Mpox Illness Narratives: Stigmatising Care and Recovery During and After an Emergency Outbreak

In May 2022, a global outbreak of mpox (formerly monkeypox virus) affected thousands of mainly gay and bisexual men. Mpox is usually a time-limited illness that can involve fever, pain, and skin lesions, but may require hospitalisation. There is scant research into the firsthand experiences of people affected by mpox, including experiences of symptoms, healthcare, and recovery. This study considers the different illness narratives of people who experienced mpox in Australia in 2022. In-depth interviews and 6-month follow-up interviews were conducted with 16 people, including 13 people diagnosed with mpox and three close contacts. All participants were cisgender gay or bisexual men living in Australia. Participants' accounts described minor to severe periods of sickness, negative and stigmatising experiences engaging with healthcare, and some participants experienced long-term effects on their sexual well-being and complications from mpox. The emergency outbreak context meant that mpox was highly distressing, making it difficult to manage and producing varying forms of disruption to everyday life. Mpox was narrated as disruptive in different ways: as a minor interruption to holiday plans, a prolonged period of poor health, or a biographically disruptive event prompting a re-evaluation of sexual values and health. This analysis demonstrates that an unfamiliar emergent disease outbreak related to sexual practices and sociality can reconfigure personal life and sexual well-being, suggesting a need to focus on providing quality patient care in outbreaks of mpox and other infectious diseases.

The Implications of PrEP Use, Condom Use, and Partner Viral Load Status for Openness to Serodifferent Partnering Among US Sexual Minority Men (SMM)

PrEP has been reported to facilitate openness to serodifferent sexual partnerships among sexual minority men (SMM). However, other aspects of a sexual scenario likely come into play, including whether or not condoms are used and whether or not the partner living with HIV has an undetectable viral load. This online survey study evaluated the association between PrEP status and openness to serodifferent partnering, as well as the effects of various sexual scenario variables (condom use and partner's viral load) among 268 HIV-negative SMM in the US. Each participant reported their PrEP status and rated their openness to serodifferent partnering in four sexual scenarios, which varied by condom use (with/without) and partner viral load status (detectable/undetectable). Analyses of covariance (ANCOVAs) were conducted to assess differences in openness to serodifferent partnering by PrEP status in each scenario, adjusting for background characteristics. A two-way repeated measures ANCOVA and a three-way mixed factorial ANCOVA, including PrEP status as a between-subjects variable, were also performed to assess the effects of condom use and partner viral load status on openness. Across all scenarios, current PrEP users expressed significantly greater openness to serodifferent partnering compared to participants who had never used PrEP. Current PrEP users were also more likely than former PrEP users to consider partnering with someone with an undetectable viral load without using condoms. Both PrEP users and PrEP-inexperienced individuals had greater openness to serodifferent partnering with a partner having an undetectable (vs. detectable) viral load, which was magnified by condom use among the latter.

Trends in illicit drug use and their association with HIV transmission risks from behavioural surveillance of Australian gay and bisexual men

INTRODUCTION

Investigating drug trends among Australian gay and bisexual men (GBM) is crucial for understanding levels of use and the potential for harm, including HIV transmission risk.

METHOD

Using repeated, national, cross-sectional survey data collected between 2012 and 2021 (69,567 surveys), trends of recent (previous 6 months) and frequent (weekly) drug use were analysed, using logistic regression models. The last round of data from each jurisdiction (6709 surveys) was used to compare GBM who reported no use, infrequent (less than weekly) use and frequent (at least weekly) use of party drugs to investigate the association between party drug use and HIV transmission risk, using multinomial logistic regression models.

RESULTS

There was a significant upward trend in any recent drug use (from 58.4% in 2012 to 64.1% in 2021; p < 0.001). Frequent party drug use remained a minority practice over the period (consistently less than 3%). In cross-sectional analysis, frequent party drug users were more likely to report behaviours with HIV transmission risks, such as condomless anal intercourse without biomedical prevention strategies (30.0% vs. 13.1%; adjusted relative risk ratio [aRRR], 2.08; 95% CI, 1.24-3.47), weekly group sex (16.3% vs. 0.6%; aRRR, 12.36; 95% CI, 5.75-26.56) and more than 20 recent sexual partners (42.5% vs. 5.0%; aRRR, 21.44; 95% CI, 5.82-78.89), compared with GBM who did not use party drugs.

DISCUSSION AND CONCLUSION

Our findings suggest that the frequent use of party drugs remains a marker of HIV transmission risk among Australian GBM, despite the increased adoption of biomedical HIV prevention strategies over the past few years.

The Potential Role of Undetectable = Untransmittable (U = U) in Reducing HIV Stigma among Sexual Minority Men in the US

The Undetectable = Untransmittable (U = U) message and its scientific underpinnings have been widely suggested to reduce HIV stigma. However, misunderstanding and skepticism about U = U may prevent this destigmatizing potential from being fully realized. This cross-sectional study examined associations between U = U belief (belief that someone with a sustained undetectable viral load has zero risk of sexually transmitting HIV) and HIV stigma among US sexual minority men. Differences by serostatus and effects of brief informational messaging were also explored. The survey was completed online by 106 men living with HIV and 351 HIV-negative/status-unknown men (2019-2020). Participants were 18-83 years old (M[SD] = 41[13.0]). Most were non-Hispanic White (70.0%) and gay (82.9%). Although nearly all participants (95.6%) were aware of U = U, only 41.1% believed U = U. A greater percentage of participants living with HIV (66.0%) believed U = U compared with HIV-negative/status-unknown participants (33.6%). Among participants living with HIV, U = U belief was not significantly associated with perceived, internalized, or experienced HIV stigma or with viral load prejudice (prejudice against people who have a detectable HIV viral load). Among HIV-negative/status-unknown participants, U = U belief was associated with less frequently enacted HIV discrimination, more positive feelings toward people with an undetectable viral load, and lower personal endorsement of stigmatizing beliefs. Brief informational messaging about U = U did not affect most stigma dimensions and did not favorably affect any. Interventions are needed to correct commonly held, outdated misconceptions about HIV transmission risk. Such initiatives must not only engage people living with HIV but also engage HIV-negative/status-unknown people to maximize the destigmatizing potential of U = U.

Assessing HIV risk and the social and behavioural characteristics of gay and bisexual men who have recently migrated to Australia: an analysis of national, behavioural surveillance data 2019-2021

INTRODUCTION

Overseas-born gay and bisexual men (GBM) are overrepresented in HIV diagnoses in Australia. We assessed social and sexual behaviours, and the use of HIV prevention and testing, by region of birth and length of residence in Australia. We sought to identify similarities and differences between recently arrived and non-recently arrived GBM from non-English-speaking countries to improve targeting and engagement with HIV testing and prevention.

METHODS

Data were collected in national repeated, behavioural surveillance surveys conducted across Australia during 2019-2021. Logistic regression was used to identify factors that differentiated between recently arrived (<2 years) and non-recently arrived (≥2 years in Australia) GBM from non-English-speaking countries.

RESULTS

Among 24,707 participants in 2019-21, 2811 (11.4%) were from high-income English-speaking countries, 714 (2.9%) were recently arrived overseas-born GBM and 3833 (15.5%) were non-recently arrived migrants. Recently arrived GBM were most likely to be born in Asia (36.1%) and Europe (21.1%). Compared with non-recently arrived GBM, recently arrived GBM from non-English-speaking countries were younger (aOR = 0.95, 95% CI = 0.94-0.96, p<0.001), more likely to be students (aOR = 1.43, 95% CI = 1.11-1.85, p = 0.005), less likely to be in full-time employment (aOR = 0.56, 95% CI = 0.46-0.69, p <0.001), more likely to report consistent condom use (aOR = 1.30, 95% CI = 1.01-1.66, p = 0.039), but had lower awareness (aOR = 0.62, 95% CI = 0.48-0.80, p<0.001) and use of pre-exposure prophylaxis (PrEP) (22.8%, vs. 32.3%, χ2 (1, 4185) = 23.78, p<0.001), and similar levels of casual sex with a risk of HIV acquisition or transmission (aOR = 1.29, 95% CI = 0.98-1.69, p = 0.066). Recently arrived GBM reported similar levels of lifetime HIV testing (aOR = 0.97, 95% CI = 0.54-1.74, p = 0.915) and recent HIV testing (OR = 1.03, 95% CI = 0.86-1.22, p = 0.779), but were much less likely to have tested at general practitioners (aOR = 0.53, 95% CI = 0.41-0.68, p<0.001) and more likely to report testing at hospitals (aOR = 3.35, 95% CI = 2.53-4.43, p<0.001), at home (aOR = 2.85, 95% CI = 1.63-4.99, p<0.001), or community-based services (aOR = 1.36, 95% CI = 1.01-1.84, p = 0.043).

CONCLUSIONS

Recently arrived GBM from non-English-speaking countries reported similar levels of risk of HIV acquisition to longer-term residents in Australia, but lower levels of PrEP awareness and use, and more reliance on HIV testing services which are free or low cost. It is necessary to enhance access to HIV testing and prevention among recently arrived GBM in Australia.

Trends in Testing and Self-Reported Diagnoses of Sexually Transmitted Infections in Gay and Bisexual Men in Australia, 2017 to 2021: Analysis of National Behavioral Surveillance Surveys

BACKGROUND

Gay, bisexual, and other men who have sex with men (GBM) are overrepresented in diagnoses of sexually transmitted infections (STIs) relative to their population size. This study assessed trends in STI testing and diagnoses among GBM in Australia.

METHODS

The Gay Community Periodic Surveys are repeated cross-sectional behavioral surveillance surveys of GBM. Participants reported the number of anal swabs, throat swabs, urine samples, and blood tests for syphilis they undertook in the last year. "Frequent comprehensive testing" was defined as ≥3 of each test in the previous year. Participants reported STI diagnoses of chlamydia, gonorrhea, syphilis, and other STIs in the last year. Trends in testing and diagnoses from 2017 to 2020 and 2020 to 2021 were assessed with logistic regression models.

RESULTS

We analyzed 24,488 survey responses from participants reporting casual sex in the last 6 months. Between 2017 and 2020, frequent comprehensive STI testing decreased among HIV-negative GBM on preexposure prophylaxis (PrEP) from 71.7% to 68.9% and declined further to 58.6% in 2021. Frequent comprehensive STI testing was stable during 2017-2020 among HIV-negative/untested GBM not on PrEP (17.4%-14.6%) and HIV-positive GBM (30.4%-35.1%) but declined in 2021 to 7.5% among non-PrEP-users and 25.7% among HIV-positive participants. There were minimal changes in STI diagnoses during 2017-2020, but diagnoses declined in 2021.

CONCLUSIONS

Many GBM do not meet Australian STI testing guidelines that recommend quarterly testing. Further evaluation of whether this recommendation is realistic or necessary to reduce STIs among GBM is recommended.

Mpox (monkeypox) knowledge, concern, willingness to change behaviour, and seek vaccination: results of a national cross-sectional survey

BACKGROUND

In mid-2022, a global mpox (formerly 'monkeypox') outbreak affecting predominantly gay and bisexual men emerged in non-endemic countries. Australia had never previously recorded mpox cases and there was no prior research on knowledge or attitudes to mpox among gay and bisexual men across Australia.

METHODS

We conducted a national, online cross-sectional survey between August 2022 and September 2022. Participants were recruited through community organisation promotions, online advertising, and direct email invitations. Eligible participants were gay, bisexual or queer; identified as male (cisgender or transgender) or non-binary; aged 16years or older; and lived in Australia. The main outcome measures were: knowledge and concern about mpox; recognition of mpox symptoms and transmission routes; vaccination history; acceptability of behavioural changes to reduce mpox risk, and willingness to be vaccinated.

RESULTS

Of 2287 participants, most participants were male (2189/2287; 95.7%) and gay (1894/2287; 82.8%). Nearly all had heard about mpox (2255/2287; 98.6%), and the majority were concerned about acquiring it (1461/2287; 64.4%). Most of the 2268 participants not previously diagnosed with mpox correctly identified skin lesions (2087; 92%), rash (1977; 87.2%), and fever (1647; 72.6%) as potential symptoms, and prolonged and brief skin-to-skin contact as potential ways to acquire mpox (2124, 93.7%; and 1860, 82%, respectively). The most acceptable behavioural changes were reducing or avoiding attendance at sex parties (1494; 65.9%) and sex-on-premises venues (1503; 66.4%), and having fewer sexual partners (1466; 64.6%). Most unvaccinated and undiagnosed participants were willing to be vaccinated (1457/1733; 84.1%).

CONCLUSIONS

People at risk of mpox should be supported to adopt acceptable risk reduction strategies during outbreaks and to seek vaccination.

Variations in HIV Prevention Coverage in Subpopulations of Australian Gay and Bisexual Men, 2017-2021: Implications for Reducing Inequities in the Combination Prevention Era

Using repeated behavioural surveillance data collected from gay and bisexual men (GBM) across Australia, we assessed trends in HIV prevention coverage (the level of 'safe sex' achieved in the population by the use of effective prevention methods, including condoms, pre-exposure prophylaxis [PrEP] and having an undetectable viral load). We stratified these trends by age, country of birth/recency of arrival, sexual identity, and the proportion of gay residents in the participant's suburb. Among 25,865 participants with casual male partners, HIV prevention coverage increased from 69.8% in 2017 to 75.2% in 2021, lower than the UNAIDS target of 95%. Higher levels of coverage were achieved among older GBM (≥ 45 years), non-recently-arrived migrants, and in suburbs with ≥ 10% gay residents. The lowest levels of prevention coverage (and highest levels of HIV risk) were recorded among younger GBM (< 25 years) and bisexual and other-identified participants. Younger, recently-arrived, and bisexual GBM were the most likely to use condoms, while PrEP use was concentrated among gay men, 25-44-year-olds, and in suburbs with more gay residents. The use of undetectable viral load was most common among participants aged ≥ 45 years. Our analysis shows that high HIV prevention coverage can be achieved through a mixture of condom use, PrEP use, and undetectable viral load, or by emphasising PrEP use. In the Australian context, younger, bisexual and other-identified GBM should be prioritised for enhanced access to effective HIV prevention methods. We encourage other jurisdictions to assess the level of coverage achieved by combination prevention, and variations in uptake.

Changing Characteristics of HIV-Positive Gay and Bisexual Men's Relationships in the Era of Biomedical Prevention

OBJECTIVE

To assess changes in personal and relationship characteristics among HIV-positive Australian gay and bisexual men (GBM) as rates of antiretroviral therapy and knowledge and confidence regarding the effectiveness of viral suppression in preventing HIV transmission have increased.

DESIGN

Repeated behavioral surveillance of GBM recruited from venues, events, and online in 7 Australian states and territories.

METHODS

HIV-positive participants were included. Trends in demographics, HIV treatment, and relationship characteristics were assessed with binary and multivariable logistic regression.

RESULTS

A total of 3643 survey responses (2016-2020) were included. Over time, HIV-positive GBM became less likely to identify as gay or report an Anglo-Australian ethnicity. The average length of time since HIV diagnosis increased and the frequency of attending HIV-related clinical appointments decreased. There were no changes in the reported number of recent sex partners or proportion reporting regular male partners over time. Among HIV-positive GBM in relationships, the proportion reporting HIV-positive partners decreased and the proportion reporting HIV-negative partners increased. Levels of condomless sex with regular partners increased over time; however, this was concentrated among HIV-positive GBM in serodiscordant relationships.

CONCLUSION

Findings suggest that increased accessibility and trust in biomedical prevention strategies have contributed to broader relationship and sexual opportunities for HIV-positive GBM in Australia. Our findings suggest that future health promotion activities could highlight the social and relationship benefits of treatment as prevention to further increase trust in it as an HIV prevention strategy among GBM.

Corrigendum to: Familiarity with, perceived accuracy of, and willingness to rely on Undetectable=Untransmittable (U=U) among gay and bisexual men in Australia: results of a national cross-sectional survey

BACKGROUND

The Undetectable=Untransmittable (U=U) message has been promoted since it was demonstrated that viral suppression through HIV treatment prevents sexual transmission between serodiscordant partners (HIV treatment as prevention). Our study assessed familiarity with, perceived accuracy of, and willingness to rely on U=U in a national sample of gay and bisexual men in Australia.

METHODS

We conducted a national, online cross-sectional survey in April-June 2021. Eligible participants were gay, bisexual and queer men and non-binary people who lived in Australia. Logistic regression was used to identify factors associated with familiarity, perceived accuracy and willingness to rely on U=U (by having condomless sex with a partner with HIV who has an undetectable viral load).

RESULTS

Of 1280 participants, most were familiar with U=U (1006/1280; 78.6%), the majority of whom believed U=U was accurate (677/1006; 67.3%). Both familiarity and perceived accuracy were higher among participants living with HIV, followed by pre-exposure prophylaxis (PrEP) users, HIV-negative participants not taking PrEP, and untested/unknown status participants. Knowing at least one person living with HIV, among other factors, was associated with familiarity and perceived accuracy of U=U; and familiarity was associated with perceived accuracy. Among participants familiar with U=U, less than half were willing to rely on U=U (473/1006; 47.0%). Familiarity with U=U and knowing at least one person living with HIV were associated with willingness to rely on U=U, among other factors.

CONCLUSIONS

We found familiarity with U=U was associated with perceived accuracy and willingness to rely upon it. There is an ongoing need to educate gay and bisexual men (particularly HIV-negative men) about U=U and its benefits.

Familiarity with, perceived accuracy of, and willingness to rely on Undetectable=Untransmittable (U=U) among gay and bisexual men in Australia: results of a national cross-sectional survey

BACKGROUND

The Undetectable=Untransmittable (U=U) message has been promoted since it was demonstrated that viral suppression through HIV treatment prevents sexual transmission between serodiscordant partners (HIV treatment as prevention). Our study assessed familiarity with, perceived accuracy of, and willingness to rely on U=U in a national sample of gay and bisexual men in Australia.

METHODS

We conducted a national, online cross-sectional survey in April-June 2021. Eligible participants were gay, bisexual and queer men and non-binary people who lived in Australia. Logistic regression was used to identify factors associated with familiarity, perceived accuracy and willingness to rely on U=U (by having condomless sex with a partner with HIV who has an undetectable viral load).

RESULTS

Of 1280 participants, most were familiar with U=U (1006/1280; 78.6%), the majority of whom believed U=U was accurate (677/1006; 67.3%). Both familiarity and perceived accuracy were higher among participants living with HIV, followed by pre-exposure prophylaxis (PrEP) users, HIV-negative participants not taking PrEP, and untested/unknown status participants. Knowing at least one person living with HIV, among other factors, was associated with familiarity and perceived accuracy of U=U; and familiarity was associated with perceived accuracy. Among participants familiar with U=U, less than half were willing to rely on U=U (473/1006; 47.0%). Familiarity with U=U and knowing at least one person living with HIV were associated with willingness to rely on U=U, among other factors.

CONCLUSIONS

We found familiarity with U=U was associated with perceived accuracy and willingness to rely upon it. There is an ongoing need to educate gay and bisexual men (particularly HIV-negative men) about U=U and its benefits.

Knowledge of Australia's My Health Record and factors associated with opting out: Results from a national survey of the Australian general population and communities affected by HIV and sexually transmissible infections

My Health Record is Australia's national, digital, personal health record system. All Australians have a record in the system unless they choose to opt out of it. Concerns about privacy, security and unwanted sharing of data, particularly in marginalised populations, may impede its use. We conducted a national, online survey of Australians' attitudes to digital health in April-June 2020. The sample (N = 2,240) was recruited from the general population and four priority populations affected by HIV and other sexually transmissible infections: gay and bisexual men, people living with HIV, sex workers, and trans and gender diverse people. This analysis assesses factors associated with greater knowledge of My Health Record and the likelihood of opting out of the system. Due to increased concerns about data privacy and misuse, we hypothesised that priority population members would know more about and be more likely to opt out of the system. We found that most of the sample (71.2%) knew little about My Health Record and 29.4% had opted out of the system. Greater knowledge of My Health Record was associated with younger age, having a university degree, having one or more health conditions, and being trans or gender diverse. Being a student, unemployed, receiving government benefits, or having poor self-reported health, were associated with less knowledge. Opting out of My Health Record was associated with having a university degree, one or more health conditions, and being a priority population member. The likelihood of opting out was lower among people born overseas, residents of Queensland, and people who were students, unemployed, or receiving government benefits. We recommend additional investment in community-based education to address people's concerns about My Health Record and support people to use the system without compromising their health care, privacy, or security. Opting out may be a legitimate choice for people who perceive more risks than benefits from the system.

Engaging Stigmatised Communities in Australia with Digital Health Systems: Towards Data Justice in Public Health

Introduction

In 2018, following government policy changes to Australia's national electronic health record system, 'My Health Record', consumer advocates-including organisations representing people living with HIV, people who use drugs and sex workers-raised concerns about privacy and data security. Responding to these controversies, this study explores the practical, ethical and political complexities of engaging stigmatised communities with digital health systems.

Methods

We conducted 16 qualitative semi-structured interviews in 2020 with key informants representing communities who experience stigma, discrimination and marginalisation in Australia. These communities included people living with HIV, sex workers, people who inject drugs, gay and bisexual men and transgender and gender diverse people. We conducted a reflexive thematic analysis.

Results

Key informants were sceptical of proposed benefits of electronic health records for their communities, and concerned about privacy risks and the potential for discrimination. Meaningful consultation, consent mechanisms and tackling structural stigma were raised as solutions for engaging communities.

Conclusions

Although communities could benefit from being included in digital health systems, significant cultural, legal and social reforms from government were believed to be necessary to build trust in digital health systems. We argue that these forms of data justice are necessary for effective future systems.

Policy Implications

Engaging stigmatised communities-including in relation to gender, sexuality, sex work, drug use, HIV-requires a commitment to data justice. The design and implementation of digital health systems requires investment in ongoing and meaningful consultation with communities and representative organisations.

Explicit Relationship Agreements and HIV Pre-exposure Prophylaxis Use by Gay and Bisexual Men in Relationships

Relationship agreements are important for HIV prevention among gay and bisexual men (GBM) in relationships, with research earlier in the HIV epidemic often finding that agreements specified monogamy or condom use with casual partners. There is evidence that HIV pre-exposure prophylaxis (PrEP) has shifted sexual practices among some men in relationships, such as allowing condomless sex with casual partners, but there has been little attention paid to relationship agreements among GBM who use PrEP. In this paper, we analyzed national, Australian, cross-sectional data from an online survey completed by non-HIV-positive GBM in 2021 (N = 1,185). Using logistic regression, we identified demographic characteristics, sexual practices and the types of relationship agreement that were associated with PrEP use among GBM in relationships. Using Pearson's chi-squared tests, we explored whether PrEP users in relationships reported similar sexual practices to PrEP users not in relationships. PrEP use among GBM in relationships was independently associated with older age, identifying as gay, being in a non-monogamous relationship, having a spoken (explicit) relationship agreement, having a primary HIV-negative partner taking PrEP or a primary partner living with HIV, reporting recent condomless casual sex, reporting an STI diagnosis in the past year, and knowing at least one other PrEP user. We found that PrEP users in relationships had similar sexual practices to PrEP users not in relationships. GBM in relationships who have casual sex and who meet PrEP suitability criteria may be good candidates for PrEP. Our findings suggest that explicit relationship agreements remain important for HIV prevention, and they support PrEP use among GBM in relationships.

Adjusting Behavioural Surveillance and Assessing Disparities in the Impact of COVID-19 on Gay and Bisexual Men's HIV-Related Behaviour in Australia

COVID-19 has disrupted sexual behaviour and access to health systems. We adapted regular HIV behavioural surveillance of gay and bisexual men (GBM) in Australia in response to COVID-19, assessed the impact on the profile of the sample, the participants' HIV-related behaviour, and whether COVID-19 may have accentuated existing disparities in the Australian HIV epidemic. Data collected from five states during July 2017-June 2021 were included (N = 31,460). The emphasis on online recruitment after COVID-19 led to smaller sample sizes, greater geographic reach, and a higher proportion of bisexual-identifying participants. Most participants (88.1%) reported physical distancing and 52.1% had fewer sex partners due to COVID-19. In the COVID-19-affected rounds (July 2020-June 2021), the number of male partners, recent HIV testing and pre-exposure prophylaxis (PrEP) use all fell, and HIV risk among the smaller group of participants who reported casual sex increased. COVID-related changes were generally more pronounced among GBM aged under 25 years, participants from suburbs with fewer gay residents, and bisexual men. These groups should be prioritised when encouraging GBM to reengage with HIV testing services and effective prevention methods, like condoms and PrEP.

Changing Attitudes Towards Condoms Among Australian Gay and Bisexual Men in the PrEP Era: An Analysis of Repeated National Online Surveys 2011-2019

Condoms have been the primary form of HIV prevention for gay and bisexual men (GBM) for most of the HIV epidemic. The introduction of biomedical HIV prevention may have changed attitudes towards condoms. Data from repeated national online surveys of GBM in Australia were used to examine how attitudes towards condoms and confidence discussing condoms with partners changed in the period 2011-2019. The proportion of all participants who reported a positive experience in using condoms remained low and unchanged (9.6% in 2011 to 6.0% in 2019). Confidence in discussing condoms with partners decreased over time (from 72.2% in 2011 to 56.6% in 2019). Confidence in discussing condoms was associated with concern about sexually transmitted infections, and more consistent condom use. Sustaining confidence in using condoms may be more challenging as biomedical prevention methods become more commonly used.

COVID-19 Vaccination Uptake and Hesitancy in a National Sample of Australian Gay and Bisexual Men

Minority groups may face additional barriers to vaccination. In April-June 2021, we assessed the level of COVID-19 vaccination and willingness to be vaccinated in a national, online survey of 1280 gay and bisexual men in Australia. Over a quarter of the sample (28.0%) had been partially or fully vaccinated, and 80.0% of the unvaccinated were willing to be vaccinated. Vaccination was independently associated with older age, being university educated, and HIV status (with HIV-positive participants being more likely and untested participants less likely to be vaccinated). Willingness to be vaccinated was independently associated with living in a capital city and being university educated. Those who had lost income or their job due to COVID-19 were less willing to be vaccinated. Our results suggest encouraging COVID-19 vaccination among those with lower levels of health literacy and supporting those who have experienced financial stress because of the pandemic.

Changes in Sexual Behaviour Following PrEP Initiation Among Australian Gay and Bisexual Men in Relationships: Results from a Prospective Observational Study

Few studies have examined changes in sexual behaviour following HIV pre-exposure prophylaxis (PrEP) initiation among gay, bisexual and other men who have sex with men (GBM) in relationships. In a national, online, prospective study of GBM in Australia, we compared sexual behaviours prior to and after PrEP initiation among HIV-negative and unknown-HIV-status men (recruited 2014-2017) not taking PrEP at baseline and who completed at least one six-monthly follow-up by July 2018. Among men in relationships who did not initiate PrEP (n = 339), we compared their most recent survey to their prior one, while among men in relationships who initiated PrEP (n = 81), we compared follow-ups before and after PrEP initiation. Among the 81 PrEP-initiators who were in a relationship both before and after initiation, the proportion reporting their regular partner was on PrEP increased from 8.3 to 44.4% (p < 0.001) and the proportion reporting receptive CLAIC increased from 27.2 to 44.4% (p = 0.009). Overall, men who initiated PrEP were more likely to be in a relationship with a partner on PrEP, and it appeared they started PrEP around the same time. Receptive CLAIC also became more common.

Access to Subsidized Health Care Affects HIV Pre-Exposure Prophylaxis (PrEP) Uptake Among Gay and Bisexual Men in Australia: Results of National Surveys 2013-2019

BACKGROUND

We assessed willingness to use HIV pre-exposure prophylaxis (PrEP) and current PrEP use among gay and bisexual men (GBM) in Australia.

METHODS

National, online cross-sectional surveys of GBM were conducted in 2013, 2015, 2017, and 2019. Willingness to use PrEP was measured on a previously validated scale. Trends and associations with key measures were analyzed using multivariate logistic regression.

RESULTS

During 2013-2019, 4908 surveys were completed. Among HIV-negative and untested men not currently using PrEP, willingness to use PrEP increased from 23.0% in 2013 to 36.5% in 2017 (P < 0.001) but then plateaued at 32% in 2019 (P = 0.13). The proportion of current PrEP users increased significantly from 2.5% in 2015 to 38.5% in 2019 (P < 0.001). In 2019, factors independently associated with being a current PrEP user (compared with non-PrEP users who were willing to use PrEP) included having subsidized health care (Medicare), knowing HIV-positive people, being recently diagnosed with an STI other than HIV, having higher numbers of recent male sexual partners, recent condomless sex with casual and regular partners, and frequent PrEP sorting.

CONCLUSION

Willingness to use PrEP has plateaued as its use has rapidly increased among GBM in Australia. PrEP use is concentrated among more sexually active men with access to subsidized health care. Free or low cost access schemes may facilitate broader access among GBM who want or need PrEP but lack access to subsidized health care.

Trends in Belief That HIV Treatment Prevents Transmission Among Gay and Bisexual Men in Australia: Results of National Online Surveys 2013-2019

We have tracked belief in the effectiveness of HIV treatment as prevention (TasP) among Australian gay and bisexual men (GBM) since 2013. National, online cross-sectional surveys of GBM were conducted every 2 years during 2013-2019. Trends and associations were analyzed using multivariate logistic regression. Data from 4,903 survey responses were included. Belief that HIV treatment prevents transmission increased from 2.6% in 2013 to 34.6% in 2019. Belief in the effectiveness of TasP was consistently higher among HIV-positive participants than other participants. In 2019, higher levels of belief in TasP were independently associated with university education, being HIV-positive, using pre-exposure prophylaxis, knowing more HIV-positive people, being recently diagnosed with a sexually transmitted infection (STI) and use of post-exposure prophylaxis. Belief that HIV treatment prevents transmission has increased substantially among Australian GBM, but remains concentrated among HIV-positive GBM, those who know HIV-positive people, and GBM who use antiretroviral-based prevention.

How Male Sex Workers and Their Clients Shifted from Reluctance About HIV Pre-exposure Prophylaxis to Advocating for Its Use: A Longitudinal Mixed Methods Study

We assessed individual and collective responses to HIV pre-exposure prophylaxis ('PrEP') among a network of male sex workers and clients. From 2011 to May 2017, keyword searches on an online discussion forum identified 668 posts that referenced PrEP. We conducted four analyses: (i) discourse analysis identifying reactions to PrEP, (ii) thematic analysis constructing rhetorical strategies, (iii) content analysis comparing discursive positions and rhetorical strategies, and (iv) longitudinal analyses assessing trends over time. Forum posts adopted one of three discursive positions (reluctance, interest, advocacy), drawing upon four non-exclusive strategies (deference to experts and evidence, acknowledging personal and shared experiences, establishing philosophical arguments, engaging in speculation). Posts from sex workers were more likely than clients to be supportive of PrEP (96% vs. 42%; χ² = 18.46, p < 0.001) while over time this network moved from being predominantly reluctant about PrEP (61% of posts in 2012) to advocating for its use (65% of posts in 2017; Z = 5.01, p < 0.001).