multiple aspects of the sexual health care of MSM. Where prevention of sexually transmitted infections including HIV can be addressed as an integral part of clinical care, this is consistent with the concept of combination prevention and is included. The document is designed primarily to provide guidance on the direct clinical care of MSM but also makes reference to the design and delivery of services with the aim of supporting clinicians and commissioners in providing effective services. Methodology This document was produced in accordance with the guidance set out in the BASHH CEG's document 'Framework for guideline development and assessment' published in 2010 at http://www.bashh.org/guidelines and with reference to the Agree II instrument. Following the production of the updated framework in April 2015, the GRADE system for assessing evidence was adopted and the draft recommendations were regraded. Search strategy (see also Appendix 1) Ovid Medline 1946 to December 2014, Medline daily update, Embase 1974 to December 2014, Pubmed NeLH Guidelines Database, Cochrane library from 2000 to December 2014. Search language English only. The search for Section 3 was conducted on PubMed to December 2014. Priority was given to peer-reviewed papers published in scientific journals, although for many issues evidence includes conference abstracts listed on the Embase database. In addition, for 'Identification of problematic recreational drug and alcohol use' section and 'Sexual problems and dysfunctions in MSM' section, searches included PsycINFO. Methods Article titles and abstracts were reviewed and if relevant the full text article was obtained. Priority was given to randomised controlled trial and systematic review evidence, and recommendations made and graded on the basis of best available evidence. Piloting and feedback The first draft of the guideline was circulated to the writing group and to a small group of relevant experts, third sector partners and patient representatives who were invited to comment on the whole document and specifically on particular sections. The revised draft was reviewed by the CEG and then reviewed by the BASHH patient/public panel and posted on the BASHH website for public consultation. The final draft was piloted before publication. Guideline update The guidelines will be reviewed and revised in five years' time, 2022.

Increased Detection of Pharyngeal and Rectal Gonorrhea in Men Who Have Sex With Men After Transition From Culture To Nucleic Acid Amplification Testing

BACKGROUND

This before-and-after study measured the impact of a change in testing methods from culture to nucleic acid amplification testing (NAAT) on the detection of pharyngeal and rectal gonorrhea in men who have sex with men (MSM) on a sexual health service level, including the effect on subgroups anticipated to have higher rates of gonorrhea.

METHODS

In March 2015, Melbourne Sexual Health Centre changed its laboratory method for gonococcal testing from culture to NAAT using the Aptima Combo 2 and Aptima GC tests. We compared the proportion of tests positive for rectal and pharyngeal gonorrhea in MSM using culture in 2014 with those using NAAT in 2015.

RESULTS

The proportion of tests positive for rectal gonorrhea by NAAT was double that obtained by culture (8% vs 3.9%; prevalence ratio [PR], 2.0; 95% confidence interval [CI], 1.8-2.4) and 5-fold for pharyngeal gonorrhea (8.3% vs 1.6%; PR, 5.2; 95% CI, 4.2-6.4). Similar increases in test positivity were observed in human immunodeficiency virus (HIV)-positive and HIV-negative men. By NAAT, test positivity for rectal gonorrhea was higher in HIV-positive compared with HIV-negative men (15.4% vs 7.3%; PR, 2.1; 95% CI, 1.7-2.6). Culture and NAAT had similar test positivity for rectal gonorrhea among men who reported contact with gonorrhea (24.9% vs 25.3%, PR 1.0, 95% CI 0.8-1.4) and men who presented with symptoms of proctitis (22.2% vs 27.9%, PR 1.3, 95% CI 0.8-2.0).

CONCLUSIONS

A switch from culture to Aptima Combo 2 testing for extragenital gonorrhea in MSM increased detection and was most marked for pharyngeal infections.

Can self-testing increase HIV testing among men who have sex with men: A systematic review and meta-analysis

Background

Globally, four out of ten individuals living with HIV have not been tested for HIV. Testing is especially important for men who have sex with men (MSM), among whom an increasing HIV epidemic has been identified in many regions of the world. As a supplement to site-based HIV testing services, HIV self-testing (HIVST) provides a promising approach to promote HIV testing. However, evidence is scattered and not well-summarized on the effect of HIVST to improve HIV testing behaviors, especially for MSM.

Methods

Seven databases (PubMed, Web of Science, Cochrane Library, PsycINFO, CINAHL Plus, WanFang, and China National Knowledge Internet) and conference abstracts from six HIV/sexually transmitted infections conferences were searched from January 2000-April 2017.

Results

Of 1,694 records retrieved, 23 studies were identified, 9 conducted in resource-limited countries and 14 in high-income countries. The pooled results showed that HIVST increased HIV test frequency for MSM by one additional test in a 6-month period (mean difference = 0.88 [95% CI 0.52–1.24]). The pooled proportion of first-time testers among those who took HIVST was 18.7% (95% CI: 9.9–32.4) globally, with a rate 3.32 times higher in resource-limited country settings (32.9% [95% CI: 21.3–47.6]) than in high-income countries (9.9% [95% CI: 7.4–13.8]). The pooled proportions included non-recent testers, 32.9% (95% CI: 28.1–38.3); ever or currently married MSM, 16.7% (95% CI: 14.5–19.4); and HIV positive men, 3.8% (95% CI: 2.0–5.7) globally; 6.5% [95% CI: 0.38–12.3] in resource-limited country settings; and 2.9% [95% CI: 2.0–5.0] in high-income countries). The rates reported for linkage to care ranged from 31.3% to 100%.

Conclusions

HIVST could increase HIV testing frequency and potentially have capacity equivalent to that of site-based HIV testing services to reach first-time, delayed, married, and HIV-infected testers among MSM and link them to medical care. However, more rigorous study designs are needed to explore the specific self-testing approach (oral-fluid based or finger-prick based) on improving HIV testing for MSM in different social and economic settings.