Multicentre double-blind randomised placebo-controlled trial evaluating the efficacy of the meningococcal B vaccine, 4CMenB (Bexsero), against Neisseria gonorrhoeae infection in men who have sex with men: the GoGoVax study protocol

INTRODUCTION

Gonorrhoea, the sexually transmissible infection caused by Neisseria gonorrhoeae, has a substantial impact on sexual and reproductive health globally with an estimated 82 million new infections each year worldwide. N. gonorrhoeae antimicrobial resistance continues to escalate, and disease control is largely reliant on effective therapy as there is no proven effective gonococcal vaccine available. However, there is increasing evidence from observational cohort studies that the serogroup B meningococcal vaccine four-component meningitis B vaccine (4CMenB) (Bexsero), licensed to prevent invasive disease caused by Neisseria meningitidis, may provide cross-protection against the closely related bacterium N. gonorrhoeae. This study will evaluate the efficacy of 4CMenB against N. gonorrhoeae infection in men (cis and trans), transwomen and non-binary people who have sex with men (hereafter referred to as GBM+).

METHODS AND ANALYSIS

This is a double-blind, randomised placebo-controlled trial in GBM+, either HIV-negative on pre-exposure prophylaxis against HIV or living with HIV (CD4 count >350 cells/mm3), who have had a diagnosis of gonorrhoea or infectious syphilis in the last 18 months (a key characteristic associated with a high risk of N. gonorrhoeae infection). Participants are randomised 1:1 to receive two doses of 4CMenB or placebo 3 months apart. Participants have 3-monthly visits over 24 months, which include testing for N. gonorrhoeae and other sexually transmissible infections, collection of demographics, sexual behaviour risks and antibiotic use, and collection of research samples for analysis of N. gonorrhoeae-specific systemic and mucosal immune responses. The primary outcome is the incidence of the first episode of N. gonorrhoeae infection, as determined by nucleic acid amplification tests, post month 4. Additional outcomes consider the incidence of symptomatic or asymptomatic N. gonorrhoeae infection at different anatomical sites (ie, urogenital, anorectum or oropharynx), incidence by N. gonorrhoeae genotype and antimicrobial resistance phenotype, and level and functional activity of N. gonorrhoeae-specific antibodies.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the St Vincent's Hospital Human Research Ethics Committee, St Vincent's Hospital Sydney, NSW, Australia (ref: 2020/ETH01084). Results will be disseminated in peer-reviewed journals and via presentation at national and international conferences.

TRIAL REGISTRATION NUMBER

NCT04415424.

Management of acute sexual assault presenting to a large Australian sexual health clinic in 2012-2021: a retrospective clinical audit

Background The incidence of sexual assault continues to rise in Australia. This study aimed to describe the nature of assault, HIV/STI positivity, and its management at a sexual health clinic. Methods We performed a chart review of 516 sexual assault cases presenting to Melbourne Sexual Health Centre between 2012 and 2021, collecting data on victim demographics, details of assault, HIV/STI testing and positivity, police involvement, and offer of counselling. Results We included 516 cases: 124 males (24.0%); 384 females (74.4%); and eight transgender (1.6%) victims. The proportion of assault cases presenting to Melbourne Sexual Health Centre increased from 0.1% (37/37,070) in 2012 to 0.2% (56/36,514) in 2021 (P trend =0.006). HIV post-exposure prophylaxis was prescribed for 64.5% (80/124) of males and 12.5% (48/384) of females. Among victims, 69.4% (358/516) were tested for HIV and no one tested positive, while 71.9% (371/516) were tested for syphilis, with 1.6% (6/371) positive. Gonorrhoea and chlamydia were tested at the oropharynx (44.8% [231/516] vs 28.7% [148/516]), genitals (83.7% [432/516] vs 92.4% [477/516]) and anorectum (35.3% [182/516] vs 35.3% [182/516]). Positivity for gonorrhoea and chlamydia were: 2.6% (6/231) vs 2.0% (3/148) at oropharynx, 1.4% (6/432) vs 2.9% (14/477) at genitals, and 5.5% (10/182) vs 7.1% (13/182) at anorectum. According to clinical records, 25.2% (130/516) of victims sought police involvement, and 71.7% (370/516) were offered counselling. Conclusions Sexual assault was an uncommon presentation at Melbourne Sexual Health Centre, with diverse circumstances surrounding assault; however, clinical documentation varied, indicating a need for a standard primary care protocol for clients presenting with acute sexual assault.

Identifying Individuals at High Risk for HIV and Sexually Transmitted Infections With an Artificial Intelligence-Based Risk Assessment Tool

Background

We have previously developed an artificial intelligence-based risk assessment tool to identify the individual risk of HIV and sexually transmitted infections (STIs) in a sexual health clinical setting. Based on this tool, this study aims to determine the optimal risk score thresholds to identify individuals at high risk for HIV/STIs.

Methods

Using 2008-2022 data from 216 252 HIV, 227 995 syphilis, 262 599 gonorrhea, and 320 355 chlamydia consultations at a sexual health center, we applied MySTIRisk machine learning models to estimate infection risk scores. Optimal cutoffs for determining high-risk individuals were determined using Youden's index.

Results

The HIV risk score cutoff for high risk was 0.56, with 86.0% sensitivity (95% CI, 82.9%-88.7%) and 65.6% specificity (95% CI, 65.4%-65.8%). Thirty-five percent of participants were classified as high risk, which accounted for 86% of HIV cases. The corresponding cutoffs were 0.49 for syphilis (sensitivity, 77.6%; 95% CI, 76.2%-78.9%; specificity, 78.1%; 95% CI, 77.9%-78.3%), 0.52 for gonorrhea (sensitivity, 78.3%; 95% CI, 77.6%-78.9%; specificity, 71.9%; 95% CI, 71.7%-72.0%), and 0.47 for chlamydia (sensitivity, 68.8%; 95% CI, 68.3%-69.4%; specificity, 63.7%; 95% CI, 63.5%-63.8%). High-risk groups identified using these thresholds accounted for 78% of syphilis, 78% of gonorrhea, and 69% of chlamydia cases. The odds of positivity were significantly higher in the high-risk group than otherwise across all infections: 11.4 (95% CI, 9.3-14.8) times for HIV, 12.3 (95% CI, 11.4-13.3) for syphilis, 9.2 (95% CI, 8.8-9.6) for gonorrhea, and 3.9 (95% CI, 3.8-4.0) for chlamydia.

Conclusions

Risk scores generated by the AI-based risk assessment tool MySTIRisk, together with Youden's index, are effective in determining high-risk subgroups for HIV/STIs. The thresholds can aid targeted HIV/STI screening and prevention.

Optimising HIV pre-exposure prophylaxis and testing strategies in men who have sex with men in Australia, Thailand, and China: a modelling study and cost-effectiveness analysis

BACKGROUND

Men who have sex with men (MSM) in the Asia-Pacific region have a disproportionately high burden of HIV infection compared with the general population. Although pre-exposure prophylaxis (PrEP) for HIV is highly effective at preventing new HIV infections, the cost-effectiveness of PrEP for MSM in different countries in the Asia-Pacific region with varying PrEP coverage and HIV testing frequencies remains unstudied. We aimed to analyse the economic and health benefits of long-acting injectable cabotegravir (CAB-LA) compared with oral PrEP in high-income countries and low-income and middle-income countries within the Asia-Pacific region.

METHODS

We developed a decision-analytic Markov model to evaluate the population impact and cost-effectiveness of PrEP scale-up among MSM in Australia, Thailand, and China. We assumed a static cohort of 100 000 MSM aged 18 years or older who were at risk of HIV infection, with a monthly cycle length over a 40-year time period. We evaluated hypothetical scenarios with universal PrEP coverage of 80% among 100 000 suitable MSM in each country. We modelled oral PrEP and CAB-LA for MSM with diverse HIV testing frequency strategies. We adopted the health-care system's perspective with a 3% annual discount rate. We calculated the incremental cost-effectiveness ratio (ICER), measured as additional cost per quality-adjusted life-year (QALY) gained, to compare different strategies with the status quo in each country. All costs were reported in 2021 US$. We also performed one-way, two-way, and probabilistic sensitivity analyses to assess the robustness of our findings.

FINDINGS

Compared with the status quo in each country, expanding oral PrEP to 80% of suitable MSM would avert 8·1% of new HIV infections in Australia, 14·5% in Thailand, and 26·4% in China in a 40-year period. Expanding oral PrEP use with 6-monthly HIV testing for both PrEP and non-PrEP users was cost-saving for Australia. Similarly, expanding oral PrEP use remained the most cost-effective strategy in both Thailand and China, but optimal testing frequency varied, with annual testing in Thailand (ICER $4707 per QALY gained) and 3-monthly testing in China (ICER $16 926 per QALY gained) for both PrEP and non-PrEP users. We also found that replacing oral PrEP with CAB-LA for MSM could avert more new HIV infections (12·8% in Australia, 27·6% in Thailand, and 32·8% in China), but implementing CAB-LA was not cost-effective due to its high cost. The cost of CAB-LA would need to be reduced by 50-90% and be used as a complementary strategy to oral PrEP to be cost-effective in these countries.

INTERPRETATION

Expanding oral PrEP use for MSM, with country-specific testing frequency, is cost-effective in Australia, Thailand, and China. Due to the high cost, CAB-LA is currently not affordable as a single-use strategy but might be offered as an additional option to oral PrEP.

FUNDING

Ministry of Science and Technology of the People's Republic of China, the Australian National Health and Medical Research Council, National Key Research and Development Program of China, and National Natural Science Foundation of China.

Chlamydia retesting remains low among young women in Australia: an observational study using sentinel surveillance data, 2018-2022

BACKGROUND

Chlamydia remains the most notified bacterial sexually transmissible infection in Australia with guidelines recommending testing for re-infection at 3months post treatment. This paper aimed to determine chlamydia retesting and repeat positivity rates within 2-4months among young women in Australia, and to evaluate what factors increase or decrease the likelihood of retesting.

METHODS

Chlamydia retesting rates among 16-29-year-old women were analysed from Australian Collaboration for Coordinated Enhanced Sentinel Surveillance of sexually transmissible infection and bloodborne virus (ACCESS) sentinel surveillance data (n =62 sites). Among women with at least one positive test between 1 January 2018 and 31 August 2022, retesting counts and proportions within 2-4months were calculated. Logistic regression was performed to assess factors associated with retesting within 2-4months.

RESULTS

Among 8758 women who were positive before 31 August 2022 to allow time for follow up, 1423 (16.2%) were retested within 2-4months, of whom 179 (12.6%) tested positive. The odds of retesting within 2-4months were 25% lower if tested in a coronavirus disease 2019 (COVID-9) pandemic year (2020-2022) (aOR=0.75; 95% CI 0.59-0.95). Among 9140 women with a positive test before 30 November 2022, 397 (4.3%) were retested too early (within 7days to 1month) and 81 (20.4%) of those were positive.

CONCLUSIONS

Chlamydia retesting rates remain low with around a sixth of women retested within 2-4months in line with guidelines. Re-infection is common with around one in eight retesting positive. An increase in retesting is required to reduce the risk of reproductive complications and onward transmission.

STI pathogens in the oropharynx: update on screening and treatment

PURPOSE OF REVIEW

The rise in antimicrobial resistance in several STI pathogens such as Neisseria gonorrhoeae has become a public health threat as only one first-line treatment remains. Reducing screening interval for gonorrhoea and chlamydia in high-prevalence populations has been proposed to address antimicrobial stewardship, but this remains controversial. This review aimed to revisit the epidemiology of infections at the oropharynx and review the current screening recommendations and treatment guidelines in different populations.

RECENT FINDINGS

Emerging evidence suggests that the oropharynx is the primary anatomical site for gonorrhoea transmission but maybe not for chlamydia transmission. Most international guidelines recommend 3-monthly oropharyngeal gonorrhoea and chlamydia screening for high-prevalence populations (e.g. men who have sex with men) but not low-prevalence populations (e.g. heterosexuals) given the clinical and public health benefits of screening in low-prevalence populations are still unclear. Doxycycline remains the first-line treatment for oropharyngeal chlamydia in most guidelines. However, some countries have moved from dual therapy (ceftriaxone and azithromycin) to monotherapy (ceftriaxone) for oropharyngeal gonorrhoea treatment to address antimicrobial stewardship.

SUMMARY

The transmission of gonorrhoea and chlamydia is still not fully understood. Further work will be required to evaluate the benefits and harms of reducing screening in high-prevalence populations.

Vaccine value profile for Neisseria gonorrhoeae

Neisseria gonorrhoeae infection (gonorrhoea) is a global public health challenge, causing substantial sexual and reproductive health consequences, such as infertility, pregnancy complications and increased acquisition or transmission of HIV. There is an urgency to controlling gonorrhoea because of increasing antimicrobial resistance to ceftriaxone, the last remaining treatment option, and the potential for gonorrhoea to become untreatable. No licensed gonococcal vaccine is available. Mounting observational evidence suggests that N. meningitidis serogroup B outer membrane vesicle-based vaccines may induce cross-protection against N. gonorrhoeae (estimated 30%-40% effectiveness using the 4CMenB vaccine). Clinical trials to determine the efficacy of the 4CMenB vaccine against N. gonorrhoeae are underway, as are Phase 1/2 studies of a new gonococcal-specific vaccine candidate. Ultimately, a gonococcal vaccine must be accessible, affordable and equitably dispensed, given that those most affected by gonorrhoea are also those who may be most disadvantaged in our societies, and most cases are in less-resourced settings. This vaccine value profile (VVP) provides a high level, holistic assessment of the current data to inform the potential public health, economic and societal value of pipeline vaccines. This was developed by a working group of subject matter experts from academia, non-profit organizations, public private partnerships and multi-lateral organizations. All contributors have extensive expertise on various elements of the N. gonorrhoeae VVP and collectively aimed to identify current research and knowledge gaps. The VVP was developed using published data obtained from peer-reviewed journals or reports.

Australian Sexual Health Service Users' Perspectives on Reducing the Oral Transmission of Bacterial STIs: A Qualitative Study

Growing rates of bacterial sexually transmitted infections (STIs) demand new approaches to STI prevention. Sexual practices involving saliva or direct contact with the mouth increase the risk of STI transmission, but community awareness remains largely unexplored in the literature. The Community Awareness and Surveillance of STI Transmission study sought to explore sexual health clinic attendees' awareness of oral STIs; experiences when seeking testing and treatment; and acceptable educational and clinical interventions. Twenty-one semi-structured interviews were conducted with a diverse group of Melbourne Sexual Health Center attendees'. Reflective thematic analysis was undertaken, revealing key themes across people of different genders, sexual identities, ages, and nationalities. All participants emphasized the importance of understanding how their sexual practices might put them at risk of an oral STI. They also sought care from specialist sexual health services with the expectation that health-care providers (HCPs) in these settings had more understanding of diverse sexual practices. Participants' decisions to protect themselves against oral STIs were primarily driven by the effect the decision had on pleasure and intimacy. Comfort during the health-care encounter and trust in HCPs facilitated better understanding of individual STI risk. Differences in awareness and risk reduction strategies were noted based on past experience with oral testing and STIs. These findings highlight the importance of HCPs and public health interventions providing solutions that recognize the central role of pleasure and intimacy in our sexual lives.

Corrigendum to: Optimising the delivery of sexual health services in Australia: a qualitative study

BACKGROUND

With a rise in sexually transmitted infections in Australia, it is important to evaluate and optimise current sexual health services to reduce barriers to access and increase testing. We aimed to describe the range of sexual health services in Australia, focusing on strategies to improve testing among priority populations, and any future strategies participants believed would improve service delivery.

METHODS

We conducted 20 semi-structured interviews with key informants working in Australian sexual health services from July to December 2020, and collected data on service characteristics and strategies to improve access. We used content analysis, then coded and categorised the data into recurring themes and sub-themes.

RESULTS

We identified two major themes: 'Expanding Traditional Service Delivery' and 'Thinking Outside the Box'. The first theme outlines strategies that build upon pre-existing service delivery models, such as express clinics and an increased focus on confidentiality. The second theme outlines new strategies introduced to fill gaps in service delivery, such as self-testing and outreach.

CONCLUSIONS

To improve access to HIV/STI testing, there is a need for multiple access points to cater for a range of populations and their preferences. Establishing strategies to accomplish this involves utilising a combination of expanding traditional service models and implementing new approaches to service delivery.

Rapid detection of monkeypox virus using a CRISPR-Cas12a mediated assay: a laboratory validation and evaluation study

BACKGROUND

The 2022 outbreak of mpox (formerly known as monkeypox) led to the spread of monkeypox virus (MPXV) in over 110 countries, demanding effective disease management and surveillance. As current diagnostics rely largely on centralised laboratory testing, our objective was to develop a simple rapid point-of-care assay to detect MPXV in clinical samples using isothermal amplification coupled with CRISPR and CRISPR-associated protein (Cas) technology.

METHODS

In this proof-of-concept study, we developed a portable isothermal amplification CRISPR-Cas12a-based assay for the detection of MPXV. We designed a panel of 22 primer-guide RNA sets using pangenome and gene-agnostic approaches, and subsequently shortlisted the three sets producing the strongest signals for evaluation of analytical sensitivity and specificity using a fluorescence-based readout. The set displaying 100% specificity and the lowest limit of detection (LOD) was selected for further assay validation using both a fluorescence-based and lateral-flow readout. Assay specificity was confirmed using a panel of viral and bacterial pathogens. Finally, we did a blind concordance study on genomic DNA extracted from 185 clinical samples, comparing assay results with a gold-standard quantitative PCR (qPCR) assay. We identified the optimal time to detection and analysed the performance of the assay relative to qPCR using receiver operating characteristic (ROC) curves. We also assessed the compatibility with lateral-flow strips, both visually and computationally, where strips were interpreted blinded to the fluorescence results on the basis of the presence or absence of test bands.

FINDINGS

With an optimal run duration of approximately 45 min from isothermal amplification to CRISPR-assay readout, the MPXV recombinase polymerase amplification CRISPR-Cas12a-based assay with the selected primer-guide set had an LOD of 1 copy per μL and 100% specificity against tested viral pathogens. Blinded concordance testing of 185 clinical samples resulted in 100% sensitivity (95% CI 89·3-100) and 99·3% specificity (95% CI 95·7-100) using the fluorescence readout. For optimal time to detection by fluorescence readout, we estimated the areas under the ROC curve to be 0·98 at 2 min and 0·99 at 4 min. Lateral-flow strips had 100% sensitivity (89·3-100) and 98·6% specificity (94·7-100) with both visual and computational assessment. Overall, lateral-flow results were highly concordant with fluorescence-based readouts (179 of 185 tests, 96·8% concordant), with discrepancies associated with low viral load samples.

INTERPRETATION

Our assay for the diagnosis of mpox displayed good performance characteristics compared with qPCR. Although optimisation of the assay will be required before deployment, its usability and versatility present a potential solution to MPXV detection in low-resource and remote settings, as well as a means of community-based, on-site testing.

FUNDING

Victorian Medical Research Accelerator Fund and the Australian Government Department of Health.

Mpox knowledge, vaccination and intention to reduce sexual risk practices among men who have sex with men and transgender people in response to the 2022 mpox outbreak: a cross-sectional study in Victoria, Australia

BACKGROUND

The first mpox case was reported in May 2022 in Australia. Most cases have been diagnosed in men who have sex with men (MSM). This study aimed to examine community understanding of mpox, attitudes towards vaccination, and potential changes in sexual practices surrounding the mpox outbreak among MSM and transgender people in Victoria, Australia.

METHODS

Participants were recruited from sexual health clinics and communities in Victoria, Australia, in August-October 2022. Participants were asked about their understanding and knowledge of mpox, vaccination uptake and intentions to change sexual practices. Univariable and multivariable logistic regression was performed to examine the factors associated with mpox vaccine uptake.

RESULTS

Most participants (97.8%, 525/537) had heard about mpox and 10.5% (55/525) knew someone who had had mpox. Of the 12 mpox knowledge questions, the median score of correct answers was 10 (IQR=8-11) out of a maximum of 12. More than a third (36.6%, 191/522) had been vaccinated against mpox. MSM who had a good knowledge of mpox had the highest odds of receiving mpox vaccine compared with those who had poor knowledge (aOR=4.05; 95% CI: 1.54-10.61). To prevent mpox, half reported they would reduce having sex with casual partners, stop having chemsex (used drugs for the purpose of sex), stop attending sex-on-premises-venues, and stop having group sex. A quarter reported they would increase condom use for anal sex.

CONCLUSIONS

One-third of high-risk participants and a substantial proportion of participants intended to reduce or stop certain practices, which may explain the large reduction in mpox cases.

Factors Associated With Consenting to Receive an Automated Email Summary After a Sexual Health Clinic Visit

BACKGROUND

Electronic health records allow for inexpensive communication with patients. In March 2021, the Melbourne Sexual Health Centre implemented an automated email summary ("Sexual Health Automated Visit Email" [SHAVE]) of a client's visit. This study evaluates the proportion of attendees at a sexual health service who opted in or out of SHAVE.

METHODS

This study was conducted at the Melbourne Sexual Health Centre in Australia between March 2021 and June 2022. Univariable and multivariable logistic regression analyses were used to examine the client characteristics associated with consenting to SHAVE.

RESULTS

There were 18,528 clients (men, 12,700; women, 5828) included in the final analysis and 55.2% (n = 10,233) consented to receiving SHAVE. Comparing with those who did not have a new sexually transmitted infection diagnosis, clients with a new diagnosis of a sexually transmitted infection, but not HIV, had lower odds of consenting to receiving SHAVE (chlamydia: adjusted odds ratio [aOR], 0.64 [95% confidence interval {CI}, 0.57-0.72]; gonorrhea: aOR, 0.71 [95% CI, 0.62-0.82]; syphilis: aOR, 0.75 [95% CI, 0.59-0.96]). Men had lower odds of consenting when compared with women (men who have sex with women only: aOR, 0.77 [95% CI, 0.71-0.84]; men who have sex with men: aOR, 0.68 [95% CI, 0.62-0.75]). Comparing with those born in Australia or Oceania, clients born in Europe had lower odds of consenting (aOR, 0.81; 95% CI, 0.70-0.94), whereas those born in Latin America or Caribbean had higher odds of consenting (aOR, 1.25; 95% CI, 1.04-1.51).

CONCLUSIONS

Email summaries may serve as a valuable strategy to improve health communication and record keeping for clients. Understanding the client characteristics associated with consenting SHAVE will allow for the implementation of strategies to better communicate with clients.

Trends and associated factors in HIV testing among heterosexual men and women in Melbourne, Australia, 2011-2020

BACKGROUND

Despite the increase in the proportion of HIV notifications attributed to heterosexuals in Australia, little is known about their HIV testing behaviours. We investigated the trends and factors associated with HIV testing behaviours among heterosexuals.

METHODS

We analysed the trend and proportion of heterosexuals attending the centre for the first time between 2011 and 2020, who had ever tested and tested for HIV in the past 12months and the median number of months since their last HIV test. We identified factors associated with HIV testing behaviours using univariable and multivariable logistic regressions.

RESULTS

Of the 78652 heterosexuals included, 53.1% were men and 46.9% were women. Overall, the proportion of heterosexuals who had ever tested for HIV was 40.8%, with a declining testing trend from 40.2% in 2011 to 36.5% in 2020 (P trend <0.001). Overall, the proportion of heterosexuals tested for HIV in the past 12months was 15.7%, with no significant change from 15.3% in 2011 to 14.7% in 2020 (P trend =0.489). The median number of months since the last HIV test decreased from 18.0 (IQR 6.9-37.3) in 2011 to 15.0 (IQR 6.4-32.5) in 2020 (P trend <0.001). Individuals who had condomless sex with casual partners (aOR 0.92, 95% CI 0.88-0.96) and who were diagnosed with a sexually transmitted infection (aOR 0.88, 95% CI 0.84-0.93) were less likely to have ever tested for HIV.

CONCLUSIONS

HIV testing was low among heterosexuals, and individuals who engaged in condomless sex and had another sexually transmitted infection were less likely to be tested. To reduce HIV transmission, strategies to improve HIV testing among heterosexuals are needed.

Treponema pallidum Detection at Asymptomatic Oral, Anal, and Vaginal Sites in Adults Reporting Sexual Contact with Persons with Syphilis

We investigated Treponema pallidum PCR positivity at mucosal sites (oral, anal, and vaginal sites) among adults who had sexual contact with a person with syphilis (syphilis contacts). All syphilis contacts had oral rinse and swab samples collected for testing. Men who have sex with men had anal swab and women had vaginal swab samples collected for testing, regardless of the presence of lesions. Of 407 persons tested, 42 (10%) had early syphilis diagnosed; of those, 19 (45%) tested positive by PCR from any anatomic site and had a positive serologic test. T. pallidum was positive from vaginal samples in 3 women, anal samples in 3 men, and oral cavity samples in 2 women and 3 men, without symptoms at those sites. Three women had no prior syphilis serologic test. T. pallidum detection at asymptomatic mucosal sites suggests early syphilis infections, particularly in cases that would conventionally be staged as latent syphilis of unknown duration.

Emerging sexual and reproductive health in Australia and New Zealand: gaps, challenges and solutions

This Virtual Special Issue explores emerging topics in reproductive health in the Australian and New Zealand context. The included manuscripts cover pregnancy and termination of pregnancy, priority populations for sexual and reproductive health, digital technology and its impact on reproductive health, and perspectives from clinicians.

Treponema pallidum PCR screening at mucosal sites of asymptomatic men who have sex with men taking HIV pre-exposure prophylaxis

Early detection and treatment of syphilis will reduce the infectious period and transmission. We aimed to determine whether screening men who have sex with men (MSM) taking HIV pre-exposure prophylaxis (PrEP) for syphilis using Treponema pallidum polymerase chain reaction (PCR) could detect syphilis before the appearance of syphilis antibodies in serology. MSM attending 3-monthly PrEP clinic visits in Melbourne, Australia, were screened with a PCR assay targeting the polA gene of T. pallidum from an anal swab and an oral rinse between November 2019 and March 2020. Participants were serologically screened for syphilis using chemiluminescence immunoassay. A total of 309 asymptomatic participants provided an anal swab and oral rinse sample for T. pallidum PCR screening. Two syphilis cases (0.6%) were detected: one man had a positive serology only; another man had T. pallidum detected by PCR from an anal swab and a positive serology. PCR positivity was 0.3% (n = 1) for anal swabs and 0% (n = 0) for oral rinse. In this study, T. pallidum PCR screening at routine PrEP clinic visits did not identify additional cases of early syphilis over serological screening performed at these visits. IMPORTANCE With the ongoing syphilis epidemic in men who have sex with men (MSM), we investigated the role of using Treponema pallidum polymerase chain reaction (PCR) testing at the oral cavity and anus in MSM taking pre-exposure prophylaxis for the early detection of syphilis. We evaluated whether the PCR tests from these mucosal sites can detect syphilis infection early, before the development of syphilis antibodies in serology. Our study found two syphilis cases among 309 MSM, and only one syphilis case had a positive anal PCR swab, although serology was positive. We conclude that additional PCR testing is likely to be expensive and would not be cost effective for individuals who regularly screen for syphilis. However, future studies with a larger sample size are required.

The role of syphilis self-testing as an additional syphilis testing approach in key populations: a systematic review and meta-analysis

BACKGROUND

Syphilis is causing epidemics in many countries. Syphilis self-testing (SST) has potential to increase testing and treatment coverage in the same manner as documented for self-testing of, for example, HIV, hepatitis C virus, and COVID-19. We aimed to synthesise current evidence on the utility of SST.

METHODS

We conducted a systematic review and, where possible, meta-analysis. We searched MEDLINE, Embase, CINAHL, Scopus, and Web of Science for publications published from Jan 1, 2000, to Oct 13, 2022. We included publications with original data on any syphilis rapid tests, including dual HIV-syphilis tests. Study populations were not restricted. We used random-effects meta-analysis to calculate the pooled proportion of people offered SST who undertook the test. The systematic review was registered in PROSPERO (CRD42022302129).

FINDINGS

In total, 40 499 citations were identified. 11 publications from seven studies from the USA, Zimbabwe, and China met eligibility criteria. Of those, four studies reported data from men who have sex with men and five studies used dual HIV-SST. Using data from one randomised controlled trial and three observational studies, the pooled proportion of people who received SST kits who undertook the test was 88% (95% CI 85-91). No studies provided data on the sensitivity or specificity of SST. Overall, user and provider preference for SST was high, with participants reporting convenience, privacy, rapid results, autonomy, trust in blood-based tests, decreased facility contact, and time savings, with individuals being able to correctly self-test. Publications from China reported that SST had lower costs per person tested than existing facility-based testing options.

INTERPRETATION

Our review builds on the literature for self-testing across different disease areas and demonstrates that SST has the potential to reach underserved populations. As this review found that SST use was acceptable and feasible to implement, SST can be used as an additional syphilis testing approach. Since no data on the sensitivity and specificity of SST were found, further implementation research will be required to guide the best strategies for SST service delivery and future scale-up.

FUNDING

WHO, Australian National Health and Medical Research Council, and Unitaid.

Prevotella and Gardnerella Are Associated With Treatment Failure Following First-line Antibiotics for Bacterial Vaginosis

BACKGROUND

Bacterial vaginosis (BV) is a common vaginal dysbiosis that often recurs following first-line antibiotics. We investigated if vaginal microbiota composition was associated with BV recurrence.

METHODS

We analyzed samples and data from 121 women who participated in 3 published trials evaluating novel interventions for improving BV cure, including concurrent antibiotic treatment of regular sexual partners (RSPs). Women diagnosed with BV received first-line antibiotics and self-collected vaginal swabs pretreatment and the day after finishing antibiotics (immediately posttreatment). 16S rRNA gene sequencing was performed on vaginal samples. Logistic regression explored associations between BV recurrence and features of the vaginal microbiota pre- and posttreatment.

RESULTS

Sixteen women (13% [95% confidence interval {CI}, 8%-21%]) experienced BV recurrence within 1 month of treatment. Women with an untreated RSP were more likely to experience recurrence than women with no RSP (P = .008) or an RSP who received treatment (P = .011). A higher abundance of Prevotella pretreatment (adjusted odds ratio [AOR], 1.35 [95% CI, 1.05-1.91]) and Gardnerella immediately posttreatment (AOR, 1.23 [95% CI, 1.03-1.49]) were associated with increased odds of BV recurrence.

CONCLUSIONS

Having specific Prevotella spp prior to recommended treatment and persistence of Gardnerella immediately posttreatment may contribute to the high rates of BV recurrence. Interventions that target these taxa are likely required to achieve sustained BV cure.

Improving access to oral pre-exposure prophylaxis for HIV among international migrant populations

Pre-exposure prophylaxis (PrEP) is recommended for people susceptible to HIV acquisition, and the scale-up of PrEP programmes has contributed to new HIV case reductions at a population level. However, international migrants continue to be disproportionately affected by HIV. Understanding barriers and facilitators to PrEP implementation among international migrants can optimise PrEP use among this population and ultimately reduce HIV incidence worldwide. We reviewed the evidence regarding factors influencing PrEP implementation among international migrants; 19 studies were included. The barriers and facilitators at the individual level were related to knowledge and risk perception of HIV. Cost, provider discriminations, and health system navigation influenced PrEP use at the service level. Positive or negative perception towards LGBT+ identities, HIV, and PrEP users affected PrEP use at the societal level. Most existing PrEP campaigns do not target international migrants; therefore, culturally tailored approaches for people from different backgrounds are warranted. Potentially migration-related and HIV-related discriminatory policies must be reviewed to increase access to HIV prevention services to end HIV transmission at a population level.

Efficacy of Minocycline for the Treatment of Mycoplasma genitalium

Background

High levels of macrolide resistance and increasing fluoroquinolone resistance are making Mycoplasma genitalium increasingly difficult to treat. Minocycline is an alternative treatment for patients with macrolide-resistant M genitalium infections that have failed moxifloxacin, or for those with fluoroquinolone contraindications or resistance. Published efficacy data for minocycline for M genitalium are limited.

Methods

We evaluated minocycline 100 mg twice daily for 14 days at Melbourne Sexual Health Centre (MSHC). Microbial cure was defined as a negative test of cure within 14-90 days after completing minocycline. The proportion cured and 95% confidence intervals (CIs) were calculated, and logistic regression was used to explore factors associated with treatment failure. We pooled data from the current study with a prior adjacent case series of patients with M genitalium who had received minocycline 100 mg twice daily for 14 days at MSHC.

Results

Minocycline cured 60 of 90 (67% [95% CI, 56%-76%]) infections. Adherence was high (96%) and side effects were mild and self-limiting. No demographic or clinical characteristics were associated with minocycline failure in regression analyses. In the pooled analyses of 123 patients, 83 (68% [95% CI, 58%-76%]) were cured following minocycline.

Conclusions

Minocycline cured 68% of macrolide-resistant M genitalium infections. These data provide tighter precision around the efficacy of minocycline for macrolide-resistant M genitalium and show that it is a well-tolerated regimen. With high levels of macrolide resistance, increasing fluoroquinolone resistance, and the high cost of moxifloxacin, access to nonquinolone options such as minocycline is increasingly important for the clinical management of M genitalium.

Intra- and interhost genomic diversity of monkeypox virus

The impact and frequency of infectious disease outbreaks demonstrate the need for timely genomic surveillance to inform public health responses. In the largest known outbreak of mpox, genomic surveillance efforts have primarily focused on high-incidence nations in Europe and the Americas, with a paucity of data from South-East Asia and the Western Pacific. Here we analyzed 102 monkeypox virus (MPXV) genomes sampled from 56 individuals in Melbourne, Australia. All genomes fell within the 2022 MPXV outbreak lineage (B.1), with likely onward local transmission detected. We observed within-host diversity and instances of co-infection, and highlight further examples of structural variation and apolipoprotein B editing complex-driven micro-evolution in the current MPXV outbreak. Updating our understanding of MPXV emergence and diversification will inform public health measures and enable monitoring of the virus' evolutionary trajectory throughout the mpox outbreak.

Combinations of Sexual Activities During a Sex Episode with Recent Casual Male Partner Among Men Who Have Sex with Men: A Cross-Sectional Study

We examined combinations of nine sexual activities that occurred during a sex episode with a recent male partner among men who have sex with men (MSM) who attended an urban sexual health clinic from April-2017 to September-2017. We collected the following sexual activities: tongue-kissing, penises touching, using saliva during mutual masturbation, performed rimming, received rimming, performed fellatio, received fellatio, insertive anal sex, and receptive anal sex. During a single-sex episode, the most common combinations of sexual activities involved all nine activities (10.6%, 166/1542). We assessed the agreement between any two sexual activities that occurred together during a sex episode. Agreement was highest for receiving rimming and receptive anal sex (kappa = 0.40; 95% CI: 0.35, 0.45), and performing rimming and insertive anal sex (kappa = 0.38; 95% CI: 0.33, 0.42). Agreement was lowest for insertive anal sex and receiving fellatio (kappa = -0.01; 95% CI: -0.05, 0.03), and receptive anal sex and insertive anal sex (kappa = -0.08; 95% CI: -0.13, 0.03). The sexual activities that occur between men are correlated with one another and this will influence transmission between anatomical sites.

Agreement of and discussion with clients about Undetectable equals Untransmissible among general practitioners in Australia: a cross-sectional survey

BACKGROUND

The message of undetectable HIV viral load equals untransmissible (U=U) is important to reduce HIV stigma. We examined Australian general practitioner (GP)s' agreement of and discussion with clients about U=U.

METHODS

We conducted an online survey through GP networks from April to October 2022. All GPs working within Australia were eligible. Univariable and multivariable logistic regression analyses were performed to identify factors associated with: (1) agreement of U=U; and (2) discussing U=U with clients.

RESULTS

Of 703 surveys, 407 were included in the final analysis. Mean age was 39.7years (s.d.: 8.4). Most GPs (74.2%, n=302) agreed with U=U, but only 33.9% (n=138) had ever discussed U=U with clients. Key barriers to discussing U=U were lack of relevant client presentations (48.7%), lack of understanding about U=U (39.9%), and difficulty identifying those who would benefit from U=U (6.6%). Agreement with U=U was associated with greater odds of discussing U=U (adjusted odds ratio (AOR) 4.75, 95% confidence interval (CI): 2.33-9.68), younger age (AOR 0.96 per additional year of age, 95%CI: 0.94-0.99), and extra training in sexual health (AOR 1.96, 95%CI: 1.11-3.45). Discussing U=U was associated with younger age (AOR 0.97, 95%CI: 0.94-1.00), extra training with sexual health (AOR 1.93, 95%CI: 1.17-3.17), and negatively associated with working in a metropolitan or suburban area (AOR 0.45, 95%CI: 0.24-0.86).

CONCLUSION

Most GPs agreed with U=U, but most had not discussed U=U with their clients. Concerningly, one in four GPs were neutral or disagreed with U=U, suggesting that further qualitative research to understand this finding, and implementation research to promote U=U among Australian GPs, is urgently needed.

Assortative Sexual Mixing by Age, Region of Birth, and Time of Arrival in Male-Female Partnerships in Melbourne, Australia

BACKGROUND

Patterns of sexual mixing may be influenced by demographic factors where individuals show a preference for partners with particular traits and may have different levels of risk for HIV and sexually transmitted infection transmission. We aimed to explore age differences and mixing by region of birth among male-female partnerships.

METHODS

Male-female partnerships who presented to Melbourne Sexual Health Centre in Australia between 2015 and 2019 were investigated. Age and country of birth of sexual partners were collected. We calculated the age differences between partners and created tables demonstrating partnership mixing by age groups and by international region of birth.

RESULTS

A total of 2112 male-female partnerships (i.e., 4224 individuals) were included. The median age was 27 years (interquartile range, 23-31 years). Between men and women in partnerships, the median age difference was 1 year. Nearly half of all individuals (49.1% [2072 of 4224]) were in a partnership with another individual in the same 5-year interval age group as their own, and a majority of individuals (58.5% [2334 of 3988]) were in a partnership with another individual from the same region of birth when compared with other regions.

CONCLUSIONS

There is a strong assortative sexual mixing pattern by age and region of birth among male-female partnerships in Melbourne, Australia. These results may have applications in further research to understand sexually transmitted infection transmission among clients attending sexual health centers, particularly those born overseas.

Corrigendum to: Efficacy and acceptability of 'nudges' aimed at promoting pre-exposure prophylaxis (PrEP) use: a survey of overseas born men who have sex with men

BACKGROUND

This study explores the potential for behavioural economics techniques called 'nudges' to encourage the use of HIV pre-exposure prophylaxis (PrEP) by overseas-born men who have sex with men (MSM) in Australia. We investigated the preferences of overseas-born MSM for different nudges and the effect of nudges on reported likelihood of seeking information about PrEP.

METHODS

We conducted an online survey of overseas-born MSM, in which they were asked: (1) how likely they and a relevant friend would be to click on PrEP advertisements that used behavioural economics strategies; and (2) what they most and least liked about each ad. We conducted ordered logistic regression of reported likelihood scores against participant age and sexual orientation, use of a model in an advertisement, use of statistics about PrEP, reference to the World Health Organization (WHO), rewards for seeking further information, and use of a call-to-action.

RESULTS

Participants (n =324) reported higher likelihoods of clicking on advertisements with images of people, statistics about PrEP, rewards for seeking further information, and calls-to-action. They reported lower likelihoods of clicking on advertisements referencing the WHO. They had negative emotional responses to sexualised humour, gambling metaphors, and the slogan 'Live Fearlessly'.

CONCLUSIONS

Overseas-born MSM prefer public health messages that feature representative messengers and statistics about PrEP. These preferences are consistent with previous data on descriptive norms (i.e. statistics about the number of peers doing the desired behaviour) and gain-framed information (i.e. focusing on what can be gained from an intervention).

Missed opportunities for HIV testing among those who accessed sexually transmitted infection (STI) services, tested for STIs and diagnosed with STIs: a systematic review and meta-analysis

INTRODUCTION

Of 37.7 million people living with HIV in 2020, 6.1 million still do not know their HIV status. We synthesize evidence on concurrent HIV testing among people who tested for other sexually transmitted infections (STIs).

METHODS

We conducted a systematic review using five databases, HIV conferences and clinical trial registries. We included publications between 2010 and May 2021 that reported primary data on concurrent HIV/STI testing. We conducted a random-effects meta-analysis and meta-regression of the pooled proportion for concurrent HIV/STI testing.

RESULTS

We identified 96 eligible studies. Among those, 49 studies had relevant data for a meta-analysis. The remaining studies provided data on the acceptability, feasibility, barriers, facilitators, economic evaluation and social harms of concurrent HIV/STI testing. The pooled proportion of people tested for HIV among those attending an STI service (n = 18 studies) was 71.0% (95% confidence intervals: 61.0-80.1, I2 = 99.9%), people tested for HIV among those who were tested for STIs (n = 15) was 61.3% (53.9-68.4, I2 = 99.9%), people tested for HIV among those who were diagnosed with an STI (n = 13) was 35.3% (27.1-43.9, I2 = 99.9%) and people tested for HIV among those presenting with STI symptoms (n = 3) was 27.1% (20.5-34.3, I2 = 92.0%). The meta-regression analysis found that heterogeneity was driven mainly by identity as a sexual and gender minority, the latest year of study, country-income level and region of the world.

DISCUSSION

This review found poor concurrent HIV/STI testing among those already diagnosed with an STI (35.3%) or who had symptoms with STIs (27.1%). Additionally, concurrent HIV/STI testing among those tested for STIs varied significantly according to the testing location, country income level and region of the world. A few potential reasons for these observations include differences in national STI-related policies, lack of standard operation procedures, clinician-level factors, poor awareness and adherence to HIV indicator condition-guided HIV testing and stigma associated with HIV compared to other curable STIs.

CONCLUSIONS

Not testing for HIV among people using STI services presents a significant missed opportunity, particularly among those diagnosed with an STI. Stronger integration of HIV and STI services is urgently needed to improve prevention, early diagnosis and linkage to care services.

A qualitative evaluation of a Nudgeathon event for the co-design of sexual health campaign images targeting overseas-born men who have sex with men

BACKGROUND

Additional approaches to HIV prevention and management, such as Nudgeathons, are required to increase access to HIV pre-exposure prophylaxis (PrEP) among overseas-born men who have sex with men (MSM).

METHODS

In September 2021, we conducted a 4-h online Nudgeathon, wherein four teams co-designed behaviourally informed adverts to improve PrEP access and uptake for overseas-born MSM. After the Nudgeathon, eight of 17 invited Nudgeathon attendees were interviewed about their experience. We conducted a qualitative content analysis of interview data to highlight participants' experiences of the co-design process.

RESULTS

We identified three major themes: (1) what worked well; (2) group dynamics; and (3) improvement and future directions. The Nudgeathon about PrEP was a positive learning experience, with valuable contributions and overall satisfaction with the end-products. The online format was perceived as less costly than if the Nudgeathon was hosted in person, and suitable for participants from different geographical regions. In-person Nudgeathons with international attendees would require costs for flights, accommodation, function room hire and catering. Within groups, sharing personal experiences essential to co-designing concepts. However, less information on how to create nudges and more information before the Nudgeathon was preferred.

CONCLUSION

Our evaluation finds that Nudgeathons are fast and efficient in developing potential solutions to complex issues related to HIV prevention.

Preferences for HIV prevention strategies among newly arrived Asian-born men who have sex with men living in Australia: A discrete choice experiment

The HIV epidemic in Australia is changing with higher risk for HIV among newly-arrived Asian-born men who have sex with men (MSM) compared to Australian-born MSM. We evaluated the preferences for HIV prevention strategies among 286 Asian-born MSM living in Australia for &lt;5 years. A latent class analysis uncovered three classes of respondents who were defined by their preferences: “PrEP” (52%), “Consistent condoms” (31%), and “No strategy” (17%). Compared to the “No strategy” class, men in the “PrEP” class were less likely to be a student or ask their partner for their HIV status. Men in the “Consistent condoms” class were more likely to get information about HIV from online, and less likely to ask their partner for their HIV status. Overall, PrEP was the preferred HIV prevention strategy for newly arrived migrants. Removing structural barriers to access PrEP can accelerate progress toward ending HIV transmission.

Changes in the Syphilis Rapid Plasma Reagin Titer Between Diagnosis and Treatment

BACKGROUND

We compared the rapid plasma reagin (RPR) titer on the day of initial presentation with that on the day of syphilis treatment to inform clinical practice as to whether a repeated RPR test should be recommended.

METHODS

We undertook a retrospective study between 1 March 2011 and 31 December 2020 at the Melbourne Sexual Health Centre in Australia among individuals who underwent syphilis serology on the day of initial presentation and the day of treatment, if the latter were within 14 days after initial presentation. We calculated the percentage of individuals with a ≥4-fold change in RPR titer, stratified by the time between initial presentation and treatment and by syphilis stage.

RESULTS

Among the 766 included syphilis cases, the median duration between initial presentation and treatment was 6 days (interquartile range, 5-7 days). Of these cases, 14.8% (n = 113) had a ≥4-fold increase or decrease during this interval. The number of cases with a ≥4-fold increase or decrease in RPR titer increased with increasing time between initial presentation and treatment, from 5.7% (n = 6) 1-3 days after initial presentation to 26.2% (n = 27) at 10-14 days (Ptrend < .001). There was no significant difference in the number of cases with a ≥4-fold increase or decrease in RPR titer between syphilis stages (P = .66).

CONCLUSIONS

Our data support the recommendation of repeating the RPR titer if the day of initial presentation and the day of treatment are different, even when treatment is within a few days after initial presentation.

Correlation between monkeypox viral load and infectious virus in clinical specimens

BACKGROUND

In the 2022 mpox outbreak, several studies have explored longitudinal DNA shedding of mpox virus (MPXV) using PCR. However, there are fewer studies assessing infectivity in cell culture, and, by inference, MPXV transmissibility. Such information could help inform infection control and public health guidelines.

AIMS AND METHODS

The aim of this study was to correlate cell culture infectivity of clinical samples with viral loads in clinical samples. Between May to October 2022, clinical samples from different body sites sent to the Victorian Infectious Diseases Reference Laboratory in Melbourne, Australia for MPXV PCR detection were cultured in Vero cells as a surrogate for infectivity.

RESULTS

In the study period, 144 samples from 70 patients were tested by MPXV PCR. Viral loads in skin lesions were significantly higher than those in throat or nasopharyngeal samples (median Ct 22.0 vs 29.0, p = 0.0013 and median Ct 22.0 vs 36.5, p = 0.0001, respectively). Similarly, viral loads were significantly higher in anal samples compared to throat or nasopharyngeal samples (median Ct 20.0 vs. 29.0, p=<0.0001 and median Ct 20.0 vs. 36.5, p=<0.0001, respectively). Viral culture was successfully performed in 80/94 samples. Using logistic regression analysis, 50% of the samples were positive in viral culture at Ct 34.1 (95% confidence intervals 32.1-37.4).

CONCLUSIONS

Our data further validate recent findings showing that samples with a higher MPXV viral load are more likely to demonstrate infectivity in cell culture. Although the presence of infectious virus in cell culture may not directly translate with clinical transmission risk, our data may be used as an adjunct help inform guidelines on testing and isolation policies in individuals with mpox.

Weight Change When Initiating, Switching to, and Discontinuing Integrase Strand Transfer Inhibitors in People Living with HIV

Further investigations into the relationship between integrase strand transfer inhibitors (INSTIs) and weight gain are required, especially whether ceasing INSTI results in weight loss. We evaluated weight changes associated with different antiretroviral (ARV) regimens. A retrospective longitudinal cohort study was conducted using data extracted from the electronic clinical database at the Melbourne Sexual Health Centre, Australia, from 2011 to 2021. The association between weight change per time unit and ARV use in people living with HIV (PLWH) and the factors associated with weight changes when using INSTIs were estimated using a generalized estimated equation model. We included 1540 PLWH contributing 7476 consultations and 4548 person-years of data. ARV-naive PLWH initiating INSTIs gained an average of 2.55 kg/year (95% confidence interval 0.56 to 4.54; p = 0.012), while those using protease inhibitors and non-nucleoside reverse transcriptase inhibitors had no significant weight change. When switching off INSTIs, there was no significant weight change (p = 0.055). These weight changes were adjusted for age, gender, time on ARVs, and/or use of tenofovir alafenamide (TAF). Weight gain was the main reason PLWH ceased INSTIs. In addition, risk factors for weight gain in INSTI users were age younger than 60 years, male gender, and concomitant use of TAF. Weight gain was found among PLWH using INSTIs. After INSTI discontinuation, PLWH's weight stopped rising, but no weight loss was observed. Careful weight measurement after initiating INSTIs and early initiation of strategies to avoid weight gain will be important to prevent permanent weight gain and the associated morbidity.

Supernatural beliefs, religious affiliations, and HIV testing among recently arrived Asian-born men who have sex with men in Australia

HIV testing rates among recently arrived (≤5 years) Asian-born men who have sex with men (MSM) in Australia remain suboptimal. Research indicates that belief in supernatural determinants of health (supernatural beliefs) may be an important barrier to greater HIV test uptake. We examined potential associations between supernatural beliefs and HIV testing among recently arrived Asian-born MSM in Australia. In 2019, an online survey was completed by 186 self-identified MSM born in Asia, and who arrived in Australia within the past five years and were never diagnosed with HIV. Supernatural belief was measured as the extent to which one felt that health was influenced by supernatural forces. Measures of association were estimated with multiple logistic regression. Participants with supernatural beliefs were significantly less likely to have tested for HIV in the past year. The adjusted predicted probability of not testing for HIV in the past year was 44.8% among those who held supernatural beliefs (95% CI: 30.5-59.2%), but only 5.2% among those who did not hold supernatural beliefs (95% CI: 1.9-8.6%). Religious affiliation was not significantly associated with testing for HIV. Supernatural beliefs may be an important but underappreciated barrier to HIV testing among recently arrived Asian-born MSM in Australia.

Efficacy and acceptability of 'nudges' aimed at promoting pre-exposure prophylaxis (PrEP) use: a survey of overseas born men who have sex with men

BACKGROUND

This study explores the potential for behavioural economics techniques called 'nudges' to encourage the use of HIV pre-exposure prophylaxis (PrEP) by overseas-born men who have sex with men (MSM) in Australia. We investigated the preferences of overseas-born MSM for different nudges and the effect of nudges on reported likelihood of seeking information about PrEP.

METHODS

We conducted an online survey of overseas-born MSM, in which they were asked: (1) how likely they and a relevant friend would be to click on PrEP advertisements that used behavioural economics strategies; and (2) what they most and least liked about each ad. We conducted ordered logistic regression of reported likelihood scores against participant age and sexual orientation, use of a model in an advertisement, use of statistics about PrEP, reference to the World Health Organization (WHO), rewards for seeking further information, and use of a call-to-action.

RESULTS

Participants (n=324) reported higher likelihoods of clicking on advertisements with images of people, statistics about PrEP, rewards for seeking further information, and calls-to-action. They reported lower likelihoods of clicking on advertisements referencing the WHO. They had negative emotional responses to sexualised humour, gambling metaphors, and the slogan 'Live Fearlessly'.

CONCLUSIONS

Overseas-born MSM prefer public health messages that feature representative messengers and statistics about PrEP. These preferences are consistent with previous data on descriptive norms (i.e. statistics about the number of peers doing the desired behaviour) and gain-framed information (i.e. focusing on what can be gained from an intervention).

Sexual activities and condom use among heterosexual men and women engaged in mixed-gender group sex events in Melbourne, Australia

BACKGROUND

Few studies investigate group sex among heterosexuals. The aim of this study was to provide an exploration of characteristics and practices among heterosexual men and women who engage in group sex.

METHOD

We conducted a cross-sectional survey between May 2019 and March 2020 among heterosexual men and women attending a sexual health clinic in Melbourne, Australia. Participants were asked whether they had participated in group sex (sex involving more than two participants) in the past 3months, the size of the most recent event, sexual activities in which they engaged, and condom use.

RESULTS

Of 3277 heterosexuals surveyed (1509 women and 1768 men), the mean age was 29.9years (s.d. 8.8) and more than half (56.0%, n =1834) were born outside Australia. One in 20 participants (5.4%) had engaged in group sex in the past 3months with the number of events ranging 1-10times. Kissing was the most common activity in group sex, and women were significantly more likely to kiss a same-sex partner than men. Overall, of 165 participants who engaged in vaginal sex, 57 (34.5%) reported always using condoms and changing condoms between consecutive partners. Of the 100 men and women who had condomless vaginal sex, 79 (79.0%) received or performed fellatio after condomless vaginal sex.

CONCLUSION

About two-thirds of heterosexuals who engaged in group sex neither used condoms nor changed condoms between partners in the most recent group sex event. Safe sex messages on changing condoms between partners and between sexual activities should be reinforced for sexually transmitted infections prevention.

Determinants and prediction of Chlamydia trachomatis re-testing and re-infection within 1 year among heterosexuals with chlamydia attending a sexual health clinic

Background

Chlamydia trachomatis (chlamydia) is one of the most common sexually transmitted infections (STI) globally, and re-infections are common. Current Australian guidelines recommend re-testing for chlamydia 3 months after treatment to identify possible re-infection. Patient-delivered partner therapy (PDPT) has been proposed to control chlamydia re-infection among heterosexuals. We aimed to identify determinants and the prediction of chlamydia re-testing and re-infection within 1 year among heterosexuals with chlamydia to identify potential PDPT candidates.

Methods

Our baseline data included 5,806 heterosexuals with chlamydia aged ≥18 years and 2,070 re-tested for chlamydia within 1 year of their chlamydia diagnosis at the Melbourne Sexual Health Center from January 2, 2015, to May 15, 2020. We used routinely collected electronic health record (EHR) variables and machine-learning models to predict chlamydia re-testing and re-infection events. We also used logistic regression to investigate factors associated with chlamydia re-testing and re-infection.

Results

About 2,070 (36%) of 5,806 heterosexuals with chlamydia were re-tested for chlamydia within 1 year. Among those retested, 307 (15%) were re-infected. Multivariable logistic regression analysis showed that older age (≥35 years old), female, living with HIV, being a current sex worker, patient-delivered partner therapy users, and higher numbers of sex partners were associated with an increased chlamydia re-testing within 1 year. Multivariable logistic regression analysis also showed that younger age (18-24 years), male gender, and living with HIV were associated with an increased chlamydia re-infection within 1 year. The XGBoost model was the best model for predicting chlamydia re-testing and re-infection within 1 year among heterosexuals with chlamydia; however, machine learning approaches and these self-reported answers from clients did not provide a good predictive value (AUC < 60.0%).

Conclusion

The low rate of chlamydia re-testing and high rate of chlamydia re-infection among heterosexuals with chlamydia highlights the need for further interventions. Better targeting of individuals more likely to be re-infected is needed to optimize the provision of PDPT and encourage the test of re-infection at 3 months.

Incidence and Risk Factors for Early Syphilis Among Men Who Have Sex With Men in Australia, 2013-2019: A Retrospective Cohort Study

Background

We aimed to examine the incidence of syphilis in men who have sex with men (MSM) and identify subgroups of MSM at a higher risk of syphilis infection.

Methods

We conducted a retrospective cohort study of MSM attending a sexual health clinic in Australia, during 2013-2019, who had at least 2 syphilis serological tests during the study period. The incidence of syphilis was expressed as per 100 person-years. A cox regression analysis was conducted to identify risk factors for syphilis.

Results

A total of 24 391 individual MSM (75 086 consultations) were included. A total of 1404 new syphilis cases were diagnosed with an incidence of 3.7/100 person-years (95% confidence interval, 3.5-3.9). Syphilis incidence was higher in MSM with human immunodeficiency virus ([HIV] 9.3/100 person-years) than in MSM taking HIV pre-exposure prophylaxis (PrEP) (6.9/100 person-years) or HIV-negative MSM not taking PrEP (2.2/100 person-years). Risk factors associated with high incidence of syphilis included the following: MSM with HIV (adjusted hazard ratio [aHR] 2.7), MSM taking HIV PrEP (aHR 2.1), past history of syphilis infection (aHR 2.4), injecting drug use (aHR 2.7), condomless anal sex (aHR 1.7), >4 sexual partners in the last 12 months (aHR 1.2), and concurrent sexually transmitted infection (chlamydia and gonorrhoea) (aHR 1.6).

Conclusions

The incidence of syphilis remains high among MSM, particularly in subgroups with associated risk factors for syphilis infections. These data highlight the need for biomedical and behavioral interventions to be targeted to subgroups of MSM at the highest risk of syphilis infection.

eSexualHealth: Preferences to use technology to promote sexual health among men who have sex with men and trans and gender diverse people

Objectives

Gay, bisexual and other men who have sex with men (GBMSM) and trans and gender diverse (TGD) people are disproportionately affected by poorer sexual health outcomes compared to heterosexual populations. We aimed to explore the preferences of GBMSM and TGD for using eHealth for sexual health (eSexualHealth).

Methods

We distributed an anonymous online survey from April to August 2021among the lesbian, gay, bisexual, transgender, intersex, queer and other people of diverse sexuality or gender (LGBTIQA+) community in Australia. The survey collected data on sociodemographic characteristics and sexual behaviors, their preferences for app/website functions and preferred HIV and sexually transmitted infection (STI) testing reminders. We used descriptive statistics to summarize the characteristics of the study population. Free-text responses were thematically analyzed.

Results

Of 466 participants included, most identified as cisgender males (92.7%). The median age was 48 [interquartile range (IQR): 37-56]. For accessing sexual health-related information, 160 (34.6%) would use either a website or an app, 165 (32.7%) would prefer a website, 119 (25.8%) would prefer an app, and 33 (7.1%) would not use either platform. There was no significant difference between GBMSM and TGD people. Participants were most interested in information about STI clinics, HIV/STI hotspots, and sexual health education. Participants stressed the need for privacy and anonymity when using eHealth. Regarding reminders to test for HIV/STIs, receiving regular SMS was most popular (112/293, 38.2%), followed by regular emails (55/293 18.8%) and a reminder function on their phone (48/293, 16.4%).

Conclusion

Our study suggests a promising future for eHealth among GBMSM and TGD people. Sexual health is still a stigmatized area, and eHealth may circumvent barriers this population faces.

The duration and body position during tongue-kissing among heterosexual men and women

Background

Emerging data suggest tongue-kissing may transmit gonorrhea. We aim to examine the duration or body position of heterosexual men and women during tongue-kissing (henceforth, known as kissing).

Methods

A cross-sectional survey among heterosexual men and women attending the Melbourne Sexual Health Centre in Australia between May 2019 and March 2020 collected data on the duration and body position (i.e., on top of or lying down underneath) of their most recent kissing partner in the past 3 months. Univariable and multivariable linear regressions were performed to examine the association between gender and kissing duration.

Results

Of 2,866 individuals, 93.6% (n = 2,683) had at least one kissing partner in the past 3 months, which included 1,342 (50.1%) men and 1,341 (49.9%) women, and 87.2% (n = 2,339) had sex with their opposite-gender kissing partner. The adjusted mean duration of kissing with the most recent opposite-gender kissing partner did not differ between men and women (12.2 vs. 11.5 min, p = 0.170). More men were on top of their most recent opposite-gender kissing partner compared to women (87.9 vs. 82.9%, p < 0.001). Men reported a longer kissing duration than women when they were on top of the opposite-gender kissing partner (8.3 vs. 7.4 min, p = 0.006). More women had same-gender kissing partners than men (9.6 vs. 2.8%, p < 0.001).

Conclusion

Men spending longer than women on top of their opposite-gender kissing partner suggests a potential alternative explanation for oropharyngeal gonorrhea being seen more commonly in women. Further research should investigate whether body positioning and duration of kissing influence the risk of gonorrhea transmission.

Improved rapid diagnostic tests to detect syphilis and yaws: a systematic review and meta-analysis

BACKGROUND

Current rapid tests for syphilis and yaws can detect treponemal and non-treponemal antibodies. We aimed to critically appraise the literature for rapid diagnostic tests (RDTs) which can better distinguish an active infection of syphilis or yaws.

METHODS

We conducted a systematic review and meta-analysis, searching five databases between January 2010 and October 2021 (with an update in July 2022). A generalised linear mixed model was used to conduct a bivariate meta-analysis for the pooled sensitivity and specificity. Heterogeneity was assessed using the I² statistic. We used the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) to assess the risk of bias and Grading of Recommendations, Assessment, Development and Evaluations (GRADE) to evaluate the certainty of evidence.

RESULTS

We included 17 studies for meta-analyses. For syphilis, the pooled sensitivity and specificity of the treponemal component were 0.93 (95% CI: 0.86 to 0.97) and 0.98 (95% CI: 0.96 to 0.99), respectively. For the non-treponemal component, the pooled sensitivity and specificity were 0.90 (95% CI: 0.82 to 0.95) and 0.97 (95% CI: 0.92 to 0.99), respectively. For yaws, the pooled sensitivity and specificity of the treponemal component were 0.86 (95% CI: 0.66 to 0.95) and 0.97 (95% CI: 0.94 to 0.99), respectively. For the non-treponemal component, the pooled sensitivity and specificity were 0.80 (95% CI: 0.55 to 0.93) and 0.96 (95% CI: 0.92 to 0.98), respectively.

CONCLUSIONS

RDTs that can differentiate between active and previously treated infections could optimise management by providing same-day treatment and reducing unnecessary treatment.

PROSPERO REGISTRATION NUMBER

CRD42021279587.

Anal and oral detection of Treponema pallidum in men who have sex with men with early syphilis infection

OBJECTIVES

We aimed to characterise patterns of anal and oral detection of Treponema pallidum among men who have sex with men (MSM) with early syphilis.

METHODS

200 MSM with serologically confirmed primary, secondary and early latent syphilis were tested with T. pallidum polA PCR using an anal canal swab, oral rinse, plus swabs from any anal and oral lesions in a prospective, cross-sectional study. Anal and oral T. pallidum cycle threshold values were compared between subsets of men and according to rapid plasma reagin (RPR) titre.

RESULTS

Of 200 men with early syphilis, 45 and 48 had anal and oral T. pallidum detected, respectively. Cycle threshold values were lower with anal compared with oral T. pallidum whether lesions were present or not. Among 27 and 42 men with anal and oral T. pallidum detected, respectively, and no anal or oral primary lesion, frequency of detection increased with increasing RPR titre, with 95% (25/27) and 98% (41/42) of shedding from respective sites occurring with RPR titres ≥1:16. 6.5% (13/200) of men with syphilis had concurrent detection of T. pallidum from both anal and oral sites: 9/13 with secondary syphilis, 7/9 of whom had anal lesions with a median duration of 30 days (range 7-180 days).

CONCLUSIONS

These data suggest T. pallidum load at the anus is higher than at the oral cavity and that a subset of men with secondary syphilis and prolonged anal lesions may be relatively infectious. Earlier detection and treatment of syphilis, when RPR titres are lower than 1:16, could potentially reduce infectiousness from anal and oral sites.

Intimacy during the COVID-19 pandemic: an online survey examining the impact of COVID-19 on the sexual practices and dating app usage of people living in Hong Kong

BACKGROUND

Little attention has been paid to understanding the impact of the coronavirus disease 2019 (COVID-19) pandemic on sexual practices and dating app usage among the Chinese population. To fill this gap, we examined the sexual practices and dating app usage of Hong Kong residents during the COVID-19 pandemic.

METHOD

An online survey was developed to collect data, and the participants were recruited via online social media. The respondents were asked to report on their sexual practices and dating app usage during the COVID-19 pandemic.

RESULTS

In total, 249 participants met the inclusion criteria for the analysis. We found that more than 70% of the participants began masturbating more. Almost half of the participants reported decreases in various sexual activities with sexual partners, including vaginal, anal and oral sex. The vast majority of the study participants also reported a decline in sexual activities with casual partners, regular non-romantic partners and sex workers. Meanwhile, dating apps were used more frequently for chatting/texting, swapping photos, sexting and virtual dating. More than 50% of the participants reported less use of dating apps for face-to-face dates and sexual encounters.

CONCLUSION

It is evident that the COVID-19 pandemic and its corresponding public health measures impacted the sexual practices and dating app usage of Hong Kong residents.

Universal lymphogranuloma venereum (LGV) testing of rectal chlamydia in men who have sex with men and detection of asymptomatic LGV

BACKGROUND

Lymphogranuloma venereum (LGV) is caused by Chlamydia trachomatis serovars L1-L3. This study determined the positivity for LGV testing before and after introduction of universal LGV testing of positive rectal Chlamydia trachomatis samples in men who have sex with men (MSM).

METHODS

From March 2015 to February 2018, MSM with rectal C. trachomatis were not routinely tested for LGV at the Melbourne Sexual Health Centre unless they had HIV or symptoms of proctitis. From February 2018, universal testing for LGV of all positive rectal C. trachomatis specimens in men over the age of 25 years, regardless of symptoms was undertaken. LGV positivity was defined as the detection of LGV-associated C. trachomatis serovars.

RESULTS

There were 3429 and 4020 MSM who tested positive for rectal chlamydia in the selective and universal LGV-testing periods, respectively. Of the total 3027 assessable specimens in both periods, 97 (3.2%; 95% CI 2.6% to 3.9%) specimens tested positive for LGV. LGV positivity in the selective testing period was higher than in the universal testing period (6.6% (33/502) vs 2.5% (64/2525), p<0.001). The proportion of LGV cases that were asymptomatic increased from 15.2% (5/33) in the selective testing period to 34.4% (22/64) in the universal testing period (p=0.045). Of the 70 symptomatic LGV cases symptoms included rectal discharge (71.4%, n=45) and rectal pain (60.0%, n=42).

CONCLUSION

Universal LGV testing of all positive rectal chlamydia samples in MSM compared with selective testing led to the detection of asymptomatic rectal LGV, which constituted 34% of rectal LGV cases.

Optimisation of treatments for oral Neisseria gonorrhoeae infection: Pharmacokinetics Study (STI-PK project) - study protocol for non-randomised clinical trial

INTRODUCTION

Neisseria gonorrhoeae infections are common and incidence increasing. Oropharyngeal infections are associated with greater treatment failure compared with other sites and drive transmission to anogenital sites through saliva. Gonococcal resistance is increasing and new treatments are scarce, therefore, clinicians must optimise currently available and emerging treatments in order to have efficacious therapeutic options. This requires pharmacokinetic data from the oral cavity/oropharynx, however, availability of such information is currently limited.

METHODS AND ANALYSIS

Healthy male volunteers (participants) recruited into the study will receive single doses of either ceftriaxone 1 g, cefixime 400 mg or ceftriaxone 500 mg plus 2 g azithromycin. Participants will provide samples at 6-8 time points (treatment regimen dependent) from four oral sites, two oral fluids, one anorectal swab and blood. Participants will complete online questionnaires about their medical history, sexual practices and any side effects experienced up to days 5-7. Saliva/oral mucosal pH and oral microbiome analysis will be undertaken. Bioanalysis will be conducted by liquid chromatography-mass spectrometry. Drug concentrations over time will be used to develop mathematical models for optimisation of drug dosing regimens and to estimate pharmacodynamic targets of efficacy.

ETHICS AND DISSEMINATION

This study was approved by Royal Melbourne Hospital Human Research Ethics Committee (60370/MH-2021). The study results will be submitted for publication in peer-reviewed journals and reported at conferences. Summary results will be sent to participants requesting them. All data relevant to the study will be included in the article or uploaded as supplementary information.

TRIAL REGISTRATION NUMBER

ACTRN12621000339853.

Time to healthcare seeking following the onset of symptoms among men and women attending a sexual health clinic in Melbourne, Australia

BACKGROUND

Timely diagnosis and treatment of sexually transmitted infections (STIs) underpin their control by reducing the duration of infectiousness. There are currently limited data exploring healthcare seeking among individuals with STI symptoms.

METHODS

We analyzed data on individuals reporting STI symptoms at the Melbourne Sexual Health Centre (MSHC) between August 2017 and December 2020. We calculated the time between symptom onset and clinic attendance by risk group for 13 STI diagnoses. We performed univariable and multivariable logistic regression analyses to explore factors associated with delayed healthcare seeking (greater than 7 days).

RESULTS

Among 7,032 symptomatic clinic attendances, the shortest time to healthcare seeking was among individuals diagnosed with gonococcal urethritis (median 3 days), and the longest was among individuals diagnosed with genital warts (median 60 days). Individuals diagnosed with gonococcal urethritis sought care earlier than individuals diagnosed with non-gonococcal urethritis (median 3 vs. 6 days, p < 0.001), and individuals diagnosed with genital herpes sought care earlier than individuals diagnosed with primary syphilis (median 4 vs. 14 days, p < 0.001). Men who have sex with men, and men taking human immunodeficiency virus pre-exposure prophylaxis (PrEP), were least likely to delay healthcare seeking. Both men and women who delayed healthcare seeking were more likely to live further from the clinic than those who did not delay their presentation [p trend < 0.001 (men) and p trend = 0.049 (women)].

CONCLUSION

Improved local access to healthcare alongside targeted strategies to encourage early healthcare seeking among groups at increased likelihood of delay may reduce STI-associated morbidity and transmission.

Non-conventional interventions to prevent gonorrhea or syphilis among men who have sex with men: A scoping review

Objectives

We assessed nonconventional interventions that did not traditionally focus on increasing condom use and/or testing among men who have sex with men (MSM) and the evidence for these interventions.

Methods

Guided by the Participants, Concept and Context (PCC) framework, we searched five online databases from inception to 9 August 2021 for original research on interventions that do not focus on increasing condom use and/or testing to prevent gonorrhea and/or syphilis in MSM. Two researchers screened titles and abstracts to assess eligibility, reviewed articles' full text and resolved discrepancies through discussion. We charted relevant study information, and the included studies were critically appraised.

Results

Of 373 articles retrieved, 13 studies were included. These studies were conducted in Australia (n = 3), Belgium (n = 2), China (n = 3), the Netherlands (n = 1) and the US (n = 4). Two randomized controlled trials (RCTs) of doxycycline as pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) reduced any STI incidence (gonorrhea, syphilis, or chlamydia), but only doxycycline PEP significantly reduced syphilis incidence. Six studies of interventions that facilitated self-collection, self-examination, and self-testing, found varied evidence for gonorrhea and/or syphilis prevention. Four RCTs and one single-arm trial examined the efficacy of mouthwash, but the evidence remains inconclusive on whether mouthwash use can prevent transmission between men.

Conclusion

We found evidence for doxycycline PEP in reducing syphilis incidence, evidence on the use of mouthwash to prevent gonorrhea transmission between men remains inconclusive. More evidence is needed for interventions that do not focus on increasing condom use and/or testing to prevent gonorrhea and/or syphilis.

Web-Based Risk Prediction Tool for an Individual's Risk of HIV and Sexually Transmitted Infections Using Machine Learning Algorithms: Development and External Validation Study

Background

HIV and sexually transmitted infections (STIs) are major global public health concerns. Over 1 million curable STIs occur every day among people aged 15 years to 49 years worldwide. Insufficient testing or screening substantially impedes the elimination of HIV and STI transmission.

Objective

The aim of our study was to develop an HIV and STI risk prediction tool using machine learning algorithms.

Methods

We used clinic consultations that tested for HIV and STIs at the Melbourne Sexual Health Centre between March 2, 2015, and December 31, 2018, as the development data set (training and testing data set). We also used 2 external validation data sets, including data from 2019 as external “validation data 1” and data from January 2020 and January 2021 as external “validation data 2.” We developed 34 machine learning models to assess the risk of acquiring HIV, syphilis, gonorrhea, and chlamydia. We created an online tool to generate an individual’s risk of HIV or an STI.

Results

The important predictors for HIV and STI risk were gender, age, men who reported having sex with men, number of casual sexual partners, and condom use. Our machine learning–based risk prediction tool, named MySTIRisk, performed at an acceptable or excellent level on testing data sets (area under the curve [AUC] for HIV=0.78; AUC for syphilis=0.84; AUC for gonorrhea=0.78; AUC for chlamydia=0.70) and had stable performance on both external validation data from 2019 (AUC for HIV=0.79; AUC for syphilis=0.85; AUC for gonorrhea=0.81; AUC for chlamydia=0.69) and data from 2020-2021 (AUC for HIV=0.71; AUC for syphilis=0.84; AUC for gonorrhea=0.79; AUC for chlamydia=0.69).

Conclusions

Our web-based risk prediction tool could accurately predict the risk of HIV and STIs for clinic attendees using simple self-reported questions. MySTIRisk could serve as an HIV and STI screening tool on clinic websites or digital health platforms to encourage individuals at risk of HIV or an STI to be tested or start HIV pre-exposure prophylaxis. The public can use this tool to assess their risk and then decide if they would attend a clinic for testing. Clinicians or public health workers can use this tool to identify high-risk individuals for further interventions.

"How PrEPared are you?": Knowledge of and attitudes toward PrEP among overseas-born and newly arrived gay, bisexual, and other men who have sex with men in Australia

Introduction

Overseas-born and newly arrived gay and bisexual men and men who have sex with men (GBMSM) are at higher risk of acquiring HIV in comparison to Australian-born GBMSM. Pre-exposure prophylaxis (PrEP) is subsidized by the Australian government under Medicare, Australia's universal health insurance scheme, however many members of this population are Medicare-ineligible, which could prevent them from accessing PrEP. We wanted to explore participants' knowledge of and attitudes toward PrEP and their opinions of new PrEP modalities, namely injectable PrEP and PrEP implants.

Methods

We conducted in-depth qualitative interviews between February 2021 to September 2021 with 22 overseas-born, newly arrived (<5 years in Australia) GBMSM of varying PrEP use. We asked their opinions of PrEP and their preferences of new PrEP modalities. Interviews were audio recorded and transcribed verbatim. We conducted a reflexive thematic analysis to interpret the data.

Results

Participants' views reflect the intersections between systemic factors, such as Medicare ineligibility and the high cost of PrEP, with socio-cultural factors, such as lack of knowledge about PrEP, internalized stigma stemming from homo- and sex-negativity, and stigmatizing attitudes toward PrEP and PrEP users. For participants who were on PrEP, being community connected, having a positive relationship with doctors and nurses, and being informed of the option to purchase PrEP from overseas pharmacies at a low cost helped them to overcome some of these barriers. Additionally, there was a strong preference for injectable PrEP but not PrEP implants. Participants stressed the importance of providing a comprehensive information about PrEP specific to this population and to make PrEP free for all.

Conclusions

We concluded that resources about PrEP specific to this population that address both systemic and socio-cultural factors are needed, and for these resources to be available in languages other than English. This is to coincide with on-going advocacy to increase the capacity of publicly funded sexual health clinics to provide multilingual PrEP services for people without Medicare, and to make PrEP free for all. These combined strategies have the potential to increase PrEP knowledge and uptake among this population.

Real-world trends in incidence of bacterial sexually transmissible infections among gay and bisexual men using HIV pre-exposure prophylaxis (PrEP) in Australia following nationwide PrEP implementation: an analysis of sentinel surveillance data

BACKGROUND

Although data from large implementation trials suggest that sexually transmissible infection (STI) risk increases among gay and bisexual men who initiate HIV pre-exposure prophylaxis (PrEP), there are few data on the trends in population-level STI incidence in the years following widespread PrEP implementation. We aimed to describe trends in bacterial STI incidence among gay and bisexual men using PrEP across Australia in the context of broad PrEP availability through Australia's subsidised medicines scheme.

METHODS

We analysed linked clinical data from HIV-negative gay and bisexual men aged 16 years or older who had been prescribed PrEP across a sentinel surveillance clinical network, including 37 clinics in Australia, between Jan 1, 2016, and Dec 31, 2019. Patients were included if they had STI testing at least twice during the observation period. Repeat testing methods were used to calculate chlamydia, gonorrhoea, syphilis, and any STI incidence rates during individuals' periods of PrEP use. Incidence rate ratios (IRRs) for estimated change in incidence per half calendar year (6-month) period were calculated using negative binomial regression. Secondary analyses compared STI incidence rates across individuals initiating PrEP in each year from 2016 to 2019, as well as by length of time using PrEP (per each additional 6 months of PrEP use).

FINDINGS

22 730 men were included in the analyses. During the observation period, 11 351 chlamydia infections were diagnosed in 6630 (30·1%) of 22 034 men over 25 991·2 person-years of PrEP use (incidence rate 43·7 cases [95% CI 42·9-44·5] per 100 person-years). Chlamydia incidence decreased from 48·7 cases per 100 person-years in July-December, 2016, to 42·0 cases per 100 person-years in July-December, 2019 (IRR for estimated change per 6-month period 0·98 [95% CI 0·97-0·99]; p=0·0031). 9391 gonorrhoea infections were diagnosed in 5885 (26·9%) of 21 845 men over 24 858·7 person-years of PrEP use (incidence rate 37·8 cases [95% CI 37·0-38·5] per 100 person-years). Gonorrhoea incidence decreased from 45·5 cases per 100 person-years in July-December, 2016, to 37·2 cases per 100 person-years in July-December, 2019 (IRR 0·97 [95% CI 0·96-0·98]; p<0·0001). Declines in chlamydia and gonorrhoea incidence were most prominent in the first 18 months of observation and incidence was stable thereafter. 2062 syphilis infections were diagnosed in 1488 (7·7%) of 19 262 men over 21 978·9 person-years of PrEP use (incidence rate 9·4 cases [95% CI 9·0-9·8] per 100 person-years). Syphilis incidence increased from 6·2 cases per 100 person-years in July-December, 2016, to 9·8 cases per 100 person-years in July-December, 2019 (IRR 1·08 [95% CI 1·05-1·10]; p<0·0001).

INTERPRETATION

Chlamydia and gonorrhoea incidence among gay and bisexual men using PrEP were highest in the early months of PrEP implementation in Australia and stabilised at slightly lower rates thereafter following wider PrEP uptake. Lower prospective STI risk among people initiating PrEP in later years contributed to the observed trends in STI incidence. Widespread PrEP implementation can contribute to increased STI screening and detection.

FUNDING

Australian Department of Health, National Health and Medical Research Council.