Sexually transmitted infections: Prevalence and clinical outcomes among pregnant women in Western Sydney

OBJECTIVE

We report the prevalence, characteristics and clinical outcomes of women with sexually transmitted infections (STIs) in pregnancy in the Western Sydney Local Health District (WSLHD) serving a large culturally and socio-economically diverse community in New South Wales (NSW), Australia, over the last 10 years.

METHODS

A retrospective cohort study of all pregnant women booked for antenatal care at three hospitals in WSLHD between September 2012 and August 2022 inclusive. Characteristics and birth outcomes associated with STIs diagnosed in pregnancy (chlamydia, gonorrhea, and syphilis) are reported using multivariable logistic regression adjusting for relevant confounders.

RESULTS

During 2012-2022, there were 102 905 births and 451 women (0.44%) with an STI diagnosis during pregnancy. The number of women with a history of chlamydia prior to their current pregnancy has increased over the last 10 years (P < 0.001). STIs in pregnancy were more common in younger women aged <20 years (adjusted odds ratio [aOR] 7.30, 95% confidence interval [CI] 5.04-10.57), 20-24 years (aOR 3.12, 95% CI 2.46-3.96), and >40 years (adj OR 1.67, 95% CI 1.07-2.59), in women with body mass index >30 (aOR 1.73, 95%CI 1.37-2.19), and those who smoked (aOR 2.24, 95% CI 1.71-2.94) and consumed alcohol (aOR 3.14, 95% CI 1.88-5.23) and illicit drugs (aOR 2.10, 95% CI 1.31-3.36). STIs in pregnancy were borderline associated with stillbirth (aOR 2.19 95% CI 0.90-5.36) but did not have a significant impact on preterm birth (aOR 1.21, 95% CI 0.87-1.68), admission to neonatal intensive care unit (NICU) (aOR 1.02, 95% CI 0.77-1.34), or having a small-for-gestational-age (SGA) baby (aOR 0.97, 95% CI 0.74-1.27).

CONCLUSIONS

Sociodemographic factors such as age, weight, smoking, and alcohol and drug use, were associated with the STI incidence in pregnancy. While the latter did not have an impact on preterm birth, NICU admission, and SGA in our cohort, there was a borderline association with stillbirth. Future research should identify barriers and facilitators to testing in a multicultural population and understanding the drivers of higher rates of STIs in certain population groups.

Protocol for an open-label, single-arm trial of HIV pre-exposure prophylaxis (PrEP) among people at high risk of HIV infection: the NSW Demonstration Project PRELUDE

INTRODUCTION

Despite a number of HIV prevention strategies, the number of new HIV infections remains high. In Australia, over three-quarters of new HIV diagnoses are in gay and bisexual men (GBM). Pre-exposure prophylaxis (PrEP) has been shown to be effective at preventing new HIV infections in several randomised trials. The PRELUDE study aims to evaluate the implementation of PrEP in healthcare settings in New South Wales (NSW), Australia, among a sample of high-risk adults.

METHODS AND ANALYSIS

PRELUDE is an ongoing open-label, single-arm demonstration project, conducted in public and private clinics across NSW, Australia. Enrolment began in November 2014. The study is designed for 300 high-risk participants-mainly GBM and heterosexual women. Participants receive daily oral PrEP, composed of emtricitabine (FTC) and tenofovir disoproxil fumarate (TDF), for up to 2.5 years. Quarterly study visits include testing for HIV and sexually transmitted infections (STIs), assessment of ongoing eligibility and side effects, and self-reported adherence. Following each study visit, online behavioural surveys are administered to collect information on medication adherence, risk behaviours and attitudes. Blood samples will be collected in a subset of patients 1, 6 and 12 months after PrEP initiation to measure FTC/TDF concentrations. Analyses using longitudinal regression models will focus on feasibility, adherence, safety, tolerability and effects of PrEP on behaviour. This study will inform PrEP policy and guide the implementation of PrEP in Australia in people at high risk of HIV.

ETHICS AND DISSEMINATION

The study will be conducted in accordance with the Declaration of Helsinki. All patients will provide written informed consent prior to participation in the study. Publications relating to each of the primary end points will be gradually released after 12 months of follow-up is complete.

TRIAL REGISTRATION NUMBER

NCT02206555; Pre-results.

Gay men who are not getting tested for HIV

Using data from Australian Gay Community Periodic Surveys 1998-2010, we assessed the prevalence, trends and characteristics of gay men not tested for HIV. In 2010, one in eight Australian gay socially-engaged men were never tested for HIV, most of them sexually active and 56.5 % reporting unprotected anal intercourse. The proportion of not tested men was significantly higher in men younger than 30, of non-European origin and living outside of gay metropolitan areas. Although frequency of testing was associated with sexual practices, significant proportions of men with multiple sex partners and reporting unprotected anal intercourse were not tested as recommended. There were issues with using gay-friendly testing services in gay metropolitan areas. Despite Australia's success in HIV testing, improvement is needed for early detection of HIV infections. Interventions should encourage regular testing, engage with young gay men, improve access and convenience of testing, train service providers and expand testing options.

Type 3 secretion system effector genotype and secretion phenotype of longitudinally collected Pseudomonas aeruginosa isolates from young children diagnosed with cystic fibrosis following newborn screening

Studies of the type 3 secretion system (T3SS) in Pseudomonas aeruginosa isolates from chronically infected older children and adults with cystic fibrosis (CF) show a predominantly exoS+/exoU- (exoS+) genotype and loss of T3SS effector secretion over time. Relatively little is known about the role of the T3SS in the pathogenesis of early P. aeruginosa infection in the CF airway. In this longitudinal study, 168 P. aeruginosa isolates from 58 children diagnosed with CF following newborn screening and 47 isolates from homes of families with or without children with CF were genotyped by pulsed-field gel electrophoresis (PFGE) and T3SS genotype and phenotype determined using multiplex PCR and western blotting. Associations were sought between T3SS data and clinical variables and comparisons made between T3SS data of clinical and environmental PFGE genotypes. Seventy-seven of the 92 clinical strains were exoS+ (71% secretors (ExoS+)) and 15 were exoU+ (93% secretors (ExoU+)). Initial exoS+ strains were five times more likely to secrete ExoS than subsequent exoS+ strains at first isolation. The proportion of ExoS+ strains declined with increasing age at acquisition. No associations were found between T3SS characteristics and gender, site of isolation, exacerbation, a persistent strain or pulmonary outcomes. Fourteen of the 23 environmental strains were exoS+ (79% ExoS+) and nine were exoU+ (33% ExoU+). The exoU+ environmental strains were significantly less likely to secrete ExoU than clinical strains. This study provides new insight into the T3SS characteristics of P. aeruginosa isolated from the CF airway early in life.

Current issues in care and support for HIV-positive gay men in Sydney

We explored current access to care among HIV-positive people in Australia. In 2006, 270 HIV-positive gay men from a community-based Positive Health cohort in Sydney were asked about their health (including medical and social) service needs and, subsequently, about difficulty in accessing services. We report the prevalence of specific needs, barriers and associated factors. Participants most commonly used general practitioners (64%) for HIV management and needed at least one HIV-related medical service (usually several: doctors experienced in HIV management, dentists and hospital pharmacies). Most participants were able to access them. Barriers in accessing services were related to their convenience rather than lack or quality. Cost emerged as a substantial barrier to dental care and psychological counselling (91% and 48% respectively of those in need). Need for an HIV-related social service was reported by 46% of respondents. Difficulties in accessing these related to poor services and staff attitudes. Income was associated with limited access to multiple services. In Australia, HIV-related medical service needs outweigh those for social services. Complex health services remain essential to HIV-positive people, but some services are currently not meeting their needs. To remain adequate, services need to understand and constantly adapt to the changing needs of HIV-positive people.

Anal human papillomavirus genotype diversity and co-infection in a community-based sample of homosexual men

OBJECTIVES

To determine the prevalence and risk factors for anal human papillomavirus (HPV) infection in community-based cohorts of homosexual men in Sydney, Australia.

METHODS

A cross-sectional study in consecutively presenting participants in the positive Health and Health in Men cohorts in 2005. HPV testing was performed on anal PreservCyt specimens collected from 316 homosexual men (193 HIV-negative, 123 HIV-positive) using the Digene Hybrid Capture 2 (HC-2) assay for detection of low-risk (LR) and high-risk (HR) genotypes. HPV genotype testing was also performed on a subset of 133 men (93 HIV-negative, 36 HIV-positive) using Roche Linear Array (LA) assay.

RESULTS

HC-2 detected HPV infection in 79% of men (LR 55%, HR 69%). HIV-positive men were more likely than HIV-negative men to have LR-HPV (OR 3.5, 95% CI 2.1 to 5.7) and HR-HPV (OR 5.5, 95% CI 3.0 to 10.2). LA detected HPV infection in 95% of men (LR 85%, HR 77%). HIV-positive men had a mean of 7.1 HPV types compared to 4.2 in HIV-negative men; the difference was significant for both LR-HPV (p<0.001) and HR-HPV (p<0.001). HPV-16 was detected in 36% of HIV-positive and 27% of HIV-negative men. There was no consistent trend in HPV prevalence with increasing age. HR-HPV detection was associated with anal bleeding for HIV-positive men and anal warts for HIV-negative men.

CONCLUSIONS

Anal HPV infection was nearly universal in this community-based sample of homosexual men. A wide variety of HPV genotypes were detected, and co-infection with multiple genotypes was common. Anal HPV infection is more prevalent and more diverse in HIV-positive than HIV-negative homosexual men.

27. CAN UNPROTECTED ANAL INTERCOURSE WITH REGULAR AND CASUAL PARTNERS EXPLAIN THE DIVERGING TRENDS IN HIV EPIDEMIC IN AUSTRALIA?

Introduction: Worldwide, increases in unprotected anal intercourse have been linked to the resurgence in HIV and STI in gay men. We assessed whether changes in UAI within regular and casual relationships may explain the diverging trends in HIV in three Australian states - NSW, Victoria and Queensland. Methods: We used the data from the annual cross-sectional Gay Community Periodic Surveys conducted annually in Sydney since 1996 and in Melbourne and Queensland since 1998. A short self-administered questionnaire asks about HIV serostatus, sexual health testing and behaviours relevant to HIV epidemic. We present time trends in seroconcordance and unprotected sex with regular and casual partners. Results: Currently, about one third of gay men report being in monogamous regular relationships, and this proportion has been slowly increasing everywhere. The self-reported UAI with regular partners (UAIR) was highest among men in seroconcordant positive relationships, lower among seroconcordant negative partners and lowest in non seroconcordant relationships. From 1998 to 2006, the rates of UAIR consistently increased by 10% in all three states and in all relationships by serostatus. The rates of UAI with casual partners (UAIC) were historically highest in NSW. From a peak in 2001, UAIC rates have consistently declined in NSW, but continuing increases were observed in Victoria and Queensland. Higher rates of nondisclosure of HIV were also observed in the context of UAIC in the latter two states. Conclusion: Changes in unprotected sex with casual partners may be responsible for the slowing of HIV epidemic in NSW. Sustained investment in policies and programs are important in achieving behaviour change.

30. TESTING FOR SEXUALLY TRANSMISSIBLE INFECTIONS AMONG GAY MEN IN SYDNEY, AUSTRALIA

Introduction: Recently, rates of sexually transmissible infections (STIs) have been increasing among gay men in Australia and elsewhere. We explored trends in STI testing among gay men in Sydney. Methods: We used behavioural data from the six-monthly Sydney Gay Community Periodic Survey (SGCPS). Men are recruited through gay community venues, clinics and events in Sydney. Since 2003 men were asked whether they had received the following tests in the previous year: Anal swab, throat swab, penile swab, urine sample, and blood test for STIs other than HIV. Men recruited from clinics were excluded from the following analyses. Results: In 2006, 3145 completed questionnaires were received from non-clinic sites, with 40.9% of respondents reporting having received an anal swab, 45.4% a throat swab, 34.6% a penile swab, 52.7% a urine sample, and 56.1% a blood test for STIs other than HIV. The majority (67.2%) reported at least one test for STIs, with 25.5% having received all five forms of STI test. Although there was no increase during 2003-2006 in having any STI tests, the proportion of men having received all five types of test increased. The largest increase was in the proportion reporting anal swabs: from 23.8% in 2003 to 40.9% in 2006. Among men reporting unprotected anal intercourse with casual partners (UAIC), as well as among men with more than ten casual partners in the previous six months, rates of STI testing were higher but the time trends were similar. Conclusion: The majority of men report STI testing in the previous year, and this testing has become more comprehensive, with men receiving a broader range of STI tests over time. Men at higher risk for STIs tested at increased rates.

28. RISK TAKING AND SAFER SEX PRACTICES IN CASUAL RELATIONSHIPS BETWEEN MEN

Introduction: Universal condom use in casual sex is unlikely. We explored whether gay men lower the risk of HIV transmission during unprotected anal intercourse with casual partners (UAIC) by disclosing HIV serostatus and engaging in lower risk practices such as strategic positioning and/or withdrawal. Methods: We used data from the annual cross-sectional Sydney Gay Community Periodic Survey. A short self-administered questionnaire collects information about HIV serostatus of the respondents, sexual practices with other men and other HIV-relevant behaviours. We present the prevalence of and time trends in disclosure of serostatus and the use of strategic positioning and withdrawal with casual partners. Results: In 2006, 2568 men reported having had a casual partner in the 6 months before the survey. Disclosure was higher among men engaging in UAIC (68.4%) compared to those who always used condoms (49.7%). This relationship was more apparent amongst HIV-positive than negative men, of whom 83.5% and 63.9%, respectively, reported any disclosure. Over time, HIV-positive and negative men have increasingly reported disclosing to 'all' of their casual partners (p�<�0.01). HIV-positive men were less likely to report insertive-only positioning during UAIC (8.9%) compared to HIV-negative men (39.2%), with no changes emerging since over time. Significant increases were also noted in the proportion of HIV-positive men reporting withdrawal during insertive-UAIC (p�<�0.001) and HIV-negative men reporting withdrawal during receptive-UAIC (p�<�0.001). Conclusion: In the context of UAIC, gay men appear to be employing a range of risk-reduction strategies. Increasing levels of disclosure and/or practices such as strategic positioning and withdrawal demonstrate the complexity of gay men's construction of, and engagement with, risk associated with HIV transmission. A more thorough understanding of these practices is essential for ongoing education and prevention.