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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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: The Australian Chlamydia Control Effectiveness Pilot (ACCEPt) was a cluster randomised controlled trial designed to assess the effectiveness of annual chlamydia testing through general practice in Australia. The trial showed that testing rates increased among sexually active men and women aged 16-29 years, but after 3 years the estimated chlamydia prevalence did not differ between intervention and control communities. We developed a mathematical model to estimate the potential longer-term impact of chlamydia testing on prevalence in the general population.Methods: We developed an individual-based model to simulate the transmission of Chlamydia trachomatis in a heterosexual population, calibrated to ACCEPt data. A proportion of the modelled population were tested for chlamydia and treated annually at coverage achieved in the control and intervention arms of ACCEPt. We estimated the reduction in chlamydia prevalence achieved by increasing retesting and by treating the partners of infected individuals up to 9 years after introduction of the intervention.Results: Increasing the testing coverage in the general Australian heterosexual population to the level achieved in the ACCEPt intervention arm resulted in reduction in the population-level prevalence of chlamydia from 4.6% to 2.7% in those aged 16-29 years old after 10 years (a relative reduction of 41%). The prevalence reduces to 2.2% if the proportion retested within 4 months of treatment is doubled from the rate achieved in the ACCEPt intervention arm (a relative reduction of 52%), and to 1.9% if the partner treatment rate is increased from 30%, as assumed in the base case, to 50% (a relative reduction of 59%).Conclusion: A reduction in C. trachomatis prevalence could be achieved if the level of testing as observed in the ACCEPt intervention arm can be maintained at a population level. More substantial reductions can be achieved with intensified case management comprising retesting of those treated and treatment of partners of infected individuals. [ABSTRACT FROM AUTHOR]

Objectives: As most chlamydia cases are asymptomatic, regular testing and timely management may be necessary for control. We aimed to determine the preferences of people living in Hong Kong for chlamydia testing and management services.Methods: An online panel of sexually active individuals living in Hong Kong completed the survey with two discrete choice experiments (DCEs). The first DCE examined the preferred attributes of a chlamydia testing service (cost, location, appointment time, speed of results, delivery of results and availability of other STI testing). The second DCE examined the preferred attributes of a chlamydia management service (cost, access to patient-delivered partner therapy, location, travel time, type of person consulted and attitude of staff).Results: In total, 520 individuals participated: average age 36.8 years (SD 9.9), 40% males and 66% had a bachelor's degree or higher. Choosing to test was most influenced by cost, followed by speed of results, delivery of results, extra STI testing, appointment available and the least important was the location of testing. Choosing to attend for management was most influenced by staff's attitude, followed by cost, who they consult, access to patient-delivered partner therapy, travel time and the least important was treatment location.Conclusion: To design effective chlamydia testing and management services, it is vital to respond to patient needs and preferences. For people living in Hong Kong, cost and staff attitude were the most important factors for deciding whether to test or be managed for chlamydia, respectively. [ABSTRACT FROM AUTHOR]

Background: While the contribution of Mycoplasma genitalium (MG) to symptoms in men is well described, less is known about its association with common genital symptoms in women. We aimed to determine the prevalence of MG and macrolide resistance, and its association with common genital symptoms in women attending a sexual health service, to inform indications for testing and clinical practice.Methods: We undertook a cross-sectional study of symptomatic and asymptomatic women attending Melbourne Sexual Health Centre (MSHC), between April 2017 and April 2019. Women were tested for MG and macrolide resistance, Chlamydia trachomatis (CT), Neisseria gonorrhoeae, Trichomonas vaginalis, bacterial vaginosis and vulvovaginal candidiasis. Women completed a questionnaire on symptoms, and symptomatic women underwent examination. The prevalence of MG (and macrolide resistance) and other genital infections was calculated with 95% CIs, and associations between these outcomes and specific genital symptoms were examined using logistic regression.Results: Of 1318 women, 83 (6%, 95% CI: 5% to 8%) had MG, of which 39 (48%, 95% CI: 36% to 59%) had macrolide-resistant MG; 103 (8%, 95% CI: 6% to 9%) women had CT. MG prevalence was similar in asymptomatic (10 of 195; 5%) and symptomatic (73 of 1108; 7%) women, p=0.506. MG was associated with mucopurulent cervicitis on examination (adjusted OR=4.38, 95% CI: 1.69 to 11.33, p=0.002), but was not associated with other specific genital symptoms or signs.Conclusions: MG was as common as CT among women attending MSHC. MG was not associated with genital symptoms, but like CT, was significantly associated with cervicitis. These data provide evidence that routine testing for MG in women with common genital symptoms is not indicated. The presence of macrolide resistance in 48% of women supports use of resistance-guided therapy. [ABSTRACT FROM AUTHOR]

Background: Serology is negative in a proportion of primary syphilis cases where Treponema pallidum PCR testing is positive. We aimed to identify discordant, T. pallidum PCR-positive, serology-negative primary syphilis cases and any clinical or laboratory factors associated with failure to subsequently seroconvert.Methods: Serodiscordant primary syphilis cases that were T. pallidum PCR-positive and serology-negative (including rapid plasma reagin, T. pallidum particle agglutination, T. pallidum enzyme immunoassay or T. pallidum chemiluminescence assay) were identified from the Melbourne Sexual Health Centre electronic records between April 2011 and December 2019. Clinical and laboratory associations were examined.Results: There were 814 primary syphilis cases in the study period and 38 (4.7%) were serodiscordant, 35 in men who have sex with men. Thirty-two had follow-up serology performed a median of 24 days later, of which 16 (50%) seroconverted, mostly (81%) within 6 weeks. Failure to seroconvert was significantly associated with treatment on day 1. Of the 12 cases treated on day 1, 10 (83%) failed to seroconvert compared with 6 of 20 (30%) among those who were treated after day 1.Discussion: Earlier treatment of primary syphilis can prevent the development of serological markers. T. pallidum PCR can identify primary syphilis lesions before the development of serological markers and improve diagnosis of early primary syphilis lesions. Serology alone will miss a proportion of primary syphilis infections and should be repeated if a diagnosis of syphilis is being considered. [ABSTRACT FROM AUTHOR]

Objective: Chlamydia and gonorrhoea are common sexually transmitted infections that infect the oropharynx, anorectum and urethra in men who have sex with men (MSM). This study aimed to examine the pattern of infection at more than one site (multisite) for chlamydia and gonorrhoea among MSM.Methods: This was a retrospective study of MSM attending the Melbourne Sexual Health Centre for the first time between 2018 and 2019. We included MSM aged ≥16 years who had tested for Neisseria gonorrhoeae and Chlamydia trachomatis at all three sites (oropharynx, anorectum and urethra). We compared infections that occurred at a single site (termed single-site infection) and those that occurred at more than one site (termed multisite infections).Results: Of the 3938 men who were tested for chlamydia and gonorrhoea, 498/3938 men (12.6%, 95% CI 11.5% to 13.6%) had chlamydia at any site, of whom 400/498 (80.3%, 95% CI 78.9% to 81.2%) had single-site chlamydia infection, and 98/498 (19.7%, 95% CI 16.2% to 23.1%) had multisite infections. A similar proportion of men had gonorrhoea at any site (447/3938, 11.4%, 95% CI 10.3% to 12.2%), but among these 447 men, single-site infection was less common (256/447, 57.3%, 95% CI 52.6% to 61.7%, p<0.001) and multisite infection (191/447, 42.7%, 95% CI 38.2% to 47.3%, p<0.001) was more common than chlamydia. There were also marked differences by anatomical site. Urethral infection commonly occurred as single sites (75/122, 61.5%, 95% CI 52.8% to 70.1%) for chlamydia but uncommonly occurred for gonorrhoea (12/100, 12.0%, 95% CI 5.6% to 18.3%, p<0.001). In contrast, anorectal infection uncommonly occurred as multisite infection for chlamydia (98/394, 24.9%, 95% CI 20.6% to 29.1%) but was common (184/309, 59.5%, 95% CI 54.0% to 64.9%, p<0.001) for gonorrhoea.Conclusions: The markedly different pattern of site-specific infection for chlamydia and gonorrhoea infections among the same MSM suggests significant differences in the transmissibility between anatomical sites and the duration of each infection at each site. [ABSTRACT FROM AUTHOR]

Background: There are upward trends of STI rates among young people in most high-income countries. We reviewed the literature to provide a summary of information to support health services with the aim of increasing testing of STIs among young people living in high-income countries.Methods: We conducted a systematic review (Prospero: CRD42020179720) using PubMed, Embase, PsychINFO and CINAHL. The search was performed on 10 January 2020 for studies between January 2000 and 10 January 2020. Two reviewers independently screened articles, and any discrepancies were resolved by a third reviewer. Studies were included if they were performed in high-income countries and contained data on both young people (<26 years) and STI testing preferences. Data regarding the characteristics of STI testing services that young people preferred was extracted. We categorised these characteristics using the framework of a social-ecological model.Results: We identified 1440 studies, and 63 studies were included in the final review. We found 32 studies that addressed individual factors, 62 studies that addressed service factors and 17 studies that addressed societal factors. At an individual level, we identified eight attributes including the need for improved sexual health education. At a service level, 14 attributes were identified including preferences from different subgroups of young people (such as sexual and ethnic minorities) for the types of services. At a societal level, we identified two attributes including the need to address stigma associated with STIs.Conclusion: We provide an overview of the growing body of literature capturing the preferences of young people for STI testing services. To optimise the uptake of STI testing among young people, factors from all socioecological levels should be considered. In addition, understanding and accounting for distinct preferences from subgroups of young people could increase demand for STI testing services for those at greatest need. [ABSTRACT FROM AUTHOR]

Objectives: This prospective cohort study aimed to determine the natural history and incidence of oropharyngeal gonorrhoea and chlamydia among a cohort of men who have sex with men (MSM) over a 12-week period, and to examine risk factors associated with incident oropharyngeal infections.Methods: MSM either aged ≥18 years and had a diagnosis of oropharyngeal gonorrhoea by nucleic acid amplification test (NAAT) in the past 3 months or aged 18-35 years who were HIV-negative taking pre-exposure prophylaxis (PrEP) were eligible for this study. Enrolled men were followed up for 12 weeks. Oropharyngeal swabs were collected at week 0 (baseline) and week 12 (end of study). Between these time points, weekly saliva specimens and the number of tongue kissing, penile-oral and insertive rimming partners were collected by post. Oropharyngeal swabs and saliva specimens were tested by NAAT for Neisseria gonorrhoeae and Chlamydia trachomatis. Poisson regression was performed to examine the risk factors (weekly number of partners) associated with incident oropharyngeal gonorrhoea.Results: A total of 100 MSM were recruited. The incidence of oropharyngeal gonorrhoea and chlamydia was 62 (95% CI 37 to 105) and 9 (95% CI 2 to 35)/100 person-years, respectively. The median duration of incident oropharyngeal infection with gonorrhoea was 28 days (IQR=21-36, n=7). The incidence rate ratio (IRR) for oropharyngeal gonorrhoea increased with an increased number of kissing partners (IRR=1.08; 95% CI 1.03 to 1.12) an increased number of penile-oral sex partners (IRR=1.07, 95% CI 1.01 to 1.14) but not with an increased number of insertive rimming partners (IRR=1.11, 95% CI 0.96 to 1.29) or other demographic factors. The IRR and duration of incident oropharyngeal chlamydia were not calculated due to the small number of cases (n=2).Conclusions: MSM have a high incidence of oropharyngeal gonorrhoea and the median duration of infection was less than 3 months. [ABSTRACT FROM AUTHOR]

Objectives: To investigate rates of acute epididymitis diagnosed in Australian hospital settings.Methods: Yearly hospital admission and emergency department (ED) rates of epididymitis as primary diagnoses were calculated for 15-44-year-old men for three states (Victoria, New South Wales, Queensland) from 2009 to 2014 using population denominators. Zero inflated Poisson regression models were used to analyse variation in rates by year, age, and residential area. Additionally, we investigated national epididymitis admission trends from 2009 to 2018 using generalised linear models.Results: Between 2009 and 2014, there was a total of 7375 admissions and 17 281 ED presentations for which epididymitis was the main reason for care. Most epididymitis diagnoses (94.0% in admissions, 99.7% in EDs) were without abscess, and 2.5% of admissions were for chlamydial epididymitis. Almost a quarter (23.3%) of epididymitis diagnosed in EDs resulted in hospital admission. In 2014, the epididymitis rate per 100 000 men was 38.7 in admissions and 91.9 in EDs. Comparing 2014 with 2009, the overall epididymitis diagnosis rate increased in admissions by 32% (adjusted incident rate ratio (aIRR) 1.32, 95% CI 1.20 to 1.44) and in ED attendances by 40% (aIRR 1.40, 95% CI 1.31 to 1.49). By age, the highest rates were among men 35-44 years in admissions and men 15-24 years in EDs. National admission rates of epididymitis during 2009-2018 showed a similar pattern.Conclusion: Rates of epididymitis diagnosis in hospital admission and ED presentations increased. Different age-related rates in these settings suggest a different aetiology or differential severity by age group. [ABSTRACT FROM AUTHOR]

Background: The spectrum of sexual practices that transmit Neisseria gonorrhoeae in men who have sex with men (MSM) is controversial. No studies have modelled potential Neisseria gonorrhoeae transmission when one sexual practice follows another in the same sexual encounter ('sequential sexual practices'). Our aim was to test what sequential practices were necessary to replicate the high proportion of MSM who have more than one anatomical site infected with gonorrhoea ('multisite infection').Methods: To test our aim, we developed eight compartmental models. We first used a baseline model (model 1) that included no sequential sexual practices. We then added three possible sequential transmission routes to model 1: (1) oral sex followed by anal sex (or vice versa) (model 2); (2) using saliva as a lubricant for penile-anal sex (model 3) and (3) oral sex followed by oral-anal sex (rimming) or vice versa (model 4). The next four models (models 5-8) used combinations of the three transmission routes.Results: The baseline model could only replicate infection at the single anatomical site and underestimated multisite infection. When we added the three transmission routes to the baseline model, oral sex, followed by anal sex or vice versa, could replicate the prevalence of multisite infection. The other two transmission routes alone or together could not replicate multisite infection without the inclusion of oral sex followed by anal sex or vice versa.Conclusions: Our gonorrhoea model suggests sexual practices that involve oral followed by anal sex (or vice versa) may be important for explaining the high proportion of multisite infection. [ABSTRACT FROM AUTHOR]

Objective: The rapid expansion of the recreational drug market becomes a global health concern. It is worrying that the bacterial and viral infection epidemics linking to drug use may worsen accordingly. This study aimed to estimate the impacts of changing trend and behaviours of using heroin only, synthetic drug (SD) only and polydrug (using SD and heroin concurrently) on HIV, hepatitis C virus (HCV) and syphilis epidemics among people who use drugs in China by 2035.Methods: We constructed a compartmental model to estimate HIV, HCV and syphilis epidemics in the dynamic drug-use trend by three scenarios: SD-only use, heroin-only use and polydrug use based on Monte Carlo simulations. The parameters for the model were collected from a comprehensive literature search.Results: Our model estimated that polydrug use led to the highest HIV and HCV prevalence among three drug-use patterns. The prevalences were projected to increase from 10.9% (95% CI 10.2% to 11.5%) and 61.7% (95% CI 59.4% to 62.5%) in 2005 to 19.0% (95% CI 17.3% to 20.7%) and 69.1% (95% CI 67.3% to 69.5%), respectively, in 2035 among people using polydrug. Similarly, HIV and HCV prevalence in the SD-only group were projected to increase from 0.4% (95% CI 0.3% to 0.4%) and 19.5% (95% CI 19.4% to 21.7%) to 1.8% (95% CI 1.4 to 2.1%) and 33.7% (95% CI 33.2% to 34.9%) in 2005-2035. Conversely, HIV prevalence in the heroin-only group was projected to decrease from 8.0% (95% CI 7.6% to 8.1%) to 2.2% (95% CI 2.0% to 2.3%) in 2005-2035. Syphilis prevalence was estimated to remain unchanged in all population groups within this time frame. It was projected that the proportion of HIV transmitted by sexual transmission will increase compared with unsafe injection transmission in all people who use drugs from 2005 to 2035.Conclusion: Our modelling suggests that polydrug use is projected to lead to the highest HIV and HCV disease burden by 2035, and the proportion of HIV transmitted by sexual transmission will increase. Current HIV intervention among people using heroin seems effective according to our estimation. [ABSTRACT FROM AUTHOR]

Objective: To systematically review and appraise published data, to determine the prevalence of Mycoplasma genitalium (MG) in men who have sex with men (MSM) tested at each anatomical site, that is, at the urethra, rectum and/or pharynx.Design: Systematic review and meta-analysis.Data Sources: Ovid Medline, PubMed, Embase were searched for articles from 1st January 1981 (the year MG was first identified) to 1st June 2018.Review Methods: Studies were eligible for inclusion if they reported MG prevalence in MSM tested at the urethra, rectum and/or pharynx, in at least 50 MSM, using nucleic acid amplification testing. Data were extracted by anatomical site, symptom and HIV status. Summary estimates (95% CIs) were calculated using random-effects meta-analysis. Subgroup analyses were performed to assess heterogeneity between studies.Results: Forty-six studies met inclusion criteria, with 34 reporting estimates of MG prevalence at the urethra (13 753 samples), 25 at the rectum (8629 samples) and 7 at the pharynx (1871 samples). MG prevalence was 5.0% (95% CI 3.5 to 6.8; I2=94.0) at the urethra; 6.2% (95% CI 4.6 to 8.1; I2=88.1) at the rectum and 1.0% (95% CI 0.0 to 5.1; I2=96.0) at the pharynx. The prevalence of MG was significantly higher at urethral and rectal sites in symptomatic versus asymptomatic MSM (7.1% vs 2.2%, p<0.001; and 16.1% vs 7.5%, p=0.039, respectively). MG prevalence at the urethra was significantly higher in HIV-positive compared with HIV-negative MSM (7.0% vs 3.4%, p=0.006).Conclusion: MG was common in MSM, particularly at urethral and rectal sites (5% to 6%). MG was more commonly detected in symptomatic men at both sites, and more common in HIV-positive men at the urethra. MG was uncommonly detected in the pharynx. Site-specific estimates are similar to those for chlamydia and will be helpful in informing testing practices in MSM.Prospero Registration Number: CRD42017058326. [ABSTRACT FROM AUTHOR]

Objectives: Pharyngeal gonorrhoea disproportionately affects men who have sex with men (MSM). We explored temporal trends in pharyngeal gonorrhoea positivity among MSM compared with anorectal and urogenital positivity.Methods: Data (2011-2015) were extracted from 41 publicly funded sexual health clinics participating in a national surveillance network. Positivity was defined as the proportion of first-visit testing occasions where gonorrhoea was detected. Logistic regression explored trends in positivity and correlates of positive pharyngeal tests.Results: From 2011 to 2015, 24 792 MSM tested (16 710 pharyngeal, 19 810 urogenital and 15 974 anorectal first-visit tests). Pharyngeal positivity increased by 183% from 139/3509 (4.0%) in 2011 to 397/3509 (11.3%) in 2015, p-trend <0.001; urogenital positivity by 39% from 257/4615 (5.6%) to 295/3783 (7.8%), p-trend=0.006; and anorectal positivity by 87% from 160/3469 (4.6%) to 286/3334 (8.6%), p-trend <0.001. The annual temporal increase in positivity was greater in the pharynx (OR 1.33; 95% CI 1.27 to 1.38) than at urogenital (OR 1.06; 95% CI 1.02 to 1.10) and anorectal (OR 1.16; 95% CI 1.11 to 1.21) sites. Factors independently associated with pharyngeal gonorrhoea were: younger age (p<0.001), higher numbers of recent sexual partners (p-trend=0.004), contact with a person with a diagnosed STI (p<0.001), injecting drug use (p<0.001), anogenital symptoms (p<0.001) and HIV-positive status (p=0.050).Conclusion: Temporal increases in gonorrhoea positivity occurred at all anatomical sites, with the greatest increase in the pharynx. Risk factors could be used to help to develop testing and prevention strategies among MSM at highest risk. Strengthening sexual health service delivery, testing and surveillance remain priorities for pharyngeal gonorrhoea control. [ABSTRACT FROM AUTHOR]

Background: Outbreaks of hepatitis A are being reported more commonly among men who have sex with men (MSM) globally. Australia has also reported a sharp increase in the number of cases of hepatitis A in 2017. This study aimed to determine the level of immunity to hepatitis A among MSM attending a large urban sexual health clinic in Victoria in the lead up to recent outbreak.Methods: This was a retrospective audit of serological testing data from first-time MSM attendees at Melbourne Sexual Health Centre (MSHC) in Australia from 1 January 2012 to 31 December 2018. We determined the proportion of MSM who were tested and who had serological detection of hepatitis A IgG, stratified by age and calendar year. We used univariable and multivariable logistic regression to investigate factors associated with testing for and detection of hepatitis A IgG.Results: There were 16 609 first-time MSM attendees at MSHC over the 7-year period, of which 9718 (59%, 95% CI 58% to 60%) were tested for hepatitis A IgG. There was a 2% annual increase in the proportion of men tested (from 60% in 2012 to 69% in 2018; OR=1.02, 95% CI 1.00 to 1.03, p=0.025). Men born outside of Australia/New Zealand, and younger men <30 years had higher odds of being tested. Of those tested, 44% (n=4304, 95% CI 43% to 45%) had hepatitis A IgG detected at their first visit, with no change over time (OR=1.01, 95% CI 0.99 to 1.03, p=0.210). Detection of hepatitis A IgG was associated with being aged 30 years or older (adjusted OR=2.06, 95% CI 1.89 to 2.24, p<0.001) or being born overseas versus Australia/New Zealand (AOR=1.21, 95% CI 1.11 to 1.31, p<0.001).Conclusion: Hepatitis A immunity among MSM remains below the estimated 70% required to prevent outbreaks. Measures including increased testing and higher vaccination coverage are needed to prevent outbreaks and to limit the number of cases and deaths. [ABSTRACT FROM AUTHOR]

Objective: In 2017, there was an outbreak of invasive meningococcal disease (IMD) serogroup C among men who have sex with men (MSM) in Victoria, Australia. A government-funded free meningococcal (MenACWY) vaccination programme targeting all MSM living in Victoria was launched between December 2017 and December 2018. The aim of this study was to examine the vaccine uptake among MSM attending a sexual health clinic in Melbourne.Methods: This was a retrospective clinical audit of MSM attending the Melbourne Sexual Health Centre (MSHC) during the vaccination programme. We calculated the proportion of MSM who received the meningococcal vaccine on their first visit and at any time during the programme. We performed univariable and multivariable logistic regression to identify the factors associated with the vaccine uptake on the first visit.Results: Of the 10 370 MSM who attended MSHC, 55.5% received the vaccine on their first visit and 67.4% at any time during the programme. MSM had higher odds of receiving the vaccine on the first visit if they were aged 16-25 years (adjusted OR (aOR) 1.21; 95% CI 1.08 to 1.35) or 26-35 years (aOR 1.17; 95% CI 1.07 to 1.29) in comparison with MSM older than 35 years; were HIV-negative and not on pre-exposure prophylaxis (aOR 1.80; 95% CI 1.56 to 2.09); had more than four male partners in the last 12 months (aOR 1.16; 95% CI 1.06 to 1.27); had male partners only (aOR 2.24; 95% CI 1.96 to 2.55); or were born overseas (aOR 1.11; 95% CI 1.03 to 1.21).Conclusions: Two-thirds of the MSM attending a sexual health clinic received at least one dose of meningococcal vaccine. The vaccination programme coincided temporally with a dramatic reduction in the incidence of IMD. Vaccination should be further promoted among MSM and men who have sex with both men and women. [ABSTRACT FROM AUTHOR]

Objectives: In 2017, an outbreak of hepatitis A among gay, bisexual and other men who have sex with men (MSM) was reported in Victoria, Australia. In 2018, the Victorian government implemented a free hepatitis A vaccination programme targeting all Victorian MSM. This study aimed to determine hepatitis A vaccine uptake among MSM in a sexual health clinic in Melbourne.Methods: All MSM attending the Melbourne Sexual Health Centre (MSHC) in 2018 were included. Chart review was performed to determine the proportion of men vaccinated for at least one dose of hepatitis A and to examine why men did not receive the vaccine. Multivariable logistic regression was performed to examine the factors associated with vaccine uptake. Vaccine uptake was defined as receipt of at least one dose of hepatitis A vaccine.Results: Of the 9582 MSM who attended MSHC in 2018, 61.3% (95% CI 60.3% to 62.2%) self-reported already being immune to hepatitis A. Of the 3713 remaining eligible men, 62.7% (95% CI 61.1% to 64.2%) received at least one dose of the hepatitis A vaccine on the day of attendance. Compared with MSM not living with HIV and not taking pre-exposure prophylaxis (PrEP), MSM taking PrEP (adjusted OR 1.28; 95% CI 1.01 to 1.62) were more likely to receive the vaccine. 1386 men (37.3%) did not receive the vaccine and 55.4% were not offered the vaccine by their treating clinician. 300 men (21.6%) were identified as non-immune after serological testing but did not return for vaccination. By the end of 2018, 85.5% of MSHC attendees (8196/9582) were immune to hepatitis A.Conclusion: The critical vaccination threshold for hepatitis A has been estimated at >70%. Continuation of the targeted hepatitis A vaccination programme will improve immunity among the MSM population to prevent ongoing transmission and the likelihood of future outbreaks. [ABSTRACT FROM AUTHOR]

Objectives: There are limited data on the prevalence of Mycoplasma genitalium (Mgen) coinfection with rectal chlamydia (Chlamydia trachomatis (CT)) and rectal gonorrhoea (Neisseria gonorrhoeae (NG)) infections and few studies examining the prevalence of pharyngeal Mgen in men who have sex with men (MSM). Using transcription-mediated amplification assay, this study aimed to determine the proportion of rectal CT and rectal NG infections in MSM who are coinfected with rectal Mgen, and the proportion of MSM with Mgen detected in the pharynx in order to inform clinical practice.Methods: This was a cross-sectional study conducted at Melbourne Sexual Health Centre in Australia. Consecutively collected rectal swabs from MSM that tested positive for CT (n=212) or NG (n=212), and consecutively collected pharyngeal samples (n=480) from MSM were tested for Mgen using the Aptima Mycoplasma genitalium Assay (Hologic, San Diego). Samples were linked to demographic data and symptom status.Results: Rectal Mgen was codetected in 27 of 212 rectal CT (13%, 95% CI 9 to 18) and in 29 of 212 rectal NG (14%, 95% CI 9 to 19) samples, with no difference in the proportion positive for Mgen. MSM with rectal CT/Mgen coinfection had more sexual partners than those with rectal CT monoinfection (mean 6 vs 11, p=0.06). MSM with rectal NG/Mgen coinfection were more likely to be HIV-positive than those with rectal NG monoinfection (OR=2.96, 95% CI 1.21 to 7.26, p=0.023). MSM with rectal CT/Mgen coinfection were more likely to be using pre-exposure prophylaxis than MSM with rectal NG/Mgen coinfection (OR 0.25, 95% CI 0.10 to 0.65, p=0.002). Pharyngeal Mgen was uncommon and detected in 8 of 464 samples (2%, 95% CI 1% to 3%). Pharyngeal Mgen was associated with having a rectal STI (OR=10.61, 95% CI 2.30 to 48.87, p=0.002), and there was a borderline association with being HIV-positive (p=0.079).Conclusion: These data indicate one in seven MSM treated for rectal CT or rectal NG will have undiagnosed Mgen that is potentially exposed to azithromycin during treatment of these STIs. Rectal Mgen coinfection was associated with specific risk factors which may inform testing practices. Pharyngeal Mgen was uncommon. [ABSTRACT FROM AUTHOR]

Objectives: A mathematical model suggested that a significant proportion of oropharyngeal gonorrhoea cases are acquired via oropharynx-to-oropharynx transmission (ie, tongue-kissing), but to date, no empirical study has investigated this. This study aimed to examine the association between kissing and oropharyngeal gonorrhoea among gay and bisexual men who have sex with men (MSM).Methods: MSM attending a public sexual health centre in Melbourne, Australia, between March 2016 and February 2017 were invited to participate in a brief survey that collected data on their number of male partners in the last 3 months, in three distinct categories: kissing-only (ie, no sex including no oral and/or anal sex), sex-only (ie, any sex without kissing), and kissing-with-sex (ie, kissing with any sex). Univariable and multivariable logistic regression analyses were performed to examine associations between oropharyngeal gonorrhoea positivity by nucleic acid amplification tests and the three distinct partner categories.Results: A total of 3677 men completed the survey and were tested for oropharyngeal gonorrhoea. Their median age was 30 (IQR 25-37) and 6.2% (n=229) had oropharyngeal gonorrhoea. Men had a mean number of 4.3 kissing-only, 1.4 sex-only, and 5.0 kissing-with-sex partners in the last 3 months. Kissing-only and kissing-with-sex were associated with oropharyngeal gonorrhoea, but sex-only was not. The adjusted odds for having oropharyngeal gonorrhoea were 1.46-fold (95% CI 1.04 to 2.06) for men with ≥4 kissing-only partners and 1.81-fold (95% CI 1.17 to 2.79) for men with ≥4 kissing-with-sex partners.Conclusions: These data suggest that kissing may be associated with transmission of oropharyngeal gonorrhoea in MSM, irrespective of whether sex also occurs. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objective: Gonorrhoea transmission between men is currently thought to occur primarily to and from the urethra. Transmission without urethral involvement, from throat-to-throat and throat-to-anus, is considered to be uncommon. Using gonorrhoea results from male couples, we aimed to investigate the transmission dynamics of gonorrhoea. If current medical consensus is correct, then most throat and anal infections should be explained by the partner's urethral infection.Methods: This is a cross-sectional analysis of gonorrhoea diagnosed by nucleic acid amplification tests in both partners in male couples who attended Melbourne Sexual Health Centre together between March 2015 and June 2017. Isolates obtained from culture-positive infections underwent whole genome sequencing to assess phylogenetic relatedness between partners.Results: In all 60 couples (120 men) at least one partner had gonorrhoea, and isolates had very high phylogenetic relatedness between partners. After excluding men with urethral gonorrhoea, among 32 men with anal gonorrhoea, 34% (95% CI 19% to 53 %) had a partner with throat gonorrhoea. After excluding couples where either man had urethral gonorrhoea, among 48 couples in which at least one man had throat gonorrhoea, in 23% (95% CI 12% to 37 %) of couples both men had throat gonorrhoea.Conclusions: The observed gonorrhoea positivity when urethral infection is absent supports a new paradigm of gonorrhoea transmission, where the throat is a major source of gonorrhoea transmission between men, through tongue kissing, oroanal sex and saliva use as anal lubricant. Public health messages may need to address the risk of saliva exposure during sex. [ABSTRACT FROM AUTHOR]

Objective: The Victorian legislation requires sex workers to have quarterly screening for genital chlamydia and gonorrhoea, but screening for oropharyngeal infection is not mandatory in Victoria, Australia. In 2017, oropharyngeal screening for gonorrhoea and chlamydia was added as part of the routine quarterly screening for sex workers attending the Melbourne Sexual Health Centre (MSHC). The aim of this study was to examine the prevalence of oropharyngeal gonorrhoea and chlamydia among female sex workers (FSW).Methods: We included females who (1) self-identified as sex workers or were attended MSHC for a sex work certificate and (2) had tested for any STI or HIV, between March 2015 and December 2017. The prevalence of HIV, syphilis, chlamydia and gonorrhoea was calculated.Results: There were 8538 FSW consultations among 2780 individuals during the study period. There was a twofold increase in genital gonorrhoea (from 0.5% (95% CI 0.3% to 0.9%) to 1.1% (95% CI 0.8% to 1.5%); ptrend=0.047) and a 1.5-fold increase in genital chlamydia (from 2.2% (95% CI 1.6% to 2.8%) to 3.2% (95% CI 2.6% to 3.8%); ptrend=0.031) during the period. Overall, the prevalence of HIV (0.2% (95% CI 0.1% to 0.3%)) and syphilis (0.1% (95% CI 0.0% to 0.2%)) remained low and did not change over time. In 2017, the prevalence of oropharyngeal gonorrhoea was 2.0% (95% CI 1.6% to 2.6%) and oropharyngeal chlamydia was 2.1% (95% CI 1.6% to 2.7%). Among FSW who were tested positive for gonorrhoea and chlamydia, 55% (n=41) and 34% (n=45) only tested positive in the oropharynx but not genital for gonorrhoea and chlamydia, respectively.Conclusion: The prevalence of oropharyngeal gonorrhoea and chlamydia is similar to the prevalence at genital sites and is often independent of genital infection. It is important to test the oropharynx and genital site for chlamydia and gonorrhoea among FSW. [ABSTRACT FROM AUTHOR]

Objectives: There has been considerable discussion about anorectal Chlamydia trachomatis (CT) in women, with some calling for anorectal CT screening, but little about anorectal Neisseria gonorrhoeae (NG). Given that urogenital NG is more strongly associated with pelvic inflammatory disease, this is an evidence gap. This systematic review and meta-analysis investigates the associations between anorectal CT in women and CT positivity at other sites (urogenital/oropharyngeal) and with anal intercourse, and compares these with anorectal NG within the same study populations.Methods: Electronic databases were searched for English-language studies published to October 2018 using the following terms: ("Chlamydia" OR "Chlamydia trachomatis") AND (("anal" OR "rect*" OR "anorect*") OR ("extra?genital" OR "multi?site")). Studies were included if anorectal NG data were available. Random-effects meta-analyses calculated pooled estimates; heterogeneity was investigated using meta-regression.Results: 25 studies were eligible. Anorectal CT positivity ranged from 0% to 17.5%, with a summary estimate of 8.0% (95% CI 7.0 to 9.1; I2=88.5%). Anorectal NG positivity ranged from 0% to 17.0%, with a summary estimate of 2.1% (95% CI 1.6 to 2.8; I2=92.7%). The association between urogenital and anorectal positivity was stronger for NG than CT (summary prevalence ratio (PR)=89.3 (95% CI 53.1 to 150.3; I2=80.1%), PR=32.2 (95% CI 25.6 to 40.7; I2=70.3%), respectively), and between oropharyngeal and anorectal positivity it was stronger for NG than CT (PR=34.8 (95% CI 10.2 to 118.2; I2=89.9%), PR=8.8 (95% CI 6.8 to 11.5; I2=58.1%), respectively). Anal intercourse was associated with anorectal NG (PR=4.3; 95% CI 2.2 to 8.6; I2=0.0%) but not with anorectal CT (PR=1.0; 95% CI 0.7 to 1.4; I2=0.0%).Conclusions: Anorectal CT is more common than anorectal NG, but anorectal NG is more strongly associated with anal intercourse, urogenital and oropharyngeal NG, suggesting that ongoing discussion about anorectal CT should also include NG. Longitudinal data are required to further understanding of the aetiology of anorectal STIs and assess whether anorectal screening is needed in women.Trial Registration Number: CRD42df017080188. [ABSTRACT FROM AUTHOR]

Objectives: Reports of rising herpes simplex virus type 1 (HSV-1) genital infections relative to HSV-2 have been published up to 2006 in Australia. These changes have been attributed to declining childhood immunity to HSV-1. We described the temporal trends of HSV-1 and HSV-2 up to 2017 in Melbourne, Australia, to determine if the earlier trend is continuing.Methods: We conducted a retrospective review of the medical records of 4517 patients who were diagnosed with first episode of anogenital HSV infection at the Melbourne Sexual Health Centre, Australia, between January 2004 and December 2017. HSV-1 and HSV-2 were calculated as a proportion of all first episode of anogenital HSV infections. The change in the proportions of HSV-1 and HSV-2 over time was assessed by a χ2 trend test. Risk factors associated with HSV-1 were examined using a multivariable logistic regression model.Results: The proportion of first episode of anogenital herpes due to HSV-1 increased significantly over time in women (from 45% to 61%; ptrend<0.001) and heterosexual men (from 38% to 41%; ptrend=0.01) but not in men who have sex with men (MSM) (ptrend=0.21). After adjusting for condom use, partner number and age, the annual increase remained significant only in women (OR 1.08, 95% CI 1.03 to 1.13, p<0.001). In MSM, HSV-1 caused up to two-thirds of anogenital herpes in most years and HSV-1 was more likely to be diagnosed at an anal site than genital site (OR 1.69, 95% CI 1.23 to 2.32, p<0.001). Younger age (<28 years) was an independent risk factor for HSV-1 in all groups.Conclusions: The proportion of first-episode anogenital herpes due to HSV-1 has been rising in women since 2004. HSV-1 has become the leading cause of anogenital herpes in younger populations, women and MSM. [ABSTRACT FROM AUTHOR]

Objectives To examine barriers and facilitators to sustaining a sexual health continuous quality improvement (CQI) programme in clinics serving remote Aboriginal communities in Australia. Design Qualitative study. Setting Primary health care services serving remote Aboriginal communities in the Northern Territory, Australia. Participants Seven of the 11 regional sexual health coordinators responsible for supporting the Northern Territory Government Remote Sexual Health Program. Methods Semi-structured in-depth interviews conducted in person or by telephone; data were analysed using an inductive and deductive thematic approach. Results Despite uniform availability of CQI tools and activities, sexual health CQI implementation varied across the Northern Territory. Participant narratives identified five factors enhancing the uptake and sustainability of sexual health CQI. At clinic level, these included adaptation of existing CQI tools for use in specific clinic contexts and risk environments (eg, a syphilis outbreak), local ownership of CQI processes and management support for CQI. At a regional level, factors included the positive framing of CQI as a tool to identify and act on areas for improvement, and regional facilitation of clinic level CQI activities. Three barriers were identified, including the significant workload associated with acute and chronic care in Aboriginal primary care services, high staff turnover and lack of Aboriginal staff. Considerations affecting the future sustainability of sexual health CQI included the need to reduce the burden on clinics from multiple CQI programmes, the contribution of regional sexual health coordinators and support structures, and access to and use of high-quality information systems. Conclusions This study contributes to the growing evidence on how CQI approaches may improve sexual health in remote Australian Aboriginal communities. Enhancing sustainability of sexual health CQI in this context will require ongoing regional facilitation, efforts to build local ownership of CQI processes and management of competing demands on health service staff. [ABSTRACT FROM AUTHOR]

Objective: In mid-2017, the Victorian Government funded a free time-limited human papillomavirus (HPV) vaccination catch-up programme for gay and bisexual men who have sex with men (MSM) aged up to 26 years through sexual health clinics or other immunisation centres. We aimed to examine the uptake of the HPV vaccine among young MSM attending the Melbourne Sexual Health Centre (MSHC).Methods: MSM aged ≤26 attending MSHC between 27 April 2017 and 31 December 2017 were included in the analysis. HPV vaccine uptake was calculated based on the first consultation of each patient during the period. Multivariable logistic regression was performed to examine the association between vaccine uptake and patient factors.Results: There were 2108 MSM aged ≤26 who attended MSHC over the study period, with 7.6% (n=161) reporting previous HPV vaccination. Of the 1947 eligible men, 1134 (58.2%, 95% CI 56.0% to 60.4%) were offered the vaccine by the clinicians, and 830 men received it on the day. The vaccine coverage among all eligible MSM was 42.6% (95% CI 40.4% to 44.9%; 830 of 1947) and among MSM who were offered the vaccine by the clinicians was 73.2% (95% CI 70.5% to 75.8%; 830 of 1134). Men with a history of genital warts (adjusted OR (aOR)=3.11, 95%CI 1.39 to 6.99) and those who had >4male partners in the last 12 months (aOR=1.38, 95% CI 1.04 to 1.85) were more likely to receive the HPV vaccine on the day. 304 men declined the vaccine; most men did not specify the reason (31.3%, n=95), while 27.3% (n=83) needed time to think.Conclusion: Although vaccine uptake was 73.2% among those offered, the actual coverage of those eligible remained unsatisfactory (42.6%) in a sexual health clinic. This highlights a clinic-based targeted MSM programme may not reach sufficiently high vaccine coverage to provide MSM with the same vaccine benefits as heterosexuals. [ABSTRACT FROM AUTHOR]

Objectives: Internet-based STI testing programmes may overcome barriers posed by in-clinic testing, though uptake could reflect social gradients. The role these services play in comparison to clinical testing services is unknown. We compared experiences of testing barriers between STI clinic clients to clients of GetCheckedOnline.com (GCO; where clients take a printed lab form to a lab).Methods: Our 10-month cross-sectional study was conducted after GCO was promoted to STI clinic clients and men who have sex with men (MSM). Clinic and GCO clients completed an online survey assessing testing barriers and facilitators; responses were compared using bivariate analysis (level of significance P<0.01; significant results below).Results: Compared with 321 clinic clients, the 73 GCO clients were more likely to be older (median 35 vs 30 years), MSM (45% vs 16%), be testing routinely (67% vs 39%), have delayed testing for any reason (76% vs 54%) and due to clinic distance (28% vs 9%), report delays due to wait times (50% vs 17%), embarrassment with testing (16% vs 6%), discomfort discussing sexual health where they usually go for testing (39% vs 22%), as well as discomfort discussing sexual history with (19% vs 5%) and fearing judgement from (30% vs 15%) any healthcare provider. GCO clients were less likely to have found clinic hours convenient (59% vs 77%) and clinic appointments easy to make (49% vs 66%), and more likely to report long wait times (50% vs 17%). We found no differences in technology skills/use.Conclusions: In this urban setting, an internet-based testing service effectively engaged individuals experiencing testing barriers, with few social gradients in uptake. While some testing barriers could be addressed through increasing access to clinical services, others require social and structural changes, highlighting the importance of internet-based STI testing services to increasing test uptake. [ABSTRACT FROM AUTHOR]

Objective: Internet-based HIV testing offers the potential to address privacy-related barriers to testing and increase frequency of testing but may result in missed opportunities related to sexual health education and prevention that typically occur in face-to-face encounters. In this study, we assessed the HIV test knowledge and sexual risk behaviour of clients testing for HIV through GetCheckedOnline, an internet-based sexually transmitted and bloodborne infection testing platform inclusive of HIV testing, in comparison to clients testing through a large sexual health clinic.Methods: We concurrently recruited GetCheckedOnline clients and clinic clients from Vancouver, Canada, over the course of a 10-month period during 2015-2016. Participants completed baseline and 3-month questionnaires, anonymous and online. A six-item score was used to estimate knowledge of HIV test concepts typically conveyed during an HIV pretest encounter in a clinic. We used multiple regression to estimate associations between testing modality (online vs clinic based) and two outcomes-HIV test knowledge and change in condom use pre/post-test-with adjustment for relevant background factors.Results: Among 352 participants, online testers demonstrated higher HIV post-test knowledge than clinic-based testers (mean score 4.65/6 vs 4.09/6; p<0.05); this difference was reduced in adjusted analysis (p>0.05). Men who have sex with men, clients with a university degree, those who have lived in Canada >10 years and English speakers had higher HIV post-test knowledge (p<0.05). Eighteen per cent of online testers and 10% of clinic-based testers increased condom use during the 3 months post-test (p>0.05).Conclusions: In this comparative study between online and clinic-based testers, we found no evidence of decreased HIV test knowledge or decreased condom use following HIV testing through GetCheckedOnline. Our findings suggest that with careful design and attention to educational content, online testing services may not lead to missed opportunities for HIV education and counselling. [ABSTRACT FROM AUTHOR]

Objectives: All males and females attending the Melbourne Sexual Health Centre (MSHC) from August 2017 were asked whether they had had sex with a transgender or gender diverse (TGD) person using computer-assisted self-interviewing (CASI). We aimed to verify the self-reported responses via chart review. The secondary aim of this study was to identify whether having sex with a TGD person was associated with STI risk.Methods: This was a retrospective chart analysis of patients visiting MSHC between August and December 2017. Chart review was performed to verify the self-reported responses. Multivariable logistic regression was performed to examine the association between having sex with a TGD person and patients' characteristics and STI risk.Results: Of the 10 100 male and female consultations, the proportion who reported having sex with a TGD person was 111 (1.0%) and was higher among males (1.3%) than females (0.6%) (p=0.001). After chart review, we could verify 66.9% of the responses, more for males (75.2%) than females (45.2%) (p<0.001). Of the 6822 males, men aged ≥35 years (adjusted OR=2.2; 95% CI 1.1 to 4.1) were more likely to have sex with a TGD person compared with men aged ≤24 years, after adjusting for confounding factors. Sex with a TGD person was not associated with sexual orientation in males. Of the 3278 females, gay and bisexual females had 13.7-fold (95% CI 5.1 to 37.0) higher odds of having sex with a TGD person than heterosexual females. There was no association between chlamydia positivity and sex with a TGD person in both males and females.Conclusion: When a question on TGD partners is asked as part of routine sexual history using CASI, the majority of responses could be verified. TGD partners were most commonly reported among males. These findings underscore the value of asking patients about sex with TGD partners. [ABSTRACT FROM AUTHOR]

Objectives: Oropharyngeal gonorrhoea is increasing among men who have sex with men and is commonly found in the tonsils and at the posterior pharyngeal wall. To address this rise, investigators are currently trialling mouthwash to prevent oropharyngeal gonorrhoea. We aimed to determine which parts of the oropharynx were reached by different methods of mouthwash use (oral rinse, oral gargle and oral spray).Methods: Twenty staff at Melbourne Sexual Health Centre participated in the study from March to May 2018. Participants were asked to use mouthwash mixed with food dye, by three application methods on three separate days: oral rinse (15 s and 60 s), oral gargle (15 s and 60 s) and oral spray (10 and 20 times). Photographs were taken after using each method. Three authors assessed the photographs of seven anatomical areas (tongue base, soft palate, uvula, anterior tonsillar pillar, posterior tonsillar pillar, tonsil, posterior pharyngeal wall) independently and scored the dye coverage from 0% to 100%. Scores were then averaged.Results: The mean coverage at the sites ranged from 2 to 100. At the posterior pharyngeal wall, spraying 10 times had the highest mean coverage (29%) and was higher than a 15 s rinse (2%, p=0.001) or a 15 s gargle (8%, p=0.016). At the tonsils, there was no difference in mean coverage between spray and gargle at any dosage, but spraying 20 times had a higher mean coverage than a 15 s rinse (42% vs 12%, p=0.012).Conclusion: Overall, spray is more effective at reaching the tonsils and posterior pharyngeal wall compared with rinse and gargle. If mouthwash is effective in preventing oropharyngeal gonorrhoea, application methods that have greater coverage may be more efficacious. [ABSTRACT FROM AUTHOR]

Objective: To analyse yearly rates of pelvic inflammatory disease (PID) and ectopic pregnancy (EP) diagnosed in hospital settings in Australia from 2009 to 2014.Methods: We calculated yearly PID and EP diagnosis rates in three states (Victoria, New South Wales, Queensland) for women aged 15-44 years using hospital admissions and emergency department (ED) attendance data, with population and live birth denominators. We stratified PID diagnoses as chlamydial-related or gonorrhoeal-related (Chlamydia trachomatis (CT)-related or Neisseria gonorrhoeae (NG)-related), acute, unspecified and chronic, and analysed variations by year, age and residential area using Poisson regression models.Results: For PID, the rate of all admissions in 2014 was 63.3 per 100 000 women (95% CI 60.8 to 65.9) and of all presentations in EDs was 97.0 per 100 000 women (95% CI 93.9 to 100.2). Comparing 2014 with 2009, the rate of all PID admissions did not change, but the rate of all presentations in EDs increased (adjusted incidence rate ratio (aIRR) 1.34, 95% CI 1.24 to 1.45), and for admissions by PID category was higher for CT-related or NG-related PID (aIRR 1.73, 95% CI 1.31 to 2.28) and unspecified PID (aIRR 1.09, 95% CI 1.00 to 1.19), and lower for chronic PID (aIRR 0.84, 95% CI 0.74 to 0.95). For EP, in 2014 the rate of all admissions was 17.4 (95% CI 16.9 to 17.9) per 1000 live births and of all ED presentations was 15.6 (95% CI 15.1 to 16.1). Comparing 2014 with 2009, the rates of all EP admissions (aIRR 1.06, 95% CI 1.04 to 1.08) and rates in EDs (aIRR 1.24, 95% CI 1.18 to 1.31) were higher.Conclusions: PID and EP remain important causes of hospital admissions for female STI-associated complications. Hospital EDs care for more PID cases than inpatient departments, particularly for young women. Updated primary care data are needed to better understand PID epidemiology and healthcare usage. [ABSTRACT FROM AUTHOR]

Objective: Human papillomavirus (HPV) infection causes multiple cancers in both women and men. In China, both HPV vaccination and cervical cancer screening coverages are low. We aim to investigate the temporal and geographical trends of HPV DNA prevalence in heterosexual men, women, men who have sex with men (MSM) and people living with HIV (PLHIV) in China.Methods: We conducted a systematic review, collecting publications in PubMed, Web of Science, China National Knowledge Infrastructure (CNKI) and Wanfang Data from January 2000 to May 2017. A total of 247 studies were selected for this meta-analysis to estimate pooled HPV prevalence, incidence of cervical cancer and risk of infection for subgroups. Meta-regression was applied to identify contributing factors to prevalence heterogeneities.Results: The national HPV prevalence was 15.6% (95% CI (14.4% to 16.9%)) in women with normal cervical cytology, and Central China had the highest prevalence (20.5% (15.2% to 25.8%)). HPV prevalence in heterosexual men (14.5% (11.3% to 17.7%)) was comparable with that of women (OR=1.09 (0.98 to 1.17)), but HPV prevalence in MSM (59.9% (52.2% to 67.6%)) was significantly higher than that in heterosexual men (OR=8.81 (8.01 to 9.69)). HIV-positive women (45.0% (38.4% to 51.6%)) and HIV-positive MSM (87.5% (82.3% to 90.9%)) had 4.67 (3.61 to 6.03) and 6.46 (5.20 to 8.02) times higher risk of HPV infection than their HIV negative counterparts.Conclusion: HPV infection is prevalent in China, particularly in Central China, in comparison with the global level and neighbouring countries. Targeted HPV vaccination for women, MSM and PLHIV and scale-up of cervical screening for women are priorities in curbing the HPV epidemic in China. [ABSTRACT FROM AUTHOR]

Objectives: Oropharyngeal gonorrhoea is common among men who have sex with men (MSM). We aimed to clarify which oral sex practices were independent risk factors for oropharyngeal gonorrhoea: tongue kissing, receptive oro-penile sex (fellatio) or insertive oro-anal sex (rimming), and whether daily use of mouthwash and recent antibiotic use was protective.Methods: In 2015, we conducted an age-matched case-control study of MSM who attended the Melbourne Sexual Health Centre. Cases had tested positive for oropharyngeal gonorrhoea by nucleic acid amplification testing, and controls had tested negative. Questionnaire items included tongue kissing, oral sex practices, condom use, recent antibiotic use, mouthwash use and alcohol consumption.Results: We identified 177 cases, age matched to 354 controls. In univariable analyses, cases were 1.90 times (95% CI 1.13 to 3.20) more likely than controls to have had casual sexual partners (CSP) in the preceding 3 months, were 2.17 times (95% CI 1.31 to 3.59) more likely to have kissed CSP and were 2.04 times (95% CI 1.26 to 3.30) more likely to have had receptive oro-penile sex with CSP. Oropharyngeal gonorrhoea was not associated with insertive oro-anal sex or mouthwash use. The number of CSP for tongue kissing and receptive oral sex and total CSP were highly correlated, and in multivariable analysis neither kissing nor receptive oro-penile sex was significantly associated with having oropharyngeal gonorrhoea, after adjusting for total number of CSP.Conclusions: The finding that oropharyngeal gonorrhoea was associated with a higher number of sexual partners but not specific sexual practices highlights the need for further research in the area of gonorrhoea transmission to define the probability of transmission from specific sex acts. [ABSTRACT FROM AUTHOR]

Objectives: A new molecular test for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) (GeneXpert CT/NG) has been demonstrated to be as accurate as conventional nucleic acid amplification tests (NAAT), but performance has not been evaluated in routine primary care, performed at the point of care by clinicians. We aimed to examine its diagnostic performance when used by clinicians in remote community health services in Australia with high prevalences of CT and NG infection. The trial was registered with the Australian and New Zealand Clinical Trials Registry (#12613000808741) METHODS: At 12 health services, training was provided to 99 clinicians in the use of the GeneXpert CT/NG assay who tested specimens from all patients undergoing STI screening. Specimens were also sent in parallel for conventional laboratory-based NAATs and the concordance of results was evaluated.Results: Clinicians conducted 2486 tests: CT concordance was 99.4% (95% CI 99.1 to 99.7) with a positive concordance of 98.6% (95% CI 95.9 to 99.7) and negative concordance of 99.5% (95% CI 99.1 to 99.8); NG concordance was 99.9% (95% CI 99.7 to 100.0) with a positive concordance of 100.0% (95% CI 97.5 to 100.0) and negative concordance of 99.9% (95% CI 99.7 to 100.0).Conclusions: In this first study reporting routine point-of-care use of GeneXpert CT/NG by primary care clinicians, we found excellent concordance with conventional NAATs. The use of the GeneXpert CT/NG at the point of care could potentially transform management and control of these infections in many endemic settings, including low/middle-income countries. [ABSTRACT FROM AUTHOR]

Objectives: The objective of this study was to examine the associations between clinicians' self-reported sampling technique and the detection rate of gonorrhoea at the oropharynx and anorectum using a highly sensitive nucleic acid amplification test (NAAT).Methods: We analysed oropharyngeal and anorectal gonorrhoea swab results among men who have sex with men attending the Melbourne Sexual Health Centre (MSHC) between March 2015 and December 2016. Swabs were tested by NAAT using the Aptima Combo 2 transcription-mediated amplification assay due to its high sensitivity. Clinicians at MSHC were invited to complete a questionnaire on sampling techniques in November 2016. Univariable generalised estimating equations (GEE) logistic regressions were performed to determine the association between gonorrhoea detection rates and clinicians' sampling technique. Patients' epidemiological risk factors were included in the multivariable GEE logistic model.Results: A total of 2605 oropharyngeal gonorrhoea and 2392 anorectal gonorrhoea swab results were analysed. There was no significant difference in the detection rates of gonorrhoea between the 23 clinicians at the oropharynx (range 3.6%-16.9%, median 8.2%, P=0.302) or and anorectum (range 2.4%-17.3%, median 10.5%, P=0.177). Variations in clinicians' self-reported sampling technique were not associated with oropharyngeal or anorectal gonorrhoea detection rates after adjusting for patients' epidemiological risk factors.Conclusions: This study shows that differences in clinicians' self-reported sampling technique did not result in measurable differences in the detection rate for oropharyngeal or anorectal gonorrhoea when using NAAT. [ABSTRACT FROM AUTHOR]

Objective: Human papillomavirus (HPV) surveillance is important to monitor the effectiveness of national HPV vaccination programmes. Positivity of HPV in urine in men varies with different sampling methods. We aimed to determine the positivity for detection of HPV-6/11 in urine samples among men in relation to the position of genital warts and circumcision status.Method: We analysed stored chlamydia-positive urine specimens in young heterosexual men aged less than 25 years attending Melbourne Sexual Health Centre, Australia, between 2004 and 2015, for HPV genotypes. Positivity of HPV-6/11 and high-risk genotypes were stratified according to the position of genital warts and circumcision status. Positivity of HPV-6/11 was calculated using diagnosis of warts as the gold standard. Warts were classified as proximal penile warts from suprapubic area to midshaft of penis, and distal penile warts from distal shaft of penis to meatus.Results: Of the 934 specimens, 253 (27.1%) men were positive for any HPV and 82 men (8.8%) had genital warts. The ORs of HPV-6/11 detection in urine were 4.63 (95% CI: 1.68 to 12.78) and 40.20 (95% CI: 19.78 to 81.70) times higher among men who had proximal penile warts and distal penile warts, respectively, compared with men who did not have genital warts. Circumcised men were less likely to have high-risk HPV (OR 0.31; 95% CI: 0.14 to 0.65) than uncircumcised men. Uncircumcised men were more likely to have distal penile warts than circumcised men (OR 8.22; 95% CI: 1.34 to 337.46).Conclusion: Positivity of HPV-6/11 in urine increases greatly in men with distal penile warts. Circumcised men are less likely to have distal penile warts, any HPV or high-risk HPV detected. Urine is likely to be an alternative sampling method for HPV-6/11 surveillance programme in men in countries with low circumcision rates. [ABSTRACT FROM AUTHOR]

Objective: Literature surrounding the healthcare needs of transgender individuals is limited in Australia. This study aimed to investigate the demographic characteristics, risk behaviours and HIV/STI positivity among male-to-female (MTF) and female-to-male (FTM) transgender individuals attending Melbourne Sexual Health Centre (MSHC), Australia, between 2011 and 2014.Method: A retrospective cohort analysis for 133 transgender individuals was conducted based on the first visit of individuals to MSHC during the study period. Demographic characteristics, sexual behaviours and HIV/STI positivity were examined.Results: The majority of transgender individuals were single or never married (74%; n=99). Almost half of the individuals (47%; n=62) had ever engaged in sex work during their lifetime. The median number of male sexual partners (MSP) reported in the last 3 months was 1 (IQR: 1-2) and with female sexual partners (FSP) was 2 (IQR: 1-4). For those who reported having sexual partners in the previous 3 months, always using condoms with MSP was 31% (n=22), and that with FSP was 18% (n=2). HIV/STI positivity during the study period was 7% (n=8) for chlamydia, 5% (n=6) for gonorrhoea, 5% (n=5) for syphilis and 1% (n=1) for HIV. Hormone use for reassignment was reported by 63% (n=90) of individuals and reassignment surgery was reported by 27% (n=29+6=35).Conclusions: Transgender individuals in this study were found to be a diverse group, with a history of sex work being a common feature. These findings indicate that transgender individuals' sexual healthcare needs differ substantially from those in other countries, including the US and Canada. Attention to differences in MTF and FTM transgender persons must be considered in healthcare settings in Australia. [ABSTRACT FROM AUTHOR]

Objectives: Drug-resistant Neisseria gonorrhoeae are now a global public health threat. Direct transmission of antibiotic-resistant gonococci between individuals has been proposed as a driver for the increased transmission of resistance, but direct evidence of such transmission is limited. Whole-genome sequencing (WGS) has superior resolution to investigate outbreaks and disease transmission compared with traditional molecular typing methods such as multilocus sequence typing (MLST) and N. gonorrhoeae multiantigen sequence (NG-MAST). We therefore aimed to systematically investigate the transmission of N. gonorrhoeae between men in sexual partnerships using WGS to compare isolates and their resistance to antibiotics at a genome level.Methods: 458 couples from a large prospective cohort of men who have sex with men (MSM) tested for gonorrhoea together between 2005 and 2014 were included, and WGS was conducted on all isolates from couples where both men were culture-positive for N. gonorrhoeae. Resistance-determining sequences were identified from genome assemblies, and comparison of isolates between and within individuals was performed by pairwise single nucleotide polymorphism and pangenome comparisons, and in silico predictions of NG-MAST and MLST.Results: For 33 of 34 (97%; 95% CI 85% to 100%) couples where both partners were positive for gonorrhoea, the resistance-determining genes and mutations were identical in isolates from each partner (94 isolates in total). Resistance determinants in isolates from 23 of 23 (100%; 95% CI 86% to 100%) men with multisite infections were also identical within an individual. These partner and within-host isolates were indistinguishable by NG-MAST, MLST and whole genomic comparisons.Conclusions: These data support the transmission of antibiotic-resistant strains between sexual partners as a key driver of resistance rates in gonorrhoea among MSM. This improved understanding of the transmission dynamics of N. gonorrhoeae between sexual partners will inform treatment and prevention guidelines. [ABSTRACT FROM AUTHOR]

Background: China has strengthened its primary care workforce and implemented a wide network of community health centres (CHCs). However, STI testing and management are not currently included in the 'Essential Package of Primary Health Care in China'. Legislation change to encourage STI service delivery would be important, but it is also critical to determine if there are also provider-related opportunities and barriers for implementing effective STI programmes through CHCs if future legislation were to change.Methods: A national representative survey was conducted between September and December 2015 in a stratified random sample of 180 CHCs based in 20 cities in China. Primary care practitioners (PCPs) provided information on current experiences of STI testing as well as the barriers and facilitators for STI testing in CHCs. Multivariate logistic regression was conducted to determine factors associated with PCPs performing STI testing.Results: 3580 out of 4146 (86%) invited PCPs from 158 CHCs completed the survey. The majority (85%, 95% CI 84% to 87%) of doctors stated that STI testing was an important part of healthcare. However, less than a third (29%, 95% CI 27% to 31%) would perform an STI test if the patients asked. Barriers for performing STI testing included lack of training, concerns about reimbursement, concerns about damage to clinics' reputations and the stigma against key populations. Respondents who reported that they would perform an STI test were likely to be younger, received a bachelor degree or higher, received specific training in STIs, believed that STI test was an important part of healthcare or had resources to perform STI testing.Conclusions: There is potential for improving STI management in China through upskilling the primary care workforce in CHCs. Specific training in STIs is needed, and other structural, logistical and attitudinal barriers are needed to be addressed. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study was to examine the willingness of men who have sex with men (MSM) to change their behaviours to potentially reduce the risk of pharyngeal gonorrhoea transmission and acquisition.Methods: A cross-sectional questionnaire-based study was conducted among MSM attending the Melbourne Sexual Health Centre, Australia, between March and September 2015. Participants were asked how likely they would change their behaviours to reduce the risk of pharyngeal gonorrhoea. Six different potential preventive interventions were asked: (1) stop tongue kissing; (2) stop having receptive oral sex; (3) stop performing rimming; (4) stop using saliva as a lubricant during anal sex; (5) use of condoms during oral sex; and (6) use of alcohol-containing mouthwash daily.Results: Of the 926 MSM who completed the questionnaire, 65.4% (95% CI 62.3% to 68.5%) expressed they were likely to use mouthwash daily to reduce the risk of pharyngeal gonorrhoea, 63.0% (95% CI 59.8% to 66.1%) would stop using saliva as a lubricant, and 49.5% (95% CI 46.2% to 52.7%) would stop rimming. In contrast, 77.6% (95% CI 74.8% to 80.3%) of MSM expressed they were unlikely to stop tongue kissing. MSM who were younger and had less male partners expressed they were unlikely to use mouthwash daily as an intervention to reduce risk of pharyngeal gonorrhoea acquisition.Conclusions: The practices MSM are willing to change to reduce the risk of pharyngeal gonorrhoea transmission and acquisition vary greatly; however, the majority of men are likely to use mouthwash daily to reduce the risk of pharyngeal gonorrhoea. [ABSTRACT FROM AUTHOR]

Objective There are limited data on the patterns of early sexual behaviours among Australian teenage heterosexual boys. This study describes the nature and onset of early sexual experiences in this population through a crosssectional survey. Design A cross-sectional survey between 2014 and 2015 Setting Major sexual health clinics and community sources across Australia Participants Heterosexual men aged 17-19 years Results There were 191 men in the study with a median age of 19.1 years. Median age at first oral sex was 16.4 years (IQR: 15.5-17.7) and 16.9 years (IQR: 16.0-18.0) for first vaginal sex. Most men had engaged in oral sex (89.5%) and vaginal sex (91.6%) in the previous 12 months with 32.6% reporting condom use at last vaginal sex. Of the total lifetime female partners for vaginal sex reported by men as a group (n=1187): 54.3% (n=645) were the same age as the man, 28.3% (n=336) were a year or more younger and 17.4% (n=206) were a year or more older. Prior anal sex with females was reported by 22% with 47% reporting condom use at last anal sex. Median age at first anal sex was 18.2 years (IQR: 17.3-18.8). Anal sex with a female was associated with having five or more lifetime female sexual partners for oral and vaginal sex. Conclusions These data provide insights into the trajectory of sexual behaviours experienced by teenage heterosexual boys following sexual debut, findings which can inform programme promoting sexual health among teenage boys. [ABSTRACT FROM AUTHOR]