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Objective: High-risk human papillomavirus (HRHPV) causes anal cancer, which disproportionately affects gay and bisexual men (GBM). We examined sexual behaviours associated with incident anal HRHPV in an observational cohort study of GBM in Sydney, Australia., Methods: GBM aged 35 years and above were enrolled in the Study of the Prevention of Anal Cancer. Detailed information on sexual practices in the last 6 months, including receptive anal intercourse (RAI) and non-intercourse receptive anal practices, was collected. Anal human papillomavirus (HPV) testing was performed at the baseline and three annual follow-up visits. Risk factors for incident HRHPV were determined by Cox regression using the Wei-Lin-Weissfeld method., Results: Between 2010 and 2015, 617 men were recruited and 525 who had valid HPV results at baseline and at least one follow-up visit were included in the analysis. The median age was 49 years (IQR 43-56) and 188 (35.8%) were HIV-positive. On univariable analysis, incident anal HRHPV was associated with being HIV-positive (p<0.001), having a higher number of recent RAI partners regardless of condom use (p<0.001 for both), preference for the receptive position during anal intercourse (p=0.014) and other non-intercourse receptive anal sexual practices, including rimming, fingering and receptive use of sex toys (p<0.05 for all). In multivariable analyses, being HIV-positive (HR 1.46, 95% CI 1.09 to 1.85, p=0.009) and reporting condom-protected RAI with a higher number of sexual partners (p<0.001) remained significantly associated with incident HRHPV. When stratified by recent RAI, non-intercourse receptive anal practices were not associated with incident HRHPV in men who reported no recent RAI., Conclusion: GBM living with HIV and those who reported RAI were at increased of incident anal HRHPV. Given the substantial risk of anal cancer and the difficulty in mitigating the risk of acquiring anal HRHPV, HPV vaccination should be considered among sexually active older GBM., Trial Registration Number: ANZCTR365383., Competing Interests: Competing interests: AEG has received honoraria and research funding from CSL Biotherapies and honoraria and travel funding from Merck, and sits on the Australian advisory board for the Gardasil HPV vaccine. IMP has received travel funding from Seqiris, the distributor of Gardasil vaccine in Australia. CKF owns shares in CSL Biotherapies. MNP received research funding from Gilead, Janssen, Celgene, BMS and ViiV for research outside the submitted work. SMG has received Merck Global Advisory Board fees, grant support through her institution and lecture fees from Merck. All other authors have no conflicts of interest to declare., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Gay, bisexual and other men who have sex with men (GBMSM), particularly HIV-positive GBMSM, are at increased anal cancer risk compared with the general population. This study examined the psychological and quality of life (QoL) impact of receiving abnormal anal cancer screening results during the baseline visit of the Study of the Prevention of Anal Cancer (SPANC)., Methods: SPANC was a prospective cohort study of the natural history of anal human papillomavirus (HPV) and associated abnormalities in GBM aged 35 years and over. Participants completed questionnaires including aspects of health-related QoL (HR-QoL) and psychosocial functioning at baseline. Participants underwent procedures including an anal swab for cytology, and high-resolution anoscopy with biopsy of any possibly HPV-related abnormality. Questionnaires were readministered 2 weeks and 3 months after participants were given cytology and histology results. Perceived test result served as the study factor., Results: Participants with perceived abnormal results (n=232) reported poorer HR-QoL (mean difference=1.8; p=0.004) and lower utility-based QoL (mean difference=0.02; p=0.018) 2 weeks after screening than individuals with perceived normal results (n=268). These differences did not persist at 3-month follow-up. A greater proportion of participants who perceived their results as abnormal reported feeling worse than usual about their anal health and anal cancer fear (p's<0.001), experienced more intrusive thoughts about their results (p's≤0.006) and felt more likely to develop cancer than other gay men their age (p's≤0.025) at both time points than those with perceived normal results., Conclusions: Providing abnormal results may cause psychological distress and impact HR-QoL, with sustained intrusive thoughts, increased cancer worry and perceived cancer risk. The potential for psychological harm needs to be considered when implementing anal cancer screening programmes., Competing Interests: Competing interests: AEG has received honoraria and research funding from CSL Biotherapies, and honoraria and travel funding from Merck. RJH has received support from CSL Biotherapies and MSD. JMR has received commercial research support from Hologic., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Sexually transmitted infection (STI) notifications are increasing among older individuals. Many older gay and bisexual men (GBM) are sexually active and have multiple partners. We aimed to investigate the prevalence, incidence and predictors of anal chlamydia, anal gonorrhoea and syphilis in older GBM., Methods: The Study for the Prevention of Anal Cancer (SPANC) was a prospective cohort study of HPV infections and related anal lesions among community-recruited GBM age ≥ 35 years in Sydney, Australia. At baseline and subsequent annual visits, recent STI diagnoses were collected via questionnaire ('interval diagnoses') and STI testing occurred ('study visit diagnoses'). Baseline STI prevalence was calculated using study visit diagnoses. Incidence of anal chlamydia and gonorrhoea was calculated using interval and study visit diagnoses. Syphilis incidence was calculated using interval diagnoses. Univariate and multivariate analysis using Cox proportional hazards were undertaken to investigate the association between risk factors and incident STI., Results: Among 617 GBM, the median age was 49 years (range 35-79) and 35.8% (n=221) were HIV-positive. At baseline, STI prevalence was: anal chlamydia 2.3% (n=14); anal gonorrhoea 0.5% (n=3) and syphilis 1.0% (n=6). During 1428 person-years of follow-up (PYFU), the incidence (per 100 PYFU) of anal chlamydia, anal gonorrhoea and syphilis was 10.40 (95% CI 8.82 to 12.25), 9.11 (95% CI 7.64 to 10.85) and 5.47 (95% CI 4.38 to 6.84), respectively. In multivariate analysis, HIV-positivity, higher number of recent condomless receptive anal intercourse partners and baseline methamphetamine use were associated with each STI. Sex with 'fuck-buddies' was associated with anal chlamydia and gonorrhoea. Age was not associated with any STI., Discussion: There was a high incidence of STI among SPANC participants. Age should not be used as a proxy for sexual risk and older GBM require a detailed sexual behaviour and recreational drug use history. Interventions that specifically target STI risk among older GBM should be considered., Competing Interests: Competing interests: AEG has received honoraria and research funding from CSL Biotherapies, honoraria and travel funding from Merck. CKF has received honoraria, travel funding and research funding from CSL and Merck, and owns shares in CSL Biotherapies. SMG has received advisory board fees and grant support from CSL and GlaxoSmithKline, and lecture fees from Merck, GlaxoSmithKline and Sanofi Pasteur; in addition, has received funding through her institution to conduct clinical HPV vaccine studies for MSD and GlaxoSmithKline and is a member of the Merck Global Advisory Board as well as the Merck Scientific Advisory Committee for HPV. RJH has received support from CSL Biotherapies and MSD., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Men who have sex with men (MSM) living with HIV are at high risk of infection with high-risk human papillomavirus (HPV), the cause of anal cancer. We assess whether anal HPV DNA detection is related to recent anal sexual activity, what types of anal sexual activity or the persistence of HPV genotypes., Methods: We analysed anal swabs taken at the baseline of a 2-year prospective anal cancer screening study of MSM living with HIV from four HIV clinics in Melbourne, Australia. Anal HPV detection was stratified by age and anal sexual behaviours., Results: 281 anal swabs were included in the analysis. The majority (80%, 95% CI 75 to 84) of men were positive for any HPV; 59% (95% CI 53 to 65) were positive for high-risk HPV (hr-HPV) genotypes; and 31% (95% CI 26 to 36) men were positive for HPV 16 and/or 18 with no significant differences according to age groups (p>0.261). In men who reported no receptive anal sexual activity in the last six months (22%), hr-HPV was found in 53% (95% CI 41 to 65) for no anal sexual activity versus. 60% (95% CI 54 to 67) for anal sexual activity (p=0.320). HPV 16 and/or 18 was found in 26% (95% CI 16 to 38) for no anal sexual activity versus. 32% (95% CI 27 to 39) for anal sexual activity (p=0.320)., Conclusions: Anal HPV in MSM living with HIV is detected in the majority of men throughout all age groups. Anal HPV detection remains high even in men reporting no anal sexual activity in the preceding six months., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Objectives: Anal human papillomavirus (HPV) is highly prevalent in men who have sex with men (MSM) of all ages, whereas cervical HPV declines with age. We explore the hypothesis that different sexual behavioural patterns are the basis of this difference in age distribution., Methods: Published data on age-specific HPV prevalence for women (cervical HPV) were extracted from a large meta-analysis and for MSM (anal HPV) from the EXPLORE study of HIV-negative MSM. Age-specific data on recent sexual activity were extracted from two behavioural surveys: the second Australian Study of Health and Relationships survey and the 2013 Gay Community Periodic Survey., Results: At least 50% of MSM at all ages reported more than one sexual partner in the past 6 months. In comparison, 33% of women aged 16-19 years reported more than one partner over the past year. This decreased to 19% and 6% in women aged 20-29 and 30-39 years, respectively, and to fewer than 5% of women in older age groups. Prevalent anal HPV was detected in over 50% of MSM in each age group. Prevalence did not decline with age. In contrast, there was a steady decrease in cervical HPV prevalence with age. Cervical HPV prevalence fell from 23% among North American women aged <25 years to 3% in women aged ≥65 years., Conclusions: In contrast to the decreasing prevalence with age among heterosexual women, the high prevalence and lack of decline in prevalent anal HPV among older MSM are likely to be related to continuing high rates of newly acquired HPV infection from ongoing sexual exposure through new partners., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Objective: To describe the relationships between HIV-negative Australian gay men's sexual behaviour and differences in age between them and their sex partners., Design: Anonymous computer-assisted internet survey was administered., Methods: We used multinomial logistic regression to examine factors associated with reported differences in partners' age (10 years older, within 10 years and 10 years younger) among 1476 men., Results: Two-thirds of the men reported their most recent casual sex partners were within 10 years of age to themselves, as were 79.3% of their regular partners. Neither men's own age nor relative differences in age with their partners was associated with the likelihood to engage in unprotected anal intercourse. Among men who reported sex with a regular partner, those with older partners tended to restrict themselves to the receptive position (adjusted ORs (AOR)=2.00; 95% CI 1.02 to 3.92; p=0.044). Among men who reported sex with a casual partner, those with younger partners tended to take the insertive position, both on occasions when a condom was used (AOR=2.42; 95% CI 1.39 to 4.20; p=0.002) and on occasions when a condom was not used (AOR=2.54; 95% CI 1.04 to 6.20; p=0.041)., Conclusions: Age differences between gay men and their sex partners make little difference to the likelihood of engaging in sexual risk behaviour overall with either regular or casual partners. Those whose partners are substantially older than themselves are more likely, however, to take the receptive position during anal intercourse. Where risk of HIV infection among younger men is elevated this could be due to differences in sexual position, rather than differences in unprotected anal intercourse per se, during sex with men who are substantially older than themselves.

Background: Pharyngeal gonorrhoea is common in homosexual men and may be important in maintaining community prevalence of anogenital infections., Methods: From 2003, all participants in the Health in Men cohort of HIV-negative homosexual men in Sydney were offered annual pharyngeal gonorrhoea screening by BD ProbeTec nucleic acid amplification (NAAT) assay with supplementary porA testing. Participants self-reported diagnoses of pharyngeal gonorrhoea made elsewhere between interviews. Detailed sexual behavioural data were collected 6-monthly., Results: Among 1427 participants enrolled, 65 study-visit-diagnosed pharyngeal gonorrhoea infections were identified (incidence 1.51 per 100 person-years, 95% CI 1.19 to 1.93) of which seven infections were identified on baseline testing (prevalence 0.57%, 95% CI 0.23 to 1.17%). Almost 85% of study-visit-diagnosed pharyngeal infections occurred without concurrent anogenital gonorrhoea. The combined incidence of study-visit-diagnosed and self-reported pharyngeal gonorrhoea (n=193) was 4.45 per 100 person-years (95% CI 3.86 to 5.12). On multivariate analysis, incident infection was associated with younger age (p-trend=0.001), higher number of male partners (p-trend=0.002) and reported contact with gonorrhoea (p<0.001). Insertive oro-anal sex ('rimming') was the only sexual behaviour independently associated with incident pharyngeal gonorrhoea (p-trend=0.044)., Conclusions: The majority of pharyngeal gonorrhoea occurred without evidence of concurrent anogenital infection, and the high incidence-to-prevalence ratio suggests frequent spontaneous resolution of NAAT-detected infection. The association of pharyngeal gonorrhoea with oro-anal sex indicates that a broader range of sexual practices are likely to be involved in transmission of gonorrhoea to the pharynx than previously acknowledged. Screening the pharynx of sexually active homosexual men could play a role in reducing the prevalence of anogenital Neisseria gonorrhoeae.

Background: An increasing incidence of hepatitis C virus (HCV) infection in HIV-positive homosexual men has recently been described, but it is uncertain to what extent this reflects sexual transmission. We report prevalence, incidence and risk factors for HCV infection in community-based cohorts of HIV-negative and HIV-positive homosexual men in Sydney., Methods: Both cohorts recruited participants using similar community-based strategies. Men underwent annual face-to-face interviews, and reported history of injecting-drug use (IDU) and sexual and other behaviours that might lead to blood contact. HCV screening was offered to consenting participants from 2001 to 2007., Results: At baseline, HCV prevalence was 1.07% in the HIV-negative and 9.39% in the HIV-positive men. HCV seropositivity was strongly associated with a history of IDU in both cohorts (OR=56.18, 95% CI 12.55 to 251.5 in HIV-negative, and OR=24.46, 95% CI 5.44 to 110.0 in HIV-positive). In the HIV-negative cohort, five men seroconverted to HCV over 4412.1 person-years of follow-up, an incidence of 0.11 per 100 person-years (95% CI 0.03 to 0.26). Only one seroconverter reported IDU. Of the five, four reported sexual contact with HIV-positive men (HR=8.23, 95% CI 0.91 to 74.28), and two had an incident ulcerative sexually transmitted infection. In the HIV-positive cohort, none seroconverted over 238.1 person-years of follow-up (97.5% CI 0 to 1.54, single-sided)., Conclusion: HCV prevalence was almost 10 times higher in HIV-positive homosexual men. Although incident HCV infection was uncommon in both cohorts, cases of non-IDU-related transmission did occur, possibly linked to sexual contact with HIV-positive men.