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Using repeated behavioural surveillance data collected from gay and bisexual men (GBM) across Australia, we assessed trends in HIV prevention coverage (the level of 'safe sex' achieved in the population by the use of effective prevention methods, including condoms, pre-exposure prophylaxis [PrEP] and having an undetectable viral load). We stratified these trends by age, country of birth/recency of arrival, sexual identity, and the proportion of gay residents in the participant's suburb. Among 25,865 participants with casual male partners, HIV prevention coverage increased from 69.8% in 2017 to 75.2% in 2021, lower than the UNAIDS target of 95%. Higher levels of coverage were achieved among older GBM (≥ 45 years), non-recently-arrived migrants, and in suburbs with ≥ 10% gay residents. The lowest levels of prevention coverage (and highest levels of HIV risk) were recorded among younger GBM (< 25 years) and bisexual and other-identified participants. Younger, recently-arrived, and bisexual GBM were the most likely to use condoms, while PrEP use was concentrated among gay men, 25-44-year-olds, and in suburbs with more gay residents. The use of undetectable viral load was most common among participants aged ≥ 45 years. Our analysis shows that high HIV prevention coverage can be achieved through a mixture of condom use, PrEP use, and undetectable viral load, or by emphasising PrEP use. In the Australian context, younger, bisexual and other-identified GBM should be prioritised for enhanced access to effective HIV prevention methods. We encourage other jurisdictions to assess the level of coverage achieved by combination prevention, and variations in uptake., (© 2023. The Author(s).)

Evaluating HIV preexposure prophylaxis (PrEP) use and HIV risk events concurrently remains challenging. We developed a single question method for measuring prevention-effective adherence with PrEP in self-report questionnaires. In a questionnaire completed by 409 gay and bisexual men, 46% reported condomless anal sex that was not covered by their own PrEP use, and this was more common among younger, lower-income participants. Refining this questionnaire item could improve measurement of prevention-effective adherence., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

PrEP has been reported to facilitate openness to serodifferent sexual partnerships among sexual minority men (SMM). However, other aspects of a sexual scenario likely come into play, including whether or not condoms are used and whether or not the partner living with HIV has an undetectable viral load. This online survey study evaluated the association between PrEP status and openness to serodifferent partnering, as well as the effects of various sexual scenario variables (condom use and partner's viral load) among 268 HIV-negative SMM in the US. Each participant reported their PrEP status and rated their openness to serodifferent partnering in four sexual scenarios, which varied by condom use (with/without) and partner viral load status (detectable/undetectable). Analyses of covariance (ANCOVAs) were conducted to assess differences in openness to serodifferent partnering by PrEP status in each scenario, adjusting for background characteristics. A two-way repeated measures ANCOVA and a three-way mixed factorial ANCOVA, including PrEP status as a between-subjects variable, were also performed to assess the effects of condom use and partner viral load status on openness. Across all scenarios, current PrEP users expressed significantly greater openness to serodifferent partnering compared to participants who had never used PrEP. Current PrEP users were also more likely than former PrEP users to consider partnering with someone with an undetectable viral load without using condoms. Both PrEP users and PrEP-inexperienced individuals had greater openness to serodifferent partnering with a partner having an undetectable (vs. detectable) viral load, which was magnified by condom use among the latter., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Gay, bisexual, and other men who have sex with men (GBM) are overrepresented in diagnoses of sexually transmitted infections (STIs) relative to their population size. This study assessed trends in STI testing and diagnoses among GBM in Australia., Methods: The Gay Community Periodic Surveys are repeated cross-sectional behavioral surveillance surveys of GBM. Participants reported the number of anal swabs, throat swabs, urine samples, and blood tests for syphilis they undertook in the last year. "Frequent comprehensive testing" was defined as ≥3 of each test in the previous year. Participants reported STI diagnoses of chlamydia, gonorrhea, syphilis, and other STIs in the last year. Trends in testing and diagnoses from 2017 to 2020 and 2020 to 2021 were assessed with logistic regression models., Results: We analyzed 24,488 survey responses from participants reporting casual sex in the last 6 months. Between 2017 and 2020, frequent comprehensive STI testing decreased among HIV-negative GBM on preexposure prophylaxis (PrEP) from 71.7% to 68.9% and declined further to 58.6% in 2021. Frequent comprehensive STI testing was stable during 2017-2020 among HIV-negative/untested GBM not on PrEP (17.4%-14.6%) and HIV-positive GBM (30.4%-35.1%) but declined in 2021 to 7.5% among non-PrEP-users and 25.7% among HIV-positive participants. There were minimal changes in STI diagnoses during 2017-2020, but diagnoses declined in 2021., Conclusions: Many GBM do not meet Australian STI testing guidelines that recommend quarterly testing. Further evaluation of whether this recommendation is realistic or necessary to reduce STIs among GBM is recommended., Competing Interests: Conflict of Interest and Sources of Funding: No conflicts of interests to declare. The Gay Community Periodic Surveys are supported by funds from state and territory health departments. The Centre for Social Research in Health and the Kirby Institute are supported by funding from the Australian Government Department of Health. This research was supported by an Australian Government Research Training Program Scholarship., (Copyright © 2023 American Sexually Transmitted Diseases Association. All rights reserved.)

Maintaining routines of medication dosing requires effort amidst the variabilities of everyday life. This article offers a sociomaterial analysis of how the oral HIV prevention regimen, pre-exposure prophylaxis (PrEP), is put to use and made to work, including in situations which disrupt or complicate dosing regimes. Other than a daily pill, PrEP can be taken less frequently based on anticipated sexual activity and HIV risk, including 'on-demand' and 'periodic' dosing. Drawing on 40 interviews with PrEP users in Australia in 2022, we explore PrEP and its dosing as features of assemblages in which bodies, routines, desires, material objects and the home environment interact. Dosing emerges as a practice of coordination involving dosette boxes, blister packs, alarms, partners, pets, planning sex, routines and domestic space, and as an effect of experimentations with timing to suit life circumstances and manage side effects. Dosing is materialised in the mundane; a practice that is made to work, as well as domesticated, in its situations. Although there are no 'simple' solutions to adherence, our analysis offers practical insights into how routine, planning and experimentation come together to capacitate PrEP to work in people's lives, in sometimes unexpected ways, including through adaptations of PrEP dosing., (© 2023 The Authors. Sociology of Health & Illness published by John Wiley & Sons Ltd on behalf of Foundation for the Sociology of Health & Illness.)

The introduction of HIV pre-exposure prophylaxis (PrEP) has the potential to impact the attitudes gay and bisexual men (GBM) who consequently choose to take PrEP have towards treatment as prevention (TasP), and the extent to which they are willing to have condomless anal intercourse (CLAI) with an HIV-positive sexual partner who has an undetectable viral load (UVL). Using a cross-sectional sample from an observational cohort study conducted from August 2018 to March 2020, we examined the extent to which PrEP-experienced GBM are willing to have CLAI with a partner who has a UVL. Simple and multiple logistic regression models were used to identify associated variables. Of the 1386 participants included in the analyses, 79.0% believed in the effectiveness of TasP, and 55.3% were willing to have CLAI with a partner who has a UVL. Wiling participants were less worried about getting HIV when taking PrEP and more likely to believe in TasP. Further research is needed to better understand the gap between belief in TasP and willingness to have CLAI with a partner who has a UVL among PrEP-experienced GBM., (© 2023. The Author(s).)

Background: Although HIV treatment-as-prevention reduces individual-level HIV transmission, population-level effects are unclear. We aimed to investigate whether treatment-as-prevention could achieve population-level reductions in HIV incidence among gay, bisexual, and other men who have sex with men (GBM) in Australia's most populous states, New South Wales and Victoria., Methods: TAIPAN was a longitudinal cohort study using routine health record data extracted from 69 health services that provide HIV diagnosis and care to GBM in New South Wales and Victoria, Australia. Data from Jan 1, 2010, to Dec 31, 2019, were linked within and between services and over time. TAIPAN collected data from all cisgender GBM who attended participating services, resided in New South Wales or Victoria, and were 16 years or older. Two cohorts were established: one included HIV-positive patients, and the other included HIV-negative patients. Population prevalence of viral suppression (plasma HIV viral load <200 RNA copies per μL) was calculated by combining direct measures of viral load among the HIV-positive cohort with estimates for undiagnosed GBM. The primary outcome of HIV incidence was measured directly via repeat testing in the HIV-negative cohort. Poisson regression analyses with generalised estimating equations assessed temporal associations between population prevalence of viral suppression and HIV incidence among the subsample of HIV-negative GBM with multiple instances of HIV testing., Findings: At baseline, the final sample (n=101 772) included 90 304 HIV-negative and 11 468 HIV-positive GBM. 59 234 patients in the HIV-negative cohort had two or more instances of HIV testing and were included in the primary analysis. Over the study period, population prevalence of viral suppression increased from 69·27% (95% CI 66·41-71·96) to 88·31% (86·37-90·35), while HIV incidence decreased from 0·64 per 100 person-years (95% CI 0·55-0·76) to 0·22 per 100 person-years (0·17-0·28). Adjusting for sociodemographic characteristics and HIV pre-exposure prophylaxis (PrEP) use, treatment-as-prevention achieved significant population-level reductions in HIV incidence among GBM: a 1% increase in population prevalence of viral suppression corresponded with a 6% decrease in HIV incidence (incidence rate ratio [IRR] 0·94, 95% CI 0·93-0·96; p<0·0001). PrEP was introduced in 2016 with 17·60% uptake among GBM that year, which increased to 36·38% in 2019. The relationship between population prevalence of viral suppression and HIV incidence was observed before the availability of PrEP (IRR 0·98, 95% CI 0·96-0·99; p<0·0001) and was even stronger after the introduction of PrEP (0·80, 0·70-0·93; p=0·0030)., Interpretation: Our results suggest that further investment in HIV treatment, especially alongside PrEP, can improve public health by reducing HIV incidence among GBM., Funding: National Health and Medical Research Council of Australia., Competing Interests: Declaration of interests AC has received research funding from Gilead Sciences, MSD, and ViiV Healthcare; lecture and travel sponsorships from Gilead Sciences and ViiV Healthcare; and has served on advisory boards for Gilead Sciences, MSD, and ViiV Healthcare. JH's institution received reimbursement for her participation in Advisory Boards for Gilead Sciences, Merck Sharp & Dohme, and ViiV Healthcare. JC's affiliated organisation received reimbursement for her participation in advisory boards and for consultancy services from Gilead Sciences and ViiV Healthcare. AEG reports non-financial support from Gilead Sciences and personal fees from ViiV Healthcare for an educational course. RG is a co-investigator on projects that have received non-financial and research support from Gilead Sciences. PK has received payment for consultancy services from Gilead Sciences. AP received funding from Gilead Sciences and AbbVie for research activities unrelated to this work. MHe and MS received funding from Gilead Sciences and AbbVie for investigator-initiated research unrelated to this study. All other authors declare no competing interests., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: Gay and bisexual men (GBM) who use HIV preexposure prophylaxis (HIV-PrEP) have high rates of bacterial sexually transmitted infections (STIs). The use of daily antibiotics as STI preexposure prophylaxis (STI-PrEP) may be appealing to GBM who are using or have previously used HIV-PrEP (HIV-PrEP-experienced) for the prevention of bacterial STIs., Methods: We examined willingness to use daily STI-PrEP among a cross-sectional sample of HIV-PrEP-experienced GBM in Australia who participated in an observational online cohort study from August 2018 to March 2020. Factors associated with willingness to use daily STI-PrEP were determined using bivariate and multivariate logistic regression., Results: Of the 1347 participants, half (54.3%) were willing to use daily STI-PrEP. Factors independently associated with greater willingness to use daily STI-PrEP included having >10 sexual partners in the last 6 months, using methamphetamine in the last 6 months, being more conscious about avoiding STIs, having a greater number of STIs since commencing HIV-PrEP, being willing to take HIV-PrEP for as long as they were at risk of acquiring HIV, and only using condoms when a sexual partner requested them. Conversely, factors associated with less willingness to use daily STI-PrEP included being university educated, using nondaily dosing regimens of HIV-PrEP, preferring event-driven HIV-PrEP, and being concerned about long-term HIV-PrEP adverse effects., Conclusions: Sexually transmitted infection PrEP is likely to be appealing to many HIV-PrEP-experienced GBM, especially those who engage in activities associated with a higher risk of STI transmission. However, they are less likely to be willing to use STI-PrEP unless it aligns with their HIV-PrEP dosing regimen, suggesting that research into the safety and efficacy of alternative STI prophylaxis dosing options should be prioritized., Competing Interests: Conflict of Interest and Sources of Funding: A.E.G. has received an honorarium from MSD (2021) and research support from Glaxo Smith Kline (2021–2023) and ViiV Healthcare (2022–2023). A.E.H. has received honoraria from MSD (2022) and Pfizer (2021). B.R.B. has received honoraria from Gilead Sciences (2020) and ViiV Healthcare (2022), and is currently receiving unrestricted research grants from Gilead Sciences (2021–2022) and ViiV Healthcare (2022–2023). For the remaining authors, none were declared., (Copyright © 2022 American Sexually Transmitted Diseases Association. All rights reserved.)

COVID-19 has disrupted sexual behaviour and access to health systems. We adapted regular HIV behavioural surveillance of gay and bisexual men (GBM) in Australia in response to COVID-19, assessed the impact on the profile of the sample, the participants' HIV-related behaviour, and whether COVID-19 may have accentuated existing disparities in the Australian HIV epidemic. Data collected from five states during July 2017-June 2021 were included (N = 31,460). The emphasis on online recruitment after COVID-19 led to smaller sample sizes, greater geographic reach, and a higher proportion of bisexual-identifying participants. Most participants (88.1%) reported physical distancing and 52.1% had fewer sex partners due to COVID-19. In the COVID-19-affected rounds (July 2020-June 2021), the number of male partners, recent HIV testing and pre-exposure prophylaxis (PrEP) use all fell, and HIV risk among the smaller group of participants who reported casual sex increased. COVID-related changes were generally more pronounced among GBM aged under 25 years, participants from suburbs with fewer gay residents, and bisexual men. These groups should be prioritised when encouraging GBM to reengage with HIV testing services and effective prevention methods, like condoms and PrEP., (© 2022. The Author(s).)

Relationship agreements are important for HIV prevention among gay and bisexual men (GBM) in relationships, with research earlier in the HIV epidemic often finding that agreements specified monogamy or condom use with casual partners. There is evidence that HIV pre-exposure prophylaxis (PrEP) has shifted sexual practices among some men in relationships, such as allowing condomless sex with casual partners, but there has been little attention paid to relationship agreements among GBM who use PrEP. In this paper, we analyzed national, Australian, cross-sectional data from an online survey completed by non-HIV-positive GBM in 2021 (N = 1,185). Using logistic regression, we identified demographic characteristics, sexual practices and the types of relationship agreement that were associated with PrEP use among GBM in relationships. Using Pearson's chi-squared tests, we explored whether PrEP users in relationships reported similar sexual practices to PrEP users not in relationships. PrEP use among GBM in relationships was independently associated with older age, identifying as gay, being in a non-monogamous relationship, having a spoken (explicit) relationship agreement, having a primary HIV-negative partner taking PrEP or a primary partner living with HIV, reporting recent condomless casual sex, reporting an STI diagnosis in the past year, and knowing at least one other PrEP user. We found that PrEP users in relationships had similar sexual practices to PrEP users not in relationships. GBM in relationships who have casual sex and who meet PrEP suitability criteria may be good candidates for PrEP. Our findings suggest that explicit relationship agreements remain important for HIV prevention, and they support PrEP use among GBM in relationships., (© 2022. The Author(s).)

Background: The disclosure of HIV status and pre-exposure prophylaxis (PrEP) use can be important in the negotiation of safe sex. With the rapid uptake of PrEP in Australia, norms and expectations about discussion and disclosure may have changed., Methods: We explored the disclosure of PrEP use, HIV status and communication with sex partners by HIV-negative gay men in Sydney, Australia. We conducted semi-structured interviews from October 2017 to May 2018 and analysed data using a codebook thematic analysis approach., Results: Participants had a variety of expectations of what they should tell their partners and what they expected in return. For some participants, PrEP had negated the need for any discussion about HIV. Many participants assumed their partners would find information about their HIV status or PrEP use on their online profiles or that partners would ask, if necessary., Conclusions: Building a stronger, shared understanding among gay men that disclosure and discussion no longer automatically occur before sexual encounters may be useful.

After a decade of oral HIV pre-exposure prophylaxis (PrEP), the next generation of PrEP is being anticipated, including long-acting pills, injections, and implants. The unevenness of international PrEP implementation is increasingly recognised, with successful rollout in some settings and failure in others. There is a need to better understand conditions of PrEP implementation, and its localised (and sometimes unanticipated) effects. Implementation science explores how contexts and health systems shape the successful translation of health interventions. In this essay, we consider how PrEP is evolving and argue for an 'evidence-making' approach in relation to evidence and intervention translations. This approach emphasises how both interventions and their implementation contexts are co-constituted and evolve together. Unsettling the assumed universality of an intervention's effects and potential in relation to its implementation contexts helps to harness the localised possibilities for what PrEP might become. As the next generation of PrEP offers renewed promise, we must explore how PrEP is put to use and made to work in relation to its evolving situations. We urge implementation science to consider implementation processes as 'evidence-making events' in which evidence, intervention and context evolve together.

Through the development and implementation of HIV pre-exposure prophylaxis (PrEP), the characteristics of PrEP users have been configured in a range of ways. Drawing on the concept of 'imaginaries', we consider how clinicians imagine PrEP users and related communities. We conducted 28 semi-structured interviews in 2019-2020 with PrEP-providing clinicians based in New South Wales and Western Australia. Participants included general practitioners, sexual health nurses and sexual health doctors. We inductively developed three themes through a reflexive thematic analysis: 'PrEP users as 99% gay men/MSM', 'The informed and connected PrEP user', and 'Condom users in the PrEP era'. Participants imagined PrEP users primarily as gay men, and so we focused on how gay community was imagined in relation to PrEP users. Users were imagined as supporting one another to use PrEP effectively, but some were imagined as threatening norms of condom use amongst gay community. Analysing clinician imaginaries of PrEP users reveals insight into how clinicians speculate about and engage with changing community norms related to condom use and accessing PrEP. These imaginaries reveal ongoing tensions about who is believed to be best suited to PrEP, and PrEP's impact on norms of conduct in imagined biosocial communities like gay men.

Background: The rollout of preexposure prophylaxis (PrEP) for HIV prevention among gay and bisexual men (GBM) is associated with increases in condomless anal intercourse, potentially increasing the incidence of other sexually transmissible infections (STIs)., Methods: We developed an individual-based mathematical model to simulate the transmission of Neisseria gonorrhoeae among GBM in Sydney, accounting for changes in sexual practices, STI testing, and PrEP use. We calibrated and validated the model using reported incidence rates for HIV-positive and HIV-negative GBM from 2010 to 2019. Scenarios were run with varying PrEP uptake, PrEP-related STI testing, and PrEP-related sexual behavior and testing intervals up to 2030 to assess the impact of PrEP use on gonorrhea incidence., Results: Preexposure prophylaxis uptake and associated 3-monthly STI testing from 2015 onward resulted in a predicted increase from 20 to 37 N. gonorrhoeae infections per 100 person-years among HIV-negative GBM by the end of 2020. This is lower than the counterfactual predictions of 45 per 100 person-years if PrEP were not scaled up and 48 per 100 person-years with nonadherence to 3-monthly STI testing. Increasing the time between STI tests for PrEP users by 1 month from 2018 results in the incidence rate among HIV-negative GBM increasing by 8% by 2030. If PrEP coverage doubles from 24% to 53%, incidence among HIV-negative GBM declines by ~25% by 2030., Conclusions: Behavior change due to widespread PrEP use may lead to significant increases in gonorrhea incidence in GBM, but the recommended quarterly STI testing recommended for PrEP users should reduce incidence by 18% by 2030., Competing Interests: Conflict of Interest and Sources of Funding: The authors do not have any conflicts of interest to declare. This project was funded by a New South Wales Ministry of Health Prevention Research Support Program and a National Health and Medical Research Council Project Grant (ID 1145642)., (Copyright © 2022 American Sexually Transmitted Diseases Association. All rights reserved.)

Changes to how gay, bisexual, and other men who have sex with men (GBM) connect with each other and with their communities have implications for HIV prevention. Social engagement with gay men (defined as having friends who are gay men and spending time with them) has been associated with HIV related outcomes over time among Australian GBM. Using data collected in national, repeated, cross-sectional surveys of GBM between 1998 and 2020 (N = 161,117), analyses of trends in the prevalence of gay social engagement (GSE) in Australia were conducted using linear regression. To assess changing associations with GSE at different time points in the HIV epidemic, three cross-sectional analyses were conducted on factors associated with high and low GSE in 1999/2000, 2009/2010, and 2019/2020 using bivariate and multivariable logistic regression. GSE (scored from 0 to 7) declined among all participants from 4.76 in 1998 to 4.04 in 2020 (p < 0.001) with a steeper decline among GBM aged under 25 years from 4.63 in 1998 to 3.40 in 2020 (p < 0.001). In all timepoints, high GSE was associated with older age, being university educated, full time employment, identifying as gay, recent HIV testing, and PrEP uptake. While mostly associated with protective behaviors, high GSE was also associated with some practices that may put GBM at risk of HIV infection such as drug-enhanced sex and group sex in the most recent timepoint. Changing levels of GSE have implications for health promotion among GBM, particularly how to engage GBM less connected to gay social networks., (© 2022. The Author(s).)

New medicines can transform routines and priorities in clinical practice, but how do clinicians think and feel about these changes, and how does it affect their work? In Australia, the HIV prevention regimen pre-exposure prophylaxis (PrEP) has been rapidly rolled out, transforming the sexual cultures and practices of users, but less attention has been given to the ways PrEP has reconfigured clinical practice. This paper draws on 28 qualitative semi-structured interviews conducted between 2019 and 2020 with PrEP-providing doctors and nurses in Australia to consider how they have affectively engaged with PrEP and put it into practice. Through a reflexive thematic analysis, we explore how clinicians adapted to PrEP, how the field of HIV prevention has been transformed, and how these developments have changed how clinicians approach patients. While the introduction of PrEP was initially received with uncertainty and shock, clinicians described PrEP as enjoyable to prescribe, and better aligned with the moral duties of sexual health consultations than existing HIV prevention strategies like condoms. Through approaching clinical work as an 'affective practice', we argue for attending not only to how new interventions change expectations and practices, but also how these changes are felt and valued by clinicians., (© 2022 The Authors. Sociology of Health & Illness published by John Wiley & Sons Ltd on behalf of Foundation for the Sociology of Health & Illness.)

Background: Event-driven pre-exposure prophylaxis (ED-PrEP), when taken according to the "2-1-1" dosing method, is highly effective at preventing HIV acquisition for gay, bisexual, and other men who have sex with men (GBM). Any missed doses when using ED-PrEP drastically reduce its effectiveness, so it is vital that people using this method know how to take it correctly. This study investigated Australian GBM's awareness of ED-PrEP and their knowledge of how to take it correctly., Method: We conducted a survey of 1471 PrEP-experienced GBM in Australia, between October 2019 and March 2020. The survey assessed awareness and knowledge of the 3 components of the "2-1-1" ED-PrEP dosing regimen (number of pills for loading dose, timing of loading dose, and number of days after sex to take PrEP pills) among GBM. Characteristics associated with ED-PrEP awareness and correct knowledge of how to take ED-PrEP were assessed with multivariate logistic regression., Results: Two-thirds (n = 1004, 68.4%) had heard of ED-PrEP, of whom only one-eighth (n = 125, 12.5%) knew the correct details of the "2-1-1" ED-PrEP method; one-third (n = 339, 33.8%) did not know any of the 3 key components. Awareness of ED-PrEP and correct knowledge was associated with greater belief in PrEP efficacy, university education, and intention to take a nondaily PrEP regimen in the next 6 months., Conclusions: Although ED-PrEP awareness was considerable, most participants did not know how to use ED-PrEP correctly. Further work is needed to increase awareness and knowledge of ED-PrEP among GBM., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Alternatives to daily dosing of HIV pre-exposure prophylaxis (PrEP) are continuing to emerge. From October 2019 to March 2020, we conducted an online survey of PrEP-experienced gay and bisexual men in Australia about interest in and preference for four different PrEP modalities: daily dosing, event-driven dosing, long-acting injectable (LAI)-PrEP and subdermal PrEP implants. Using data from 1477 participants, we measured interest and preference of different modalities using multivariate logistic regression. High proportions of participants were interested in LAI-PrEP (59.7%), daily PrEP (52.0%), PrEP implants (45.3%) and event-driven PrEP (42.8%). LAI-PrEP was the most frequently selected preference (30.5%), followed by PrEP implants (26.3%), daily PrEP (21.4%) and event-driven PrEP (21.2%). Higher interest and preference for non-daily PrEP modalities were associated with being concerned about side effects and perceived difficulties with daily adherence. As novel modalities emerge, attitudes to them should be considered in public health messaging to facilitate informed decision-making., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Few studies have examined changes in sexual behaviour following HIV pre-exposure prophylaxis (PrEP) initiation among gay, bisexual and other men who have sex with men (GBM) in relationships. In a national, online, prospective study of GBM in Australia, we compared sexual behaviours prior to and after PrEP initiation among HIV-negative and unknown-HIV-status men (recruited 2014-2017) not taking PrEP at baseline and who completed at least one six-monthly follow-up by July 2018. Among men in relationships who did not initiate PrEP (n = 339), we compared their most recent survey to their prior one, while among men in relationships who initiated PrEP (n = 81), we compared follow-ups before and after PrEP initiation. Among the 81 PrEP-initiators who were in a relationship both before and after initiation, the proportion reporting their regular partner was on PrEP increased from 8.3 to 44.4% (p < 0.001) and the proportion reporting receptive CLAIC increased from 27.2 to 44.4% (p = 0.009). Overall, men who initiated PrEP were more likely to be in a relationship with a partner on PrEP, and it appeared they started PrEP around the same time. Receptive CLAIC also became more common., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Preexposure prophylaxis (PrEP) prevents HIV infection but relies on good adherence at times of risk, termed "prevention-effective adherence." Most studies assess adherence without reference to sexual behaviur, making it challenging to determine if poor adherence coincides with HIV risk., Setting: We examined data from a behavioral substudy of a large-scale PrEP implementation trial in New South Wales, Australia., Methods: Trial participants completed optional brief quarterly surveys, reporting the number of pills taken and sexual behavior with male partners for each day of the "last full week" before each survey. Condomless sex (CLS) was defined as "higher risk" for HIV when with HIV-positive men with detectable/unknown viral loads or unknown HIV status men. Adequate PrEP protection was defined as ≥4 pills for participants assigned male sex at birth and ≥6 pills for participants assigned female sex at birth (including transgender men)., Results: Of 9596 participants dispensed PrEP, 4401 completed baseline and ≥1 follow-up survey. Participants reported on 12,399 "last full weeks": 7485 weeks (60.4%) involved CLS and 2521 weeks (33.7% of CLS-weeks) involved higher risk CLS. There were 103 weeks in which participants did not have adequate PrEP protection and had higher risk CLS: 4.1% of higher-risk CLS weeks (n = 103/2521), 1.4% of all CLS weeks (n = 103/7485), and 0.8% of all observed weeks (n = 103/12,399)., Conclusions: In a large PrEP trial, prevention-effective adherence to PrEP was very high at 99%. Our findings illustrate the importance of measuring pill-taking and sexual behavior in the same period so that prevention-effective adherence can be better estimated., Competing Interests: The authors have no conflict of interest to disclose., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background HIV pre-exposure prophylaxis (PrEP) has been rapidly implemented in Australia, initially through restricted access in demonstration studies, and then through prescribing across sexual health clinics and general practice settings. In 2018, PrEP was publicly subsidised for people with Medicare (universal health insurance for citizens, permanent residents and those from countries with reciprocal arrangements). There is little research examining the experiences of PrEP providers in Australia, and existing research has been primarily conducted before public subsidy., Methods: In this qualitative study, we examine the challenges that have emerged for PrEP-providing clinicians after public subsidy for PrEP was introduced. We conducted 28 semi-structured interviews in 2019-20 with PrEP providers in two Australian states, and analysed data thematically. Participants included general practitioners (GPs), sexual health nurses and sexual health physicians., Results: Sexual health services have been reconfigured to meet changing patient demand, with an emphasis on ensuring equitable financial access to PrEP. Restrictions to nurse-led PrEP frustrated some participants, given that nurses had demonstrated competence during trials. GPs were believed to be less effective at prescribing PrEP, but GP participants themselves indicated that PrEP was an easy intervention, but difficult to integrate into general practice. Participants expressed discomfort with on-demand PrEP., Conclusions: Our findings indicate that supporting ways for patients without Medicare to access PrEP inexpensively, advocating for nurse-led PrEP, and developing guidelines adapted to general practice consultations could ensure that PrEP is delivered more effectively and equitably. Additionally, PrEP providers require encouragement to build confidence in providing on-demand PrEP.

Background: We assessed willingness to use HIV pre-exposure prophylaxis (PrEP) and current PrEP use among gay and bisexual men (GBM) in Australia., Methods: National, online cross-sectional surveys of GBM were conducted in 2013, 2015, 2017, and 2019. Willingness to use PrEP was measured on a previously validated scale. Trends and associations with key measures were analyzed using multivariate logistic regression., Results: During 2013-2019, 4908 surveys were completed. Among HIV-negative and untested men not currently using PrEP, willingness to use PrEP increased from 23.0% in 2013 to 36.5% in 2017 (P < 0.001) but then plateaued at 32% in 2019 (P = 0.13). The proportion of current PrEP users increased significantly from 2.5% in 2015 to 38.5% in 2019 (P < 0.001). In 2019, factors independently associated with being a current PrEP user (compared with non-PrEP users who were willing to use PrEP) included having subsidized health care (Medicare), knowing HIV-positive people, being recently diagnosed with an STI other than HIV, having higher numbers of recent male sexual partners, recent condomless sex with casual and regular partners, and frequent PrEP sorting., Conclusion: Willingness to use PrEP has plateaued as its use has rapidly increased among GBM in Australia. PrEP use is concentrated among more sexually active men with access to subsidized health care. Free or low cost access schemes may facilitate broader access among GBM who want or need PrEP but lack access to subsidized health care., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To assess trends in HIV prevention strategies among Australian gay and bisexual men (GBM) since the introduction of preexposure prophylaxis (PrEP), the level of net prevention coverage (the use of safe strategies), and the characteristics of HIV-negative and untested GBM who remain at risk of HIV., Design: Repeated behavioural surveillance of GBM recruited from venues, events and online in seven Australian states and territories., Methods: Participants with casual male partners were included. Trends in sexual practices, prevention strategies, net prevention coverage and the characteristics of 'at risk' participants were assessed with binary and multivariate logistic regression., Results: A total of 32 048 survey responses (2014-2019) were included. The proportion of participants who reported consistent condom use declined (44.6-23.2%). The proportion who reported any condomless anal intercourse with casual partners increased (37.4-62.0%) but net prevention coverage also increased (68.1-74.9%), with higher levels of undetectable viral load among HIV-positive participants and rapidly increasing PrEP use by HIV-negative participants. PrEP became the most commonly reported prevention strategy in 2019 (31.1%). The analysis of 'at risk' participants showed that they became more likely to report frequent condomless anal intercourse with casual partners but had fewer partners and more partners with undetectable viral load or on PrEP. 'At risk' participants became more likely to identify as bisexual and to be born overseas., Conclusion: There has been a rapid, historic shift in HIV prevention among GBM in Australia. Net prevention coverage has increased among GBM and 'at risk' GBM have become less at risk of HIV, facilitating reductions in HIV transmission., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

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

Abstract: HIV pre-exposure prophylaxis (PrEP) can alleviate anxiety about acquiring HIV, particularly for gay men and other men who have sex with men. However, research with PrEP providers has rarely examined HIV anxiety. We conducted 25 semistructured interviews in 2019-2020 with PrEP providers in New South Wales and Western Australia, and analyzed data thematically. Participants included general practitioners and sexual health nurses and doctors. Our analysis explores providers' views on providing PrEP to reduce HIV anxiety for gay men, serodiscordant couples where the partner with HIV has an undetectable viral load, and for "worried well" individuals who the providers speculated might have undisclosed risk. Although providers viewed PrEP as beneficial for many people's personal lives and relationships, they felt cautious about prescribing PrEP solely for HIV anxiety, while at the same time reporting that they prescribed PrEP if individuals insisted on it and had no medical contraindications., (Copyright © 2020 Association of Nurses in AIDS Care.)

Background: In response to the novel coronavirus disease (COVID-19) pandemic, Australia introduced public health and physical distancing restrictions in late March 2020. We investigated the impact of these restrictions on HIV preexposure prophylaxis (PrEP) use among Australian gay and bisexual men (GBM)., Methods: Participants in an ongoing online cohort study previously reported PrEP use from 2014 to 2019. In April 2020, 847 HIV-negative and untested participants completed questionnaires assessing changes in PrEP use as a result of COVID-19 public health measures. Binary logistic multiple regression was used to estimate adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) to compare changes in PrEP use behaviors., Results: Among 847 men, mean age was 44.1 years (SD: 12.7). PrEP use rose from 4.9% in 2015 to 47.2% in 2020. Among those, 41.8% (n = 167) discontinued PrEP use during COVID-19 restrictions. Discontinuing PrEP during COVID-19 restrictions was independently associated with being less likely to have recently tested for HIV (aOR: 0.17; 95% CI: 0.09 to 0.34; P < 0.001) and less likely to report sex with casual partners (aOR: 0.28; 95% CI: 0.14 to 0.54; P < 0.001)., Conclusions: By April 2020, following the introduction of COVID-19 restrictions, GBM dramatically reduced PrEP use, coinciding with a reduction in sexual activity. Longer-term impacts of COVID-19 restrictions on sexual behaviors among GBM need to be monitored because they may foreshadow fluctuations in prevention coverage and risk of HIV infection. Our findings indicate a potential need for clear, targeted information about resumption of PrEP and on-demand optimal dosing regimens in response to ongoing changes in restrictions.

Background: Gay and bisexual men with undiagnosed HIV contribute disproportionately to HIV transmission in Australia., Methods: In 2014 and 2018, we recruited men at gay venues and events in Sydney. Participants self-completed surveys and provided oral fluid samples for HIV testing. We calculated the prevalence of HIV and undiagnosed infection, and assessed changes in behavior, HIV testing, and the use of pre-exposure prophylaxis. We weighted the samples to adjust for differences in where participants were recruited between rounds. Two-sample tests of proportion were used to compare prevalence estimates and χ tests to assess differences between the samples., Results: In 2014, 944 men were recruited, and 890 men were recruited in 2018. In 2014, the weighted estimate of HIV prevalence was 6.1% [95% confidence intervals (CI): 4.6 to 7.6], of which 13.8% (95% CI: 5.0 to 22.7) was undiagnosed. In 2018, weighted HIV prevalence was 6.4% (95% CI: 4.8 to 8.0), of which 5.3% (95% CI: 0.5 to 11.1) was undiagnosed. Between 2014 and 2018 among all participants, men reporting at least 10 recent casual partners increased from 22.3% to 27.7% (P = 0.008), condomless anal intercourse with casual partners in the previous 6 months increased from 23.9% to 37.3% (P < 0.001), and sexually transmitted infection diagnoses in the previous year increased from 14.4% to 27.5% (P < 0.001). HIV testing and the use of pre-exposure prophylaxis in the previous 6 months increased from 49.6% to 56.3% (P = 0.004) and 2.0%-21.0% (P < 0.001), respectively., Conclusions: Repeated, bio-behavioral surveillance suggests the prevalence of undiagnosed HIV remains low in Sydney, despite gay and bisexual men reporting more casual sex partners, condomless sex, and sexually transmitted infections.

Data from repeated, national behavioural HIV surveillance was used to identify similarities and differences between young gay and bisexual men (YGBM) aged 16-24 (n = 1608) and older GBM aged 25-49 (n = 6266), in order to quantify risks and identify gaps in HIV prevention. Trend analyses from 2014 to 2018 are also reported. While there were similar rates of condomless anal intercourse with casual partners in both age groups, YGBM had lower rates of HIV testing and PrEP use but also fewer male partners. Our results suggest most YGBM have lower HIV risk than older GBM but a minority merit enhanced testing and prevention efforts.

We report on Australian gay and bisexual men's (GBM) perceptions of preexposure prophylaxis (PrEP). Drawing on an online longitudinal cohort study, 1,404 free-text responses from HIV-negative or untested Australian GBM were qualitatively analysed. The chi-square statistic was then used to assess differences regarding PrEP-perceptions by participants' demographic and behavioral characteristics. Positive views of PrEP were twice more common than negative. Those with positive views thought PrEP helped overcome HIV fear and anxiety, enhanced sexual pleasure, and was a 'socially responsible' course of action. Those with negative views believed that people without medical conditions did not need medication and expressed concern that PrEP was replacing condoms, representing 'dangerous' behavior. Descriptive statistics revealed differences in PrEP-perceptions relating to age, recency of HIV testing, and PrEP eligibility. This study is the first to use free-text data to examine the frequency of Australian GBM's PrEP-perceptions, highlighting the potential benefits and challenges to its promotion.

Purpose: To understand the characteristics of a minority of Australian gay and bisexual men (GBM) who, despite an increase in the number and availability of HIV risk reduction strategies, do not consistently use a strategy to protect themselves from HIV., Methods: This analysis is based on data from 2,920 participants in a national, online, prospective observational cohort study. GBM who never or rarely used HIV risk reduction strategies (NRR) were compared with two groups using multivariate logistic regression: i) GBM using pre-exposure prophylaxis (PrEP) and ii) GBM frequently using risk reduction strategies (FRR) other than PrEP., Results: Compared to PrEP users, NRR men were younger (p<0.0001), less socially engaged with gay men (p<0.0001) and less likely to have completed a postgraduate (p<0.05) or undergraduate degree (p<0.05). They were also less likely to have recently used amyl nitrite (p<0.05), erectile dysfunction medication (p<0.05) and cocaine (p<0.05) in the previous 6 months. Compared with FRR men, NRR men were less likely to have completed a postgraduate (p<0.0001) or undergraduate degree (p<0.05), scored higher on the sexual sensation-seeking scale (p<0.0001) and were more likely to identify as versatile (p<0.05), a bottom (p<0.05) or very much a bottom (p<0.05) during anal sex., Conclusions: NRR men were largely similar to other Australian GBM. However, our analysis suggests it may be appropriate to focus HIV prevention interventions on younger, less socially engaged and less educated GBM, as well as men who prefer receptive anal intercourse to promote the use of effective HIV risk reduction strategies., Competing Interests: No competing financial interests exist.

Using repeated, cross-sectional behavioural surveillance data from Australia, we assessed trends in relationship agreements and casual sex among HIV-negative and untested gay and bisexual men who had regular partners during 2013-2018. We conducted three analyses: (i) trends in relationship agreements and casual sex over time; (ii) bivariate comparisons of PrEP users and non-PrEP-users to identify factors associated with PrEP use; and (iii) multivariate logistic regression to identify factors independently associated with PrEP use. The analysis of trends over time included 21,593 men, from which a sub-sample (n = 3764) was used to compare PrEP users and non-PrEP-users. We found a large increase in agreements that allowed condomless sex with casual partners, particularly by PrEP users in relationships (nearly 40% of whom had such an agreement). A further 34% of PrEP users reported having casual condomless sex without an agreement that permitted that behaviour, while 13% of non-PrEP-users also reported condomless sex with casual partners without an agreement. PrEP use was independently associated with having agreements permitting condomless sex with casual partners, recent condomless sex with casual partners, having greater numbers of male partners, recent post-exposure prophylaxis use, having an HIV-positive regular male partner, and recent condomless sex with regular male partners. Our findings show a shift away from relationship agreements in which condomless sex was only sanctioned between regular partners.

The broadening of access to HIV pre-exposure prophylaxis (PrEP) in Australia has rekindled debates about which types of clinicians are best suited to deliver HIV prevention innovations: specialist HIV services or primary care physicians and general practitioners (GPs). We conducted 21 semi-structured qualitative interviews in 2017 with Australian HIV sector experts working across policy, advocacy, clinical service provision, research, and health promotion. These interviews took place before a national policy commitment to subsidising access to PrEP was achieved. We explored how participants conceptualised PrEP, patients and GPs at this key turning point in the history of HIV prevention. Participants expressed varied views regarding GPs' anticipated ability to successfully navigate the potential complexities associated with PrEP roll-out. While participants were supportive of greater patient access to PrEP, they expressed concerns about non-specialist GPs' cultural competence and expertise regarding sexuality and clinical practice, and the potential for patients to experience discrimination and homophobia from non-expert GPs. This study has broad implications for thinking about experts and expertise, the implementation of previously specialised medicine into mainstream settings, and the anticipated challenges of LGBTIQ+ inclusive healthcare.

Background: HIV prevention cascades can assist in monitoring the implementation of prevention methods like preexposure prophylaxis (PrEP). We developed 2 PrEP cascades for Australia's primary HIV-affected population, gay and bisexual men., Methods: Data were drawn from 2 national, repeated, cross-sectional surveys (the Gay Community Periodic Surveys and PrEPARE Project). One cascade had 3 steps, and the other had 7 steps. Trends over time were assessed using logistic regression. For the most recent year, we identified the biggest drop between steps in each cascade and compared the characteristics of men between the 2 steps using multivariate logistic regression., Results: Thirty-nine thousand six hundred and seventy non-HIV-positive men participated in the Periodic Surveys during 2014-2018. PrEP eligibility increased from 28.1% (1901/6762) in 2014 to 37.3% (2935/7878) in 2018 (P < 0.001), awareness increased from 29.6% (563/1901) to 87.1% (2555/2935; P < 0.001), and PrEP use increased from 3.7% (21/563) to 45.2% (1155/2555; P < 0.001). Of 1038 non-HIV-positive men in the PrEPARE Project in 2017, 54.2% (n = 563) were eligible for PrEP, 97.2% (547/563) were aware, 67.6% (370/547) were willing to use PrEP, 73.5% (272/370) had discussed PrEP with a doctor, 78.3% (213/272) were using PrEP, 97.2% (207/213) had recently tested, and 75.8% (157/207) reported reduced HIV concern and increased pleasure because of PrEP. The break point analyses indicated that PrEP coverage was affected by geographical availability, education level, employment, and willingness to use PrEP., Conclusions: PrEP eligibility, awareness, and use have rapidly increased among Australian gay and bisexual men. The cascades identify disparities in uptake by eligible men as a result of socioeconomic factors and PrEP's acceptability.

Background: Many gay and bisexual men (GBM) experience HIV anxiety, particularly around condomless anal intercourse. HIV pre-exposure prophylaxis (PrEP) is an effective HIV prevention strategy that may reduce HIV anxiety among GBM., Methods: The Following Lives Undergoing Change (Flux) Study is a national, online, open-prospective observational study of licit and illicit drug use among GBM in Australia. In 2018, participants responded to newly included items regarding anxiety about HIV transmission. Stratifying GBM as high or low risk as determined by the Australian PrEP Guidelines, we assess whether PrEP use is associated with lower levels of HIV anxiety. Multivariate logistic regression was used to compare factors associated with PrEP use among GBM at high risk (PrEP-eligible) and low risk (PrEP-ineligible) of HIV infection. Results are reported as adjusted odds ratios and corresponding 95% confidence intervals., Results: Among 1547 men, the mean age was 37.1 years (SD 13.1). Men aged 25 years or younger had higher HIV anxiety scores than older men. Among PrEP-eligible men, men who use PrEP reported lower levels of HIV anxiety (adjusted odds ratio = 0.92; 95% confidence interval = 0.87 to 0.99; P < 0.001). No differences were observed on HIV anxiety among PrEP-ineligible men., Conclusions: Among PrEP-eligible men, PrEP use was independently associated with lower levels of HIV anxiety. In addition to avoiding HIV infection, PrEP use may help reduce anxiety among men at risk of HIV. This feature of PrEP could be promoted as part of demand creation initiatives to increase PrEP uptake.

HIV pre-exposure prophylaxis (PrEP) has been embraced in Australia, making PrEP available with public funding to people at risk of HIV. Here, we consider the associated 'problems' of reduced condom use and sexually transmissible infections (STIs), as seen by HIV professionals. Twenty-one interviews were conducted during May-August 2017. All agreed that PrEP was a valuable addition to HIV prevention, but their views about reduced condom use and STIs were variable. Using poststructural policy analysis, three main stances were identified: (1) Concerned/alarmed. PrEP was seen as causing reduced condom use, STIs and antibiotic resistance, posing threats to the general population; (2) Neutral/normalising. Stakeholders emphasised that condom use was declining and STIs increasing independently of PrEP, and that PrEP was simply a new tool to be accommodated; (3) Optimistic/critical. PrEP was seen as diminishing fear of HIV and engaging users in more frequent testing and treatment that could lead to declining STI rates. What linked all three stances was the selective performance of evidence, deploying a mixture of personal experience, clinical observations, behavioural data and epidemiology. Anticipating possible futures through evidence-making suggested practical, political and moral consequences for what PrEP could become. We encourage others to consider these consequences with care., (© 2019 Foundation for the Sociology of Health & Illness.)

Using repeated, national, online, cross-sectional surveys of Australian gay and bisexual men (GBM), we analysed trends related to HIV pre-exposure prophylaxis (PrEP). Specifically, we analysed trends in PrEP use, willingness to use PrEP, and concern about using PrEP during 2011-2017. We assessed support for GBM using PrEP and willingness to have sex with men taking PrEP between 2015 and 2017. For time-based analyses, we used multivariate logistic regression, controlling for sampling variations over time. We constructed new scales assessing reduced concern about HIV among PrEP users and non-users in 2017, and used multivariate logistic regression to identify independent correlates of PrEP use (vs. non-use). The analyses included 4567 HIV-negative and untested participants (2011-2017). PrEP use increased from 0.5% in 2011 to 25.5% in 2017 (p < 0.001). Willingness to use PrEP increased from 27.9% in 2011 to 36.5% in 2017 (p < 0.001) while concern about using PrEP fell (52.1-36.1%, p < 0.001). Support for GBM using PrEP remained stable (52.5% in 2015, 51.9% in 2017, p = 0.62), and willingness to have sex with men taking PrEP increased from 34.9% in 2015 to 49.0% in 2017 (p < 0.001). In 2017, 22.8% of non-PrEP-users had reduced HIV concern because of PrEP, while 73.6% of PrEP users had reduced HIV concern and greater sexual pleasure because of PrEP. The analysis of PrEP users vs. non-users in 2017 indicated that PrEP users were more sexually active and reported higher risk sexual practices, were more likely to live in New South Wales and Victoria, and to be in full-time employment. They were also more likely to know HIV-positive people and other PrEP users. Diffusion of Innovations theory suggests that future PrEP users in Australia may be less adventurous and require greater reassurance about PrEP's efficacy and legitimacy, to sustain rollout and address current disparities in uptake.

As evidence of the safety and effectiveness of HIV pre-exposure prophylaxis (PrEP) has grown, so has attention to the views of prospective users and providers. However, far less attention has been paid to understanding the perspectives of other stakeholders in the rollout of PrEP access programs. We conducted 21 semi-structured qualitative interviews in 2017 with key stakeholders working across the policy, advocacy, research and/or clinical dimensions of the Australian HIV response, before federal support for a subsidised access scheme was achieved. Our analysis explored three areas of shared concern: who is a suitable candidate for PrEP; why are disparities in PrEP access important; and how can disparities be addressed? In examining how this diverse group of professionals grappled with the challenges of promoting 'equitable access' to PrEP in an increasingly resource rationed health system, we can see how the principles believed to underpin the Australian response to HIV were both reaffirmed and challenged through this period of significant change.

Background: HIV pre-exposure prophylaxis (PrEP) is a highly effective biomedical HIV prevention strategy, yet some gay and bisexual men (GBM) who are eligible to access PrEP are not using it. We report the incidence of PrEP uptake, factors predicting its initiation, and identify characteristics associated with nonuptake of PrEP among Australian GBM who meet the eligibility criteria., Methods: The Following Lives Undergoing Change (Flux) Study is a national, online, prospective observational study among GBM focusing on licit and illicit drug use. Participants (N = 1257) responded to baseline and 6-monthly follow-up questionnaires. Incidence per 100 person-years and incidence rate ratios of PrEP initiation are presented. Multivariate Poisson regression was used to examine associations with PrEP initiation and logistic regression to examine associations with nonuptake of PrEP among eligible GBM., Results: Among GBM who met the eligibility criteria, 69.8% of men did not commence PrEP. Factors independently associated with nonuptake of PrEP were younger age, living in an Australian state without a PrEP trial, lower social engagement with other gay men, less use of illicit party drugs or use of illicit party drugs for sex, and less likely to have engaged in HIV sexual risk behaviors such as group sex or any condomless anal intercourse., Conclusions: Despite meeting formal eligibility criteria for PrEP, men who were relatively less sexually active or less socially connected were less likely to initiate PrEP. Men who did not initiate PrEP may assess their risk as insufficient relative to others to warrant using PrEP because they engaged in less frequent "risky" behaviors.

Introduction: HIV pre-exposure prophylaxis (PrEP) has been increasingly adopted by gay and bisexual men (GBM). Little is known about whether individual GBM change their sexual behavior after PrEP initiation., Methods: Following Lives Undergoing Change (Flux) is a national, online, prospective observational study among Australian GBM. Using McNemar statistics, we compare rates of sexual behaviors before and coincident with PrEP initiation among 1518 non-HIV-positive men recruited between August 2014 and July 2017 who had not commenced PrEP at baseline and who completed at least one 6-monthly follow-up surveys by July 2018., Results: The proportion of men using PrEP rose to 24.2% over time. In total, 348 men initiated PrEP during follow-up. PrEP initiators were more likely to report particular sexual behaviors during the follow-up period that they commenced PrEP compared with the period immediately prior: receptive condomless anal intercourse with casual partners increased from 31.0% to 48.9% (McNemar < 0.001); mean partner number increased from 21.96 partners to 34.55 partners (p-trend < 0.001). Among the 1170 men who did not initiate PrEP, prevalence of these behaviors remained lower and stable. Sexual sensation-seeking and gay social engagement were both higher among men who commenced PrEP., Conclusions: GBM tended to increase their engagement in "adventurous" sexual behaviors after PrEP initiation. Sexual behaviors among men who did not initiate PrEP were less common and did not change over time.

HIV-negative and untested gay and bisexual men from Victoria, Australia (n = 771) were surveyed during August-September 2016 about their comfort having condomless sex with casual male partners in scenarios in which pre-exposure prophylaxis (PrEP) or treatment as prevention were used. Men not using PrEP were most comfortable with the idea of condomless sex with HIV-negative partners (31%), followed by partners using PrEP (23%). PrEP users were more comfortable with the idea of condomless sex with these partner types (64 and 72%, respectively). Very few men not taking PrEP were comfortable with condomless sex with HIV-positive partners (3%), even with undetectable viral loads (6%). PrEP users were more comfortable with condomless sex with HIV-positive partners (29%), and those with undetectable viral loads (48%). Being on PrEP, having recent condomless sex with casual partners or a HIV-positive regular partner were independently associated with comfort having condomless sex.

We estimated the size of the population of gay-identified men who have sex with men (gay men) eligible for PrEP in Australia under the current national PrEP guidelines. Using input indicators from the Australian Bureau of Statistics, the national representative survey Second Australian Study of Health and Relationships, and national HIV- behavioural surveillance, we calculated the size of the population of sexually active gay men and estimated a range for the number eligible for PrEP using different scenarios based on the guidelines. In 2015, an estimated 108,850 sexually-active 16-69-year-old gay men were classified as at risk of acquiring HIV in Australia. Of these men, 10,558 to 30,913 (9.7%-28.4%) were classified as being at high risk and therefore eligible for PrEP, most commonly due to recent receptive condomless intercourse with casual partners (6.1% to 15.5%), STI infections (5.4% to 10.6%) or the use of crystal methamphetamine (1.4% to 9.4%). The higher estimates included men who may have been at HIV risk for shorter time periods or with fewer partners. Australian PrEP guidelines recommend targeting PrEP to people at high HIV risk. Our estimation of potential PrEP users informed PrEP implementation in Australia. The choice of PrEP eligibility criteria, and interpretation of the guidelines, strongly affects the population estimates. In the future, higher numbers of gay men may become eligible for PrEP, because the estimates are largely defined by and follow trends in condomless anal intercourse. Our estimation methods can be adapted to other settings., Competing Interests: IBZ has received supply of the study medication from Gilead Sciences. AEG has received research funding from BioCSL Ltd, Viiv and Gilead Sciences, as well as conference travel funding and honoraria for educational presentations from Merck. There are no patents, products in development or marketed products associated with this research to declare. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Background: Pre-exposure prophylaxis (PrEP) has been rapidly rolled out in large, publicly funded implementation projects in Victoria and New South Wales, Australia. Using behavioural surveillance of gay and bisexual men, we analysed the uptake and effect of PrEP, particularly on condom use by gay and bisexual men not using PrEP., Methods: We collected data from the Melbourne and Sydney Gay Community Periodic Surveys (GCPS), cross-sectional surveys of adult gay and bisexual men in Melbourne, VIC, and Sydney, NSW. Recruitment occurred at gay venues or events and online. Eligible participants were 18 years or older (face-to-face recruitment) or 16 years or older (online recruitment), identified as male (including transgender participants who identified as male); and having had sex with a man in the past 5 years or identified as gay or bisexual, or both. Using multivariate logistic regression, we assessed trends in condom use, condomless anal intercourse with casual partners (CAIC), and PrEP use by gay and bisexual men, controlling for sample variation over time., Findings: Between Jan 1, 2013, and March 31, 2017, 27 011 participants completed questionnaires in the Melbourne (n=13 051) and Sydney (n=13 960) GCPS. 16 827 reported sex with casual male partners in the 6 months before survey and were included in these analyses. In 2013, 26 (1%) of 2692 men reported CAIC and were HIV-negative and using PrEP, compared with 167 (5%) of 3660 men in 2016 and 652 (16%) of 4018 men in 2017 (p<0·0001). Consistent condom use was reported by 1360 (46%) of 2692 men in 2013, 1523 (42%) of 3660 men in 2016, and 1229 (31%) of 4018 men in 2017 (p<0·0001). In 2013, 800 (30%) of 2692 men who were HIV-negative or untested and not on PrEP reported CAIC, compared with 1118 (31%) of 3660 men in 2016, and 1166 (29%) of 4018 in 2017 (non-significant trend)., Interpretation: A rapid increase in PrEP use by gay and bisexual men in Melbourne and Sydney was accompanied by an equally rapid decrease in consistent condom use. Other jurisdictions should consider the potential for community-level increases in CAIC when modelling the introduction of PrEP and in monitoring its effect., Funding: Australian Government Department of Health, Victorian Department of Health and Human Services, and New South Wales Ministry of Health., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

We analyzed the concept of risk compensation and how it has been applied in HIV prevention, paying particular attention to the strategy of HIV preexposure prophylaxis (PrEP). In risk compensation, reduced perceptions of risk after the introduction of a preventative intervention lead to more frequent risk-taking behavior. Such a change may undermine the intervention's protective benefits. We found that many studies purporting to investigate risk compensation do not assess or report changes in perceptions of risk, instead relying on behavioral measures. Our analysis suggests a complex and sometimes counterintuitive relationship between the introduction of a new prevention intervention, perceptions of HIV risk, and subsequent changes in behavior. As PrEP is introduced, we believe comprehensive assessment of community-level risk compensation-that is, changes in risk perceptions and behavior as a result of increased optimism about avoiding HIV among people not directly protected by PrEP-should not be omitted. We therefore suggest ways to assess prevention optimism and community-level risk compensation.

Objective: Assess willingness to use HIV pre-exposure prophylaxis (PrEP), support for others using it and willingness to have sex with partners using PrEP among Australian gay and bisexual men (GBM)., Methods: National, online cross-sectional surveys of Australian GBM were conducted in 2011, 2013 and 2015. Scales measuring support for and willingness to have sex with men using PrEP were developed in 2015 using factor analysis. Trends and associations with key measures were analysed using multivariate logistic regression., Results: During 2011-2015, 3850 surveys were completed by GBM. Willingness to use PrEP among HIV-negative and untested men did not change between 2011 (28.2%) and 2015 (31.7%, p=0.13). In 2015, willingness to use PrEP was independently associated with younger age, having an HIV-positive regular partner, recent condomless anal intercourse with casual male partners (CAIC), more than 10 male sex partners in the previous 6 months, ever having taken postexposure prophylaxis and having fewer concerns about using PrEP. In 2015, 54.5% of GBM supported other GBM taking PrEP and 39% were willing to have sex with men using PrEP. Support for and willingness to have sex with PrEP users were both associated with being HIV-positive, having a university degree and having two or more male partners in the previous 6 months. Willingness to have sex with men on PrEP was also associated with recent CAIC and using party drugs for sex, but was less likely among men who consistently used or had a positive experience using condoms., Discussion: Interest in and support for using PrEP are concentrated among men who engage in higher risk practices and who know more about living with HIV. This is consistent with the targeting of PrEP in Australia., Competing Interests: Competing interests: This work was supported with grants from the Bloodborne virus and sexually transmissible infection Research, Intervention and Strategic Evaluation programme, funded by the New South Wales Ministry of Health, and the Australian Government Department of Health. Non-financial support from Gilead Sciences was received for studies outside the submitted work., (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/.)

Background In Australia, the preventative use of antiretroviral drugs [pre-exposure prophylaxis (PrEP) and treatment as prevention] is being embraced to protect individuals at high risk of HIV and reduce onward transmission., Methods: The adaptation of a behavioural surveillance system, the Gay Community Periodic Surveys, was reviewed to monitor the uptake and effect of new prevention strategies in Australia's primary HIV-affected population (gay and bisexual men, GBM). The national trends in key indicators during 2000-15 were reviewed and a new measure to take account of antiretroviral-based prevention was developed., Results: Between 2000 and 2015, there were significant increases (P<0.001) in annual HIV testing (56.1-64.8%), condomless sex with casual partners (26.8-38.8%) and the proportion of HIV-positive men on HIV treatment (72.5-88.4%) and with an undetectable viral load (73.7-94.7%). The proportion of casual partners who were HIV negative, not on PrEP and who engaged in receptive condomless sex also increased between 2000 and 2015 from 12.8 to 19.3%. Two scenarios anticipating the effect of PrEP highlighted the need to target GBM who engage in receptive condomless sex while also sustaining condom use at a population level., Conclusions: Behavioural surveillance can be successfully adapted to follow the effect of antiretroviral-based prevention. It is anticipated that HIV testing and HIV treatment will continue to increase among Australian GBM, but to prevent new infections, intervention in the growing proportion of GBM who have condomless sex with casual partners is needed. For PrEP to have its desired effect, condom use needs to be sustained.

This review considers Australia's progress towards the elimination of HIV and AIDS, as specified in international targets. In particular, it considers the reaction to recent media reports that Australia has 'ended AIDS' and evaluates progress towards reducing HIV transmission. Recent surveillance data and research show significant improvements in HIV testing and treatment, but countervailing trends such as increased condomless sex between gay and other men who have sex with men. Pre-exposure prophylaxis (PrEP) is being implemented at scale in some jurisdictions, with the hope that this will significantly alter the trajectory of Australia's HIV epidemic, which has been stable for the last five years (at around 1000-1100 infections per year). The ongoing challenge in maintaining investment, while also considering how to respond to the diversification of the local epidemic, means that Australia has entered a critical period in which evidence of PrEP's impact is eagerly awaited.

HIV pre-exposure prophylaxis (PrEP) is a prevention technology that involves prescribing antiretroviral drugs to HIV-negative people to protect them from infection. This paper considers how the development of the technology has necessitated the parallel configuration of its users, and how this process has affected the perception and uptake of the technology. In designing a technology, potential users are typically defined, enabled and constrained, partly to create a target population (or market) for the technology, but also to reassure people that it can be used safely and effectively. This process may or may not be helpful for the uptake and use of the technology. Published research on PrEP indicates that while the technology was under trial, the primary focus was on the 'at-risk' subject in need of PrEP, with little or no consideration of the other qualities necessary for successful use. Post-trial accounts of PrEP have begun to outline desirable qualities of successful PrEP use, such as caution, compliance and being organised. It appears that the PrEP user was only partially configured during the technology's development, and the initial focus on risk has done little to counter fears of the technology, which may partially account for its slow uptake.

We surveyed willingness to use pre-exposure prophylaxis (PrEP) and the likelihood of decreased condom use among Australian gay and bisexual men in 2011 and 2013 (n = 2384). Willingness to use PrEP declined from 28.2% to 23.3% [adjusted odds ratio = 0.83, 95% confidence interval (CI): 0.68 to 1.00, P = 0.050]. Willingness to use PrEP was the greatest among men with HIV-positive partners and among those who had taken HIV postexposure prophylaxis. Among men willing to use PrEP, the likelihood of decreased condom use remained stable between 2011 and 2013 (8.0% vs. 11.9%; adjusted odds ratio = 1.40, 95% CI: 0.80 to 2.45, P = 0.23). A minority of men remain willing to use PrEP and appear to be appropriate candidates for it.