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Background: Current clinical care for common bacterial STIs (Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and Mycoplasma genitalium (MG)) involves empiric antimicrobial therapy when clients are symptomatic, or if asymptomatic, waiting for laboratory testing and recall if indicated. Near-to-patient testing (NPT) can improve pathogen-specific prescribing and reduce unnecessary or inappropriate antibiotic use in treating sexually transmitted infections (STI) by providing same-day delivery of results and treatment., Methods: We compared the economic cost of NPT to current clinic practice for managing clients with suspected proctitis, non-gonococcal urethritis (NGU), or as an STI contact, from a health provider's perspective. With a microsimulation of 1000 clients, we calculated the cost per client tested and per STI- and pathogen- detected for each testing strategy. Sensitivity analyses were conducted to assess the robustness of the main outcomes. Costs are reported as Australian dollars (2023)., Results: In the standard care arm, cost per client tested for proctitis, NGU in men who have sex with men (MSM) and heterosexual men were the highest at $247.96 (95% Prediction Interval (PI): 246.77-249.15), $204.23 (95% PI: 202.70-205.75) and $195.01 (95% PI: 193.81-196.21) respectively. Comparatively, in the NPT arm, it costs $162.36 (95% PI: 161.43-163.28), $158.39 (95% PI: 157.62-159.15) and $149.17 (95% PI: 148.62-149.73), respectively. Using NPT resulted in cost savings of 34.52%, 22.45% and 23.51%, respectively. Among all the testing strategies, substantial difference in cost per client tested between the standard care arm and the NPT arm was observed for contacts of CT or NG, varying from 27.37% to 35.28%., Conclusion: We found that NPT is cost-saving compared with standard clinical care for individuals with STI symptoms and sexual contacts of CT, NG, and MG., Competing Interests: Declaration of Competing Interest CSB and CKF were supported by an Australian National Health and Medical Research Council Leadership Investigator Grant (GNT1173361 and GNT1172900, respectively). JJO and EPFC are supported by an Australian National Health and Medical Research Council Emerging Leadership Investigator Grant (GNT1193955 and GNT1172873). YZ is supported by an Australian Government Research Training Program (RTP) scholarship. All other authors declare no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background The incidence of sexual assault continues to rise in Australia. This study aimed to describe the nature of assault, HIV/STI positivity, and its management at a sexual health clinic. Methods We performed a chart review of 516 sexual assault cases presenting to Melbourne Sexual Health Centre between 2012 and 2021, collecting data on victim demographics, details of assault, HIV/STI testing and positivity, police involvement, and offer of counselling. Results We included 516 cases: 124 males (24.0%); 384 females (74.4%); and eight transgender (1.6%) victims. The proportion of assault cases presenting to Melbourne Sexual Health Centre increased from 0.1% (37/37,070) in 2012 to 0.2% (56/36,514) in 2021 (P trend =0.006). HIV post-exposure prophylaxis was prescribed for 64.5% (80/124) of males and 12.5% (48/384) of females. Among victims, 69.4% (358/516) were tested for HIV and no one tested positive, while 71.9% (371/516) were tested for syphilis, with 1.6% (6/371) positive. Gonorrhoea and chlamydia were tested at the oropharynx (44.8% [231/516] vs 28.7% [148/516]), genitals (83.7% [432/516] vs 92.4% [477/516]) and anorectum (35.3% [182/516] vs 35.3% [182/516]). Positivity for gonorrhoea and chlamydia were: 2.6% (6/231) vs 2.0% (3/148) at oropharynx, 1.4% (6/432) vs 2.9% (14/477) at genitals, and 5.5% (10/182) vs 7.1% (13/182) at anorectum. According to clinical records, 25.2% (130/516) of victims sought police involvement, and 71.7% (370/516) were offered counselling. Conclusions Sexual assault was an uncommon presentation at Melbourne Sexual Health Centre, with diverse circumstances surrounding assault; however, clinical documentation varied, indicating a need for a standard primary care protocol for clients presenting with acute sexual assault.

Background: Despite the increase in the proportion of HIV notifications attributed to heterosexuals in Australia, little is known about their HIV testing behaviours. We investigated the trends and factors associated with HIV testing behaviours among heterosexuals., Methods: We analysed the trend and proportion of heterosexuals attending the centre for the first time between 2011 and 2020, who had ever tested and tested for HIV in the past 12months and the median number of months since their last HIV test. We identified factors associated with HIV testing behaviours using univariable and multivariable logistic regressions., Results: Of the 78652 heterosexuals included, 53.1% were men and 46.9% were women. Overall, the proportion of heterosexuals who had ever tested for HIV was 40.8%, with a declining testing trend from 40.2% in 2011 to 36.5% in 2020 (P trend <0.001). Overall, the proportion of heterosexuals tested for HIV in the past 12months was 15.7%, with no significant change from 15.3% in 2011 to 14.7% in 2020 (P trend =0.489). The median number of months since the last HIV test decreased from 18.0 (IQR 6.9-37.3) in 2011 to 15.0 (IQR 6.4-32.5) in 2020 (P trend <0.001). Individuals who had condomless sex with casual partners (aOR 0.92, 95% CI 0.88-0.96) and who were diagnosed with a sexually transmitted infection (aOR 0.88, 95% CI 0.84-0.93) were less likely to have ever tested for HIV., Conclusions: HIV testing was low among heterosexuals, and individuals who engaged in condomless sex and had another sexually transmitted infection were less likely to be tested. To reduce HIV transmission, strategies to improve HIV testing among heterosexuals are needed.

Background: Electronic health records allow for inexpensive communication with patients. In March 2021, the Melbourne Sexual Health Centre implemented an automated email summary ("Sexual Health Automated Visit Email" [SHAVE]) of a client's visit. This study evaluates the proportion of attendees at a sexual health service who opted in or out of SHAVE., Methods: This study was conducted at the Melbourne Sexual Health Centre in Australia between March 2021 and June 2022. Univariable and multivariable logistic regression analyses were used to examine the client characteristics associated with consenting to SHAVE., Results: There were 18,528 clients (men, 12,700; women, 5828) included in the final analysis and 55.2% (n = 10,233) consented to receiving SHAVE. Comparing with those who did not have a new sexually transmitted infection diagnosis, clients with a new diagnosis of a sexually transmitted infection, but not HIV, had lower odds of consenting to receiving SHAVE (chlamydia: adjusted odds ratio [aOR], 0.64 [95% confidence interval {CI}, 0.57-0.72]; gonorrhea: aOR, 0.71 [95% CI, 0.62-0.82]; syphilis: aOR, 0.75 [95% CI, 0.59-0.96]). Men had lower odds of consenting when compared with women (men who have sex with women only: aOR, 0.77 [95% CI, 0.71-0.84]; men who have sex with men: aOR, 0.68 [95% CI, 0.62-0.75]). Comparing with those born in Australia or Oceania, clients born in Europe had lower odds of consenting (aOR, 0.81; 95% CI, 0.70-0.94), whereas those born in Latin America or Caribbean had higher odds of consenting (aOR, 1.25; 95% CI, 1.04-1.51)., Conclusions: Email summaries may serve as a valuable strategy to improve health communication and record keeping for clients. Understanding the client characteristics associated with consenting SHAVE will allow for the implementation of strategies to better communicate with clients., Competing Interests: Conflict of Interest and Sources of Funding: None declared., (Copyright © 2023 American Sexually Transmitted Diseases Association. All rights reserved.)

The AnyPlexTM II STI-7e panel assay (Seegene) detects seven sexually transmitted organisms (Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium, M. hominis, Ureaplasma urealyticum, U. parvum, and Trichomonas vaginalis). This study compared the performance of AnyPlexTM II STI-7e with standard-of-care diagnostic methods. Samples (cervical or vaginal swabs, or urine) from 1330 women were tested on standard-of-care assays; 83/1318 (6.3%) tested positive for M. genitalium (ResistancePlus® MG), 99/1317 (7.5%) positive for C. trachomatis and 11/1316 (0.8%) positive for N. gonorrhoeae (Hologic® Aptima Combo 2®), and 6/689 (0.9%) positive for T. vaginalis (wet mount microscopy). AnyPlexTM II STI-7e had good agreement for the detection of M. genitalium [Cohen's kappa of 0.80, 95% confidence intervals (CI) 0.74-0.87] and C. trachomatis (kappa of 0.87, 95% CI 0.82-0.92), with positive and negative % agreement >96% for both infections. There was lower agreement for the detection of N. gonorrhoeae (kappa of 0.37, 95%CI 0.19-0.55) and T. vaginalis (kappa of 0.521, 95%CI 0.25-0.80). In summary, the test performed well in this comparison for M. genitalium and C. trachomatis detection, but results were less conclusive for N. gonorrhoeae and T. vaginalis due to low prevalence in the population., (© The Author(s) 2022. Published by Oxford University Press on behalf of Applied Microbiology International.)

Despite rises in sexually transmitted infection (STI) notifications among Australian women in the last decade, limited STI surveillance data exist specifically for women who have sex with women. This study aimed to compare differences in sexual practices and positivity for STIs and other genital infections among women who have sex with men only (WSMO), women who have sex with women only (WSWO), and women who have sex with men and women (WSMW), and whether these changed over time. In this retrospective repeated cross-sectional study, women attending the Melbourne Sexual Health Centre for the first time between 2011 and 2019 were categorized as "WSMW," "WSWO," or "WSMO" according to self-reported sexual practices in the previous 12 months. Demographic information, sexual practices, and positivity for STIs and other genital infections were compared between the three groups and over time. A total of 36,147 women (2618 WSMW, 534 WSWO, and 32,995 WSMO) were included. WSMW reported more sexual partners (median = 6; IQR = 4-10) than WSMO (median = 3; IQR = 2-5) and WSWO (median = 2; IQR = 1-4) (p < .001). A higher proportion of WSMW always used condoms with casual male partners compared to WSMO (20.4% vs 15.9%; p < .001). The proportion of women who always used condoms with casual male partners decreased over time in WSMO, (19.9% in 2011 to 15.2% in 2019, p trend  < .001) but not in WSMW. Bacterial vaginosis was more common in WSWO (14.8%) than in WSMW (11.8%) and WSMO (7.7%) (p < .001). Chlamydia was more common in WSMO (9.3%) than in WSMW (6.6%) and WSWO (1.2%) (p < .001). Syphilis was more common in WSMO (1.0%) than in WSMW (0.3%) and WSWO (0.0%) (p = .004). Over time, chlamydia positivity in WSWO increased (from 0.0% to 2.7%, p trend  = .014), and syphilis positivity in WSMW increased (from 0.0% to 0.7%, p trend  = .028); however, positivity of these STIs did not change in other groups. Sexual practices and positivity for STIs and other genital infections differed according to the sex of women's partners in the previous 12 months. Knowledge of these differences is important to account for future changes in STI trends that may occur in these subpopulations., (© 2022. The Author(s).)

Background: There have been limited studies of group sex among heterosexual individuals. This study aimed to explore the factors associated with group sex among heterosexual males and females to improve risk assessment guidelines and inform sexually transmitted infection (STI) screening requirements., Methods: A cross-sectional survey was conducted among heterosexual males and females aged ≥16 years attending the Melbourne Sexual Health Centre between March and April 2019. The survey asked about group sex participation, methods used to meet sexual partners, number of casual and/or regular partners, and injection drug use (IDU) in the previous 3 months. HIV and STI (chlamydia, gonorrhoea, syphilis) diagnoses were extracted. A multivariable logistic regression was conducted to identify the factors associated with group sex participation., Results: A total of 698 participants (325 males, 373 females) were included and 4.7% (33/698) had participated in group sex in the previous 3 months. The proportion who participated in group sex increased with age (2.1% in 16-24 years, 5.5% in 25-34 years, 7.8% in ≥35 years, p trend =0.010). Meeting partners at sex venues (e.g. brothels) was associated with the highest odds of participating in group sex (aOR=5.74, 95% CI: 1.20-27.44), followed by dating apps (aOR=2.99, 95% CI: 1.36-6.58), friends/family (aOR=2.99, 95% CI: 1.34-6.69) and social venues (e.g. bar) (aOR=2.73, 95% CI: 1.18-6.30). Group sex was strongly associated with STI positivity (aOR=6.24, 95% CI: 2.41-16.13). There was no association between group sex and sex, casual and/or regular partners, HIV positivity or IDU., Conclusion: Heterosexual individuals participating in group sex had a six-fold risk of testing positive for STIs. Including group sex in a sexual history is useful to determine STI risk and inform testing practices. Safe sex messages on group sex that are delivered through multiple methods (e.g. at sex venues, social venues and dating apps simultaneously) would be beneficial.

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., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Mycoplasma genitalium (M. genitalium) is a recently recognised and important sexually transmitted infection among men who have sex with men (MSM). The role of oral sex, rimming, and kissing on M. genitalium transmission in MSM is unclear. We created four deterministic susceptible-infectious-susceptible epidemic models to examine the role that different sexual behaviours play in transmitting M. genitalium at the oropharynx, urethra anorectum among men who have sex with men in Australia. Our results suggest that oral and anal sex without other sexual practices (model 1) replicate well single site infection at the oropharynx, urethra and anorectum and also multi-site infection. If kissing or rimming are added to model 1 (i.e., model 2-4) no substantial improvements in the calibration of the models occur. Model 1 estimates that 3.4% of infections occur at the oropharynx, 34.8% at the urethra and 61.8% at the anorectum. Model 1 also estimates that the proportion of incident M. genitalium transmitted by anal sex was 82.4%, and by oral sex was about 17.6%. Our findings could provide an enhanced understanding of M. genitalium transmission in MSM, thus providing insights into what sexual practices contribute most to transmission.

Background: Most research focuses on individual selling sex but very few on paying for sex. This study aimed to determine the proportion of males and females who paid for sex and associated factors., Methods: We conducted a short survey at the Melbourne Sexual Health Centre between March and April 2019, which included a question on whether they had paid for sex in the past 3 months. The proportion of individuals who had paid for sex was calculated by sex and sexual orientation. Univariable and multivariable logistic regression models were conducted to identify individual's factors (e.g., demographics, sexual orientation, and HIV/sexually transmitted infection [STI] positivity) associated with paying for sex in the past 3 months., Results: The proportion who reported paying for sex in the past 3 months was 12.2% (42/345) among heterosexual males, followed by 6.4% (23/357) among men who have sex with men (MSM) and 0.2% (1/430) among females. HIV status, preexposure prophylaxis use, and sexual orientation were not associated with paying for sex among MSM. No MSM living with HIV reported paying for sex in the past 3 months. There was a significant association between paying for sex and gonorrhea (odds ratio, 2.84; 95% confidence interval, 1.05-7.71; P = 0.041) but not HIV, syphilis, and chlamydia among MSM. HIV/STI was not associated with paying for sex among heterosexual males., Conclusions: Paying for sex was more commonly reported among heterosexual males, followed by MSM. Females were very unlikely to pay for sex. There was a limited association between HIV/STI diagnosis and paying for sex among males., Competing Interests: Conflict of Interest and Sources of Funding: E.P.F.C. is supported by an Australian National Health and Medical Research Council (NHMRC) Emerging Leadership Investigator Grant (GNT1172873). C.K.F. and C.S.B. are supported by Australian NHMRC Leadership Investigator Grants (GNT1172900 and GNT1173361). J.S.H. is supported by an NHMRC Senior Research Fellowship (GNT1136117). B.D. is supported by an NHMRC Practitioner Fellowship (GNT1154828). All other authors have no conflicts of interest to declare., (Copyright © 2021 American Sexually Transmitted Diseases Association. All rights reserved.)

Much about the range of pathogens, frequency of coinfection, and clinical effects of reproductive tract infections (RTIs) among pregnant women remains unknown. We report on RTIs (Mycoplasma genitalium, Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, Treponema pallidum subspecies pallidum, bacterial vaginosis, and vulvovaginal candidiasis) and other reproductive health indicators in 699 pregnant women in Papua New Guinea during 2015-2017. We found M. genitalium, an emerging pathogen in Papua New Guinea, in 12.5% of participants. These infections showed no evidence of macrolide resistance. In total, 74.1% of pregnant women had >1 RTI; most of these infections were treatable. We detected sexually transmitted infections (excluding syphilis) in 37.7% of women. Our findings showed that syndromic management of infections is greatly inadequate. In total, 98.4% of women had never used barrier contraception. These findings will inform efforts to improve reproductive healthcare in Papua New Guinea.

Background: There are limited data on HIV/sexually transmitted infection (STI) positivity and sexual practices among male sex workers (MSWs) both globally and particularly in Australia. This study aimed to explore demographic characteristics, sexual practices, and HIV/STI positivity among MSWs attending a sexual health clinic in Melbourne., Methods: We analyzed computerized medical records of all first-visit consultations with men 18 years or older who self-identified as current sex workers and attended the Melbourne Sexual Health Centre (MSHC) between 2010 and 2018. Demographic data, sexual behavior data, and laboratory results for HIV, syphilis, chlamydia, and gonorrhea were collected as part of routine clinical care at Melbourne Sexual Health Centre., Results: Of the 190 MSWs included in the analysis, the median age was 28 years (interquartile range, 23-30 years), 30.4% (52/171) reported having condomless penile-anal sex with their clients, and 59.6% (102/171) reported having condomless penile-oral sex with their clients since their last STI screening. Most (85.6%) MSWs had noncommercial sex partners, including 56.5% with male partners only, 30.6% with female partners only, and 12.9% with both. Approximately half of MSWs used condoms consistently with noncommercial sex partners (regardless of partner gender). The positivity for incident HIV was 1.7% (95% confidence interval [CI], 0.0%-5.0%), that for syphilis was 6.1% (95% CI, 2.6%-10.5%), that for chlamydia was 9.6% (95% CI, 5.6%-14.9%), and that for gonorrhea was 10.8% (95% CI, 4.4%-20.9%). Male sex workers who exclusively had sex with women had a lower any HIV/STI positivity (0%) compared with MSW who had sex with men (15.7%; P = 0.013)., Conclusions: Male sex workers fall into 2 groups: those who had male clients and/or noncommercial partners who have a relatively high HIV/STI positivity and those who only had female partners or clients whose HIV/STI positivity is low. Both have a high proportion of condomless sex with clients and noncommercial sex partners. Strategies to increase condom use during sex work are needed., Competing Interests: Conflict of Interest and Sources of Funding: E.P.F.C. is supported by an Australian National Health and Medical Research Council Emerging Leadership Investigator Grant (GNT1172873). C.K.F. and C.S.B. are supported by Australian National Health and Medical Research Council Leadership Investigator Grants (GNT1172900 and GNT1173361, respectively). All other authors have no conflicts of interest to declare., (Copyright © 2020 American Sexually Transmitted Diseases Association. All rights reserved.)

Objective: This study aimed to determine the frequency of mouthwash use and its association to oral sex practice in heterosexuals., Design: A cross-sectional study., Setting: Data obtained from a sexual health clinic in Victoria, Australia, between March 2019 and April 2019., Participants: Heterosexual men and women attending the sexual health clinic answered a survey using computer-assisted self-interview., Primary and Secondary Outcome Measures: Univariable and multivariable logistic regression were performed to examine the association between frequent mouthwash use (ie, daily or weekly mouthwash use) and oral sex practices (including tongue kissing, fellatio, cunnilingus and insertive rimming)., Results: There were 681 heterosexuals included in the analysis: 315 (46.3%) men and 366 (53.7%) women. Of participants, 302 (44.3%) used mouthwash frequently, 173 (25.4%) used mouthwash infrequently and 206 (30.2%) never used mouthwash. There was no significant difference in the proportion of frequent mouthwash users between men and women (46.4% of men vs 42.6% of women; p=0.329). The proportion of frequent mouthwash users increased with increasing age groups (39.3% in ≤24 years, 45.2% in 25-34 years and 52.8% in ≥35 years or older; p trend =0.039) with those aged ≥35 years having a 1.80 times (95% CI: 1.12 to 2.89) higher odds of being a frequent mouthwash user than those aged ≤24 years. There were no significant associations between frequent mouthwash users had sexually transmitted infection (STI) risk after adjusting for age and country of birth., Conclusion: Older heterosexuals are more likely to use mouthwash. Given the high proportion and associations of mouthwash use in heterosexuals, future investigations related to oral STIs in this group should include mouthwash use., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The Young People's Health Service (YPHS) is a free, nurse-led Primary Health Care Clinic, in Melbourne, for young people aged 12-24 who are experiencing homelessness. Sexually transmitted infection (STI) screening is routinely offered as part of comprehensive psychosocial assessments. We wanted to determine the number of people positive for Chlamydia trachomatis (Ct) and Mycoplasma genitalium (Mg), amongst this asymptomatic high-risk population. We also wanted to review our screening practice. All asymptomatic sexually active clients seen by YPHS between 2014 and 2016 were offered a first pass urine polymerase chain reaction-based test for Ct and Mg. Urine samples were taken for men and women. Positivity for Ct and Mg out of those tested was determined and association with gender examined. Between 2014-2016, 272 males and 278 females (n = 550) were screened for Ct, and 72 infections were detected (13.1%. Chlamydia positivity did not differ between males (n = 35; 12.9%, 95% confidence interval [CI]: 8.8-16.8) and females (n = 37; 13.3%, 95%CI: 9.3-17.3). Over the same period 273 males and 284 females were screened for Mg (n = 557) and 55 infections were detected (9.9%). A higher proportion of females (n = 35; 12.3%, 95%CI: 8.5-16.1) tested positive compared to males (n = 20; 7.3%, 95%CI: 4.2-10.4), p = 0.048. Our study demonstrates both Ct and Mg are prevalent in the population, Mg being more common in young women than young men. Referral for specialist care for macrolide-resistant Mg increased and the updated Australian STI management guidelines led to a review of practice.

Bacterial vaginosis (BV) is a common vaginal infection among women of reproductive age. Increasing evidence suggests BV may be sexually transmitted indicating a potential role for the treatment of sexual partners. If partner treatment reduces BV recurrence in women, real-world success will depend on sexual partners' willingness to accept it. However, a lack of data exists on the acceptability of partner treatment among sexual partners, and no data exists on male partners' experience of BV specifically. The aim of this study was to explore male partners' views and experience of BV and their attitudes toward associated partner treatment. A social constructionist approach informed the framework of this study. Semi structured interviews were conducted with eleven men who participated in a BV partner treatment trial. Interviews were transcribed verbatim and analysed thematically. In the absence of symptoms in themselves, BV had little impact on men beyond their concerns for their partner's health and self-esteem. Acceptance of treatment was largely a demonstration of care and support. While all participants had accepted treatment, men surmised the primary reasons other men may reject treatment as being: if they felt BV had "nothing to do with them", which was related to not wanting to be viewed as having a 'problem' and exacerbated by norms of masculinity and STI-related stigma; lack of a diagnostic test to indicate if a male "had BV"; and a casual or less established relationship. Men's attitudes to BV and partner treatment were primarily influenced by the nature of their relationships. The ambiguous aetiology of BV appears to attenuate STI related stigma and questions of infidelity., Competing Interests: The authors have declared that no competing interests exist.

Background The number of sexual partners is one of the most important risk factors for sexually transmissible infections (STIs), including HIV. The aim of the present study was to examine the association between declining to report the number of partners using computer-assisted self-interviewing (CASI) and HIV or STI positivity at a public sexual health centre in Melbourne, Australia, in 2016., Methods: Individuals were categorised into three risk populations: women, men who have sex with women only (MSW) and men who have sex with men (MSM). Logistic regression analysis was used to examine the association between declining to report the number of sexual partners in the past 12 months and HIV or STI positivity for women and MSW, with generalised estimating equations (GEE) used for estimation in MSM to address repeated-measures within individuals., Results: In all, 18085 individuals (5579 women, 6013 MSW, 6493 MSM) were included in the final analysis. There was no association between chlamydia positivity and declining to respond among women and MSW. MSM who declined to respond were more likely to be chlamydia positive (adjusted odds ratio1.21; 95% confidence interval (CI) 1.01-1.43). Known HIV-positive MSM and MSM newly diagnosed with HIV had 3.31-fold (95% CI 2.48-4.42) and 2.82-fold (95% CI 1.84-4.32) greater odds respectively of declining to respond compared with HIV-negative MSM. Gonorrhoea and syphilis positivity in MSM were not associated with declining to respond., Conclusions: There was no association between declining to report the number of partners and chlamydia positivity among women and MSW. However, MSM who declined to report the number of partners were slightly more likely to have chlamydia and substantially more likely to be HIV positive.

Background: In August 2015, a nurse-led express human immunodeficiency virus (HIV)/sexually transmitted infection (STI) testing service "Test-And-Go" (TAG) for asymptomatic men who have sex with men (MSM) was implemented in a large public sexual health center in Melbourne, Australia. We aimed to compare the clients' characteristics between the TAG and routine walk-in service among asymptomatic MSM., Methods: This study was conducted at the Melbourne Sexual Health Centre, Australia, between August 5, 2015, and June 1, 2016. General estimating equation logistic regression models were constructed to examine the association between the use of TAG service and clients' demographic characteristics, sexual behaviors, and HIV/STI positivity. Clients' consultation and waiting times for both services were calculated., Results: Of the 3520 consultations, 784 (22.3%) were TAG services and 2736 (77.7%) were routine walk-in services for asymptomatic MSM. Asymptomatic MSM were more likely to use the TAG service if they were born in Australia (adjusted odds ratio, 1.29; 95% confidence interval, 1.07-1.56), and had more than 6 male partners in the last 12 months (adjusted odds ratio, 1.13; 95% confidence interval, 1.08-1.58). Age, HIV status, condomless anal sex and HIV/STI positivity did not differ between the two services. The TAG service had a shorter median waiting time (8.4 minutes vs 52.9 minutes; p < 0.001) and consultation time (8.9 minutes vs 17.6 minutes; p < 0.001) than the routine walk-in service., Conclusions: Although country of birth and sexual behaviors differed between clients attending the 2 services, there were no differences in HIV and STI positivity. Importantly, the TAG service required less waiting and consultation time and hence created additional clinic capacity at the general clinic to see clients who are at higher risk.

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., Competing Interests: Competing interests: The authors do not have a commercial or other association that might pose a conflict of interest., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

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., (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/.)

Data on the likelihood of Mycoplasma genitalium infection in sexual contacts, particularly for men who have sex with men (MSM), are needed to form an evidence base for guidelines. We conducted a cross-sectional analysis of patients attending a sexual health clinic in Melbourne, Victoria, Australia, during 2008-2016. We calculated the proportion of contacts with M. genitalium infection and determined factors associated with infection. Among those patients reporting sexual contact with an M. genitalium-infected person, 48.2% of women, 31.0% of heterosexual men, and 41.7% of MSM were infected. Among heterosexual contacts, women were twice as likely to be infected; among MSM, rectal infection was more common than urethral infection; and among persons within heterosexual partnerships, concordance of infection was high. High positivity among female and MSM contacts and high concordance in heterosexual partnerships provide some justification for presumptive treatment; however, clinicians should consider antimicrobial drug resistance and toxicity of quinolones.

Identification of priority populations such as men who have sex with men (MSM) is important in surveillance systems to monitor trends of sexually transmitted infections (STIs). We explored using routinely collected non-behavioural data as a means to establish MSM status in surveillance by assessing anorectal swab as a marker of male-to-male sexual exposure. We used chlamydia testing data from a sexual health clinic, 2007-2012. Men reporting any male sexual partner(s) in the previous 12 months were considered MSM. The dataset was split into development and validation samples to develop a univariate predictive model and assess the model fit. The dataset included 30 358 individual men and 48 554 episodes of STI testing; 45% were among reported MSM and an anorectal swab was performed in 40% of testing episodes. Anorectal swabbing had good diagnostic performance as a marker for MSM status (sensitivity = 87%, specificity = 99%, positive predictive value = 98·6%, negative predictive value = 90·3%). The model showed good fit against the internal validation sample (area under the curve = 0·93). Anorectal swabs are a valid marker of MSM behaviour in surveillance data from sexual health clinics, and they are likely to be particularly useful for monitoring STI trends among MSM with higher risk behaviour.

WHO estimated that nearly 1 million people become infected every day with any of four curable sexually transmitted infections (STIs): chlamydia, gonorrhoea, syphilis, and trichomoniasis. Despite their high global incidence, STIs remain a neglected area of research. In this Commission, we have prioritised five areas that represent particular challenges in STI treatment and control. Chlamydia remains the most commonly diagnosed bacterial STI in high-income countries despite widespread testing recommendations, sensitive and specific non-invasive testing techniques, and cheap effective therapy. We discuss the challenges for chlamydia control and evidence to support a shift from the current focus on infection-based screening to improved management of diagnosed cases and of chlamydial morbidity, such as pelvic inflammatory disease. The emergence and spread of antimicrobial resistance in Neisseria gonorrhoeae is globally recognised. We review current and potential future control and treatment strategies, with a focus on novel antimicrobials. Bacterial vaginosis is the most common vaginal disorder in women, but current treatments are associated with frequent recurrence. Recurrence after treatment might relate to evidence that suggests sexual transmission is integral to the pathogenesis of bacterial vaginosis, which has substantial implications for the development of effective management approaches. STIs disproportionately affect low-income and middle-income countries. We review strategies for case management, focusing on point-of-care tests that hold considerable potential for improving STI control. Lastly, STIs in men who have sex with men have increased since the late 1990s. We discuss the contribution of new biomedical HIV prevention strategies and risk compensation. Overall, this Commission aims to enhance the understanding of some of the key challenges facing the field of STIs, and outlines new approaches to improve the clinical management of STIs and public health., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: Gonorrhoea is one of the most common sexually transmissible infections in men who have sex with men (MSM). Gonorrhoea rates have increased substantially in recent years. There is concern that increasing gonorrhoea prevalence will increase the likelihood of worsening antibiotic resistance in Neisseria gonorrhoeae. A recent randomised controlled trial (RCT) demonstrated that a single-dose of mouthwash has an inhibitory effect against oropharyngeal gonorrhoea. We are conducting the first RCT to evaluate whether daily use of mouthwash could reduce the risk of acquiring oropharyngeal gonorrhoea., Methods/design: The OMEGA (Oral Mouthwash use to Eradicate GonorrhoeA) study is a double-blind RCT and will be conducted at several sexual health clinics and high caseload General Practice (GP) clinics in Melbourne and Sydney, Australia. A total of 504 MSM attending the participating sites will be recruited. Participants will be randomised to either using 'Study mouthwash A' or 'Study mouthwash B' for 12 weeks. Study mouthwash A was inhibitory against N. gonorrhoeae in vitro, whereas study mouthwash B was not. Participants will be instructed to rinse and gargle the study mouthwash for 60 seconds every day. The primary outcome is the proportion of participants with oropharyngeal gonorrhoea detected by nucleic acid amplification test by 12 weeks., Discussion: The results from this trial may provide a novel way to reduce gonorrhoea prevalence and transmission without the use of antibiotics that may be associated with development of resistance. If shown to be effective, the widespread use of mouthwash will reduce the prevalence of oropharyngeal gonorrhoea, which plays key role in driving the emergence of gonococcal antimicrobial resistance through DNA exchange with oral commensal bacteria. The anticipated net effect will be interruption of onward transmission of N. gonorrhoeae within high density sexual networks within MSM populations., Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12616000247471 , registered on 23rd February 2016.

Background: Bacterial vaginosis (BV) affects a third of women of reproductive age in the US and there is increasing evidence to suggest it may be sexually transmitted. This study aimed to extend and validate the findings of our earlier smaller qualitative study by exploring in detail women's views and experiences of the triggering factors associated with BV onset and recurrence., Methods: Women aged 20-49, who had experienced one or more symptomatic episode of BV within 6 months, were opportunistically recruited to complete a 38-item questionnaire on their experience of BV., Results: 103 women completed the questionnaire. Women were significantly more likely to report sexual than lifestyle factors triggered BV onset and recurrence (p<0.001). The top 3 factors women attributed to both BV onset and recurrence were identical-and all sexual. They included, in order: 1) unprotected sex; 2) sex with a new male partner; and 3) sex in general. The main lifestyle factors nominated included stress, diet, menstruation and the use of feminine hygiene products. While many women felt their BV had been transmitted through sexual contact (54%) and developed as a result of sexual activity (59%), few considered BV a sexually transmitted infection (STI) (10%). Despite this 57% felt partners should also be treated for BV., Conclusion: These data concur with our earlier qualitative findings that women believe BV is triggered by sexual activity. While many women felt BV was sexually transmitted and supported partner treatment, they did not consider BV an STI. This contradiction is likely due to information conveyed to women based on current guidelines. In the absence of highly effective BV treatments, this study highlights the need for guidelines to indicate there is scientific uncertainty around the pathogenesis of BV and to contain clear health messages regarding the evidence for practices shown to be associated with a reduced risk of BV (i.e. consistent condom use.

Objectives: To date, no study has correlated seasonal differences in sexual behaviour with the seasonal differences in sexually transmitted infections (STIs); and no seasonal study of STIs has been conducted in the southern hemisphere. Our study aimed to describe seasonal differences in sexual behaviour and correlate this with seasonal differences in STI diagnoses in Melbourne, Australia., Method: This was a cross-sectional study of individuals attending the Melbourne Sexual Health Centre over a 9-year period from 2006 to 2014. We conducted separate analyses for men who have sex with men (MSM) and men who have sex with women (MSW), and women. Seasonal patterns of sexual behaviour and STI positivity were examined within each group., Results: All groups reported a higher number of partners over the preceding three months for consultations in summer compared with winter (MSM mean 5.48 vs 5.03; MSW mean 2.46 vs 2.31; women mean 1.83 vs 1.72). Urethral gonorrhoea diagnoses among MSM were higher in summer compared with winter (OR 1.23, 95% CI 1.04 to 1.46). Similarly, non-gonococcal urethritis (NGU) diagnoses among MSW were the highest in summer (OR 1.11, 95% CI 1.03 to 1.20), but there was no seasonal difference in NGU diagnoses when we adjusted for partner numbers. In women, pelvic inflammatory disease (PID) diagnoses peaked in autumn, when rates were higher than in winter (OR 1.30, 95% CI 1.09 to 1.55)., Conclusions: Our results describe a peak in sexual partner number and STI diagnoses during consultations in summer in men and a rise in PID in autumn in women., (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/)

This study examined the contribution of Mycoplasma genitalium to sexually acquired infectious proctitis in men who have sex with men (MSM). MSM with symptomatic proctitis between May 2012 and August 2013 were tested for rectal sexually transmitted infections including chlamydia, gonorrhoea, herpes simplex virus (HSV) and M. genitalium. The load of rectal M. genitalium in men with symptomatic proctitis was compared with a separate group of men who had rectal M. genitalium but no symptoms of proctitis. Among 154 MSM with proctitis, rectal M. genitalium was detected in 18 men (12%, 95% CI 6.9-17.1) and was significantly more common among human immunodeficiency virus (HIV) -positive men (21%, 95% CI 9.5-32.6) than HIV-negative men (8%, 95% CI 2.9-13.1; prevalence ratio 3.2, 95% CI 1.2-8.8). Among HIV-positive men the detection of M. genitalium was comparable to that for chlamydia (21%, 95% CI 9.5-32.5), gonorrhoea (25%, 95% CI 16.2-41.8) and HSV (19%, 95% CI 7.9-30.1). Rectal M. genitalium load was significantly higher among the 18 men with symptomatic M. genitalium-associated proctitis than among a separate group of 18 men with asymptomatic rectal M. genitalium infection (60 000 copies of organism/swab versus 10 744 copies of organism/swab, p 0.023). Comprehensive testing for rectal pathogens in MSM with proctitis should include testing for M. genitalium., (Copyright © 2015 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.)

Objectives: To report on sexual behaviors and sexually transmitted infections (STIs) among men who have sex with men (MSM) in their teens, when many MSM engage in their first sexual experiences., Methods: MSM aged 16 to 20 years were recruited via community and other sources. Men completed a questionnaire about their sexual behaviors and were screened for gonorrhea, chlamydia, syphilis, and HIV., Results: Two hundred men were included. The median age was 19 years. The median age at first insertive or receptive anal intercourse was 17 years. Half of men reported sex with mainly older men: these men were more likely to engage in receptive anal intercourse (48% vs. 25%, p < .001) than other men. Most men had engaged in insertive (87%) and receptive (85%) anal intercourse in the prior 12 months with 60% and 53% reporting inconsistent condom use with insertive and receptive anal intercourse partners, respectively. The median number of insertive anal intercourse partners was 3 and 1.5 (p < .001) among men reporting inconsistent and consistent condom use with insertive anal intercourse over the prior 12 months. The median number of receptive anal intercourse partners was 3 and 2 (p = .006) among men reporting inconsistent and consistent condom use with receptive anal intercourse over the prior 12 months. Pharyngeal gonorrhea, rectal gonorrhea, urethral chlamydia, rectal chlamydia, and syphilis were detected in 3.0%, 5.5%, 3.0%, 4%, and 2.0% of men, respectively. All men were HIV negative., Conclusion: Many of the teenage MSM in this study were at risk for STI. Preventative messages and STI screening interventions that are age appropriate need to be developed to reduce HIV and STI risk in this under-recognized group., (Copyright © 2014 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Background: The frequency of testing sex workers for sexually transmitted infections (STIs) in Victoria, Australia, was changed from monthly to quarterly on 6 October 2012. Our aim was to determine the impact of this change to the clients seen at the Melbourne Sexual Health Centre (MHSC)., Methods: Computerised medical records of all clients attending at MHSC from 7 October 2011 to 7 October 2013 were analysed., Results: Comparing between the monthly and quarterly testing periods, the number of consultations at MSHC with female sex workers (FSW) halved from 6146 to 3453 (p<0.001) and the consultation time spent on FSW reduced by 40.6% (1942 h to 1153 h). More heterosexual men (p<0.001), and women (p<0.001) were seen in the quarterly testing period. The number of STIs diagnosed in the clinic increased from 2243 to 2589 from the monthly to quarterly period, respectively [15.4% increase (p<0.001)]. Up to AU$247,000 was saved on FSW testing after the shift to quarterly testing., Conclusions: The change to STIs screening frequency for sex workers from monthly to quarterly resulted in a 15% increase in STI diagnoses in the clinic and approximate a quarter of a million dollars was diverted from FSW testing to other clients. Overall the change in frequency is likely to have had a beneficial effect on STI control in Victoria.

Background: 'TESTme' is a sexually transmissible infection (STI) screening service for Victorian young people living in rural areas. We evaluated the effectiveness of advertising for this service over an 11-month pilot period., Methods: The advertising that was used included websites, a Facebook page, posters, flyers, business cards, wrist bands and professional development sessions for health nurses that occurred throughout the pilot period. We also used once-off methods including advertisements in newspapers, student diaries and short messages to mobile phones., Results: Twenty-eight clients had a consultation through TESTme. Twenty found the service through health professionals, six through the Melbourne Sexual Health Centre (MSHC) web page, one through the Facebook page and one through the student diary. The total direct costs incurred by the centre for advertising were $20850. The advertising cost per client reached for each advertising method was $26 for health professionals, $80 for the MSHC web advertisement, $1408 for Facebook and $790 for the student diary. Other advertising methods cost $12248 and did not attract any clients., Conclusion: Advertising STI health services for rural young people would be best to focus on referrals from other health services or health care websites.

The proportion of clinically important diagnoses in a low-risk, asymptomatic population who use a computer-assisted self-interview (CASI) to assess risk was needed to determine optimal health service delivery. Medical records were retrospectively analysed between July 2008 and June 2009 for risk characteristics and diagnoses. A total of 7733 new patients completed a CASI, of whom 1060 were asymptomatic heterosexuals. From this low-risk group, 26 diagnoses were made on the day of presentation, including 22 cases of genital warts (2.08% [95% confidence interval (CI) 1.22-2.93]), three cases of genital herpes (0.28% [95% CI 0.055-0.82]) and one case of unintended pregnancy (0.094% [95% CI 0.0061-0.52]). Additionally, there were 54 cases of chlamydia detected (5.09% [95% CI 3.77-6.42]). As chlamydia is effectively diagnosed and managed from self-collected samples, patient review is not always required. This study provides evidence for an express testing service for chlamydia to streamline the screening of low-risk, asymptomatic heterosexual patients as identified by CASI without the need to for a traditional face-to-face consultation.

Objectives: In Victoria, Australia, legislation requires sex workers to undergo monthly testing for gonorrhoea, chlamydia and trichomonas, and 3-monthly for HIV and syphilis, despite extremely low rates of sexually transmitted infections (STI) in female sex workers (FSW). The aim of this study was to quantify the resources and opportunities lost from this screening., Methods: Computerised medical records of patients attending the Melbourne Sexual Health Centre (MSHC) between October 2005 and October 2008 were reviewed., Results: Consultations with FSW accounted for 15.1% of total consultation time (5722 of 37,670 h) and of these, 2896 h (7.7%) were used for monthly consultations involving testing for gonorrhoea, chlamydia and trichomonas, but no serology (termed swab-only testing). Only 133 (3.2%) of the 4208 cases of STI (defined as gonorrhoea, chlamydia, trichomonas, early syphilis, mycoplasma genitalium or HIV) that were detected at MSHC during the study period were among FSW who underwent swab-only testing. 1726 (41%) STI were detected among men who have sex with men (MSM). The STI detected per 100 h of consultation time was (fourfold) higher for MSM (19) than for FSW (4). If FSW were tested only every 3 months for gonorrhoea, chlamydia, trichomonas, syphilis and HIV the 2896 h spent on monthly swab-only testing would have been available for higher-risk clients, Conclusion: The current legislation requiring monthly STI testing is compromising the access for higher-risk individuals to sexual health. Other countries contemplating mandatory testing need to consider the influence that the frequency of testing has on access to sexual health services for high-risk groups.

Objectives: To determine the prevalence and clinical associations of Mycoplasma genitalium in urethral, rectal and pharyngeal specimens collected from men who have sex with men (MSM) attending male-only saunas., Methods: A cross-sectional study of 521 MSM attending six male-only saunas in Melbourne was conducted between October 2001 and September 2002. Stored urine and rectal and pharyngeal swabs were tested for M genitalium by real-time polymerase chain reaction. The prevalence of M genitalium and clinical associations were determined., Results: A high prevalence (12.9%; 95% CI 10.2% to 15.9%) of sexually transmitted infections (STIs) was found in MSM. M genitalium (2.1%; 95% CI 1.1% to 3.6%) was less common than Chlamydia trachomatis (8.1%; 95% CI 5.9% to 10.6%, p<0.001), and Neisseria gonorrhoeae (4.8%; 95% CI 3.2% to 6.9%, p = 0.02). M genitalium was most likely to be detected as an asymptomatic rectal (1.6%; 95% CI 0.8% to 3.0%) or urethral infection (0.6%; 95% CI 0.2% to 1.6%, p = 0.12), but was absent from the pharynx. In comparison, C trachomatis was more common in the rectum (6.2%; 95% CI 4.3% to 8.6%) than urethra (1.8%; 95% CI 0.9% to 3.2%, p = 0.004), and was uncommon in the pharynx (0.6%; 95% CI 0.1% to 1.6%). Urethral infection with N gonorrhoeae (0.2%; 95% CI 0.01% to 1.0%) was rare, but it was as common in the pharynx (2.5%; 95% CI 1.4% to 4.2%) as the rectum (2.2%; 95% CI 1.2% to 3.8%). No significant demographic or behavioural associations with M genitalium were identified., Conclusion: M genitalium was less common than C trachomatis and N gonorrhoeae in MSM attending male-only saunas and was most often detected as an asymptomatic rectal or a urethral infection but was absent from the pharynx. To inform STI screening strategies in MSM, more data are needed to understand how common M genitalium infection is in urethral and non-urethral sites in MSM, and how it contributes to clinical symptoms.

The aim of this study is to compare risk factors in new clients attending the walk-in triage-based day clinic (WITS) to those attending a telephone-triage appointment-based evening clinic of a sexual health service. The method involves an audit of computerized medical records of new clients attending between July 2002 and December 2007. There were 37,833 new clients of which 37,223 (98.4%) attended WITS and 610 (1.6%) attended the evening clinic. WITS clients were significantly older (31% vs. 30%, P < 0.041), more likely to be male (58% vs. 43%, P < 0.001), sex workers (6% vs. 3%, P < 0.001), not employed (34% vs. 10%, P < 0.001), diagnosed with gonorrhoea (1.7% vs. 0.7%, P < 0.041), herpes (4% vs. 2%, P < 0.000), non-specific urethritis (6% vs. 2%, P < 0.000) and less likely asymptomatic (35.1% vs. 53.4%, P < 0.001). Men attending WITS had significantly more female partners in the 12 months (3.9 vs. 3.0, P < 0.001), but other risks were similar in both clinics. A telephone-triage appointment-based evening clinic is important for asymptomatic high-risk individuals.

Background: Rates of HIV in New South Wales (NSW) have been stable, but have increased significantly in other Australian states. The reasons for this are unknown and may be associated with differences in the management of sexually transmissible infections (STI) and HIV in different states in Australia. Our aim was to determine if the use of suppressive treatment for genital herpes, the treatment of HIV or STI screening practices were different between states in Australia., Methods: This study was a cross-sectional survey of medical practitioners who are S100 prescribers and members of the Australian Society for HIV Medicine., Results: In general, there were no differences between the clinical practices of practitioners in NSW and other states except that in NSW fewer practitioners tested HIV-positive men who have sex with men (MSM) for syphilis annually (NSW 78% v. others 87%, P = 0.04) or treated MSM with advanced HIV disease (CD4 < 150 x 10(6) cells L(-1)) with acicylovir in the absence of herpes simplex virus (HSV) (NSW 4% v. others 13%, P = 0.03), and more practitioners in NSW tested HIV-negative MSM for HSV type-specific serology (NSW 21% v. others 11%, P = 0.02)., Conclusions: It is unlikely that the minor differences in HSV and HIV treatment or STI screening practices among practitioners in NSW and other Australian states explains the differences in HIV notifications between these two areas.

The aim of this study was to determine whether our sexual health service could be streamlined by dispensing with routine vaginal examination of asymptomatic women, without missing important diagnoses. This was an audit of asymptomatic women presenting to the centre who had had a Papanicolaou (PAP) smear in the previous two years. Of the 421 women who were eligible, no abnormalities were found on genital inspection in 392 (93%) individuals. Abnormalities detected on clinical examination included one case (0.2%) with mucopurulent cervicitis that tested positive for Chlamydia trachomatis, four (1%) with warts or molluscum contagiosum, and one with an asymptomatic genital ulcer of unknown cause. Dispensing with the vaginal examination in asymptomatic women who have had a speculum examination as part of biennial cervical screening may be appropriate in settings where sensitive non-invasive testing for sexually transmitted infections (STI) is in use and STI prevalence is low.

Background: The purpose of the present study was to determine pathogens and behaviors associated with nongonococcal urethritis (NGU) and the usefulness of the urethral smear in predicting the presence of pathogens., Methods: We conducted a case-control study of men with and without symptoms of NGU. Sexual practices were measured by questionnaire. First-stream urine was tested for Chlamydia trachomatis, Mycoplasma genitalium, Ureaplasma parvum, U. urealyticum, herpes simplex virus (HSV)-1, HSV-2, adenoviruses, and Gardnerella vaginalis by polymerase chain reaction., Results: C. trachomatis (20%), M. genitalium (9%), adenoviruses (4%), and HSV-1 (2%) were more common in cases with NGU (n = 329) after age and sexual risk were adjusted for (P< or =.01); U. urealyticum, U. parvum, and G. vaginalis were not. Infection with adenoviruses or HSV-1 was associated with distinct clinical features, oral sex, and male partners, whereas infection with M. genitalium or C. trachomatis was associated with unprotected vaginal sex. Oral sex was associated with NGU in which no pathogen was detected (P < or = .001). Fewer than 5 polymorphonuclear leukocytes (PMNLs) per high-power field (HPF) on urethral smear were present in 32%, 37%, 38%, and 44% of cases with C. trachomatis, M. genitalium, adenoviruses, and HSV, respectively., Conclusion: We identified adenoviruses and HSV-1 as significant causes of NGU with distinct clinical and behavioral characteristics and highlighted the association between insertive oral sex and NGU. A urethral PMNL count of > or =5 PMNLs/HPF is not sufficiently sensitive to exclude pathogens in men with urethral symptoms.

Objective: Bacterial vaginosis has been associated with hormonal factors and sexual practices; however, the cause is unclear, and the notion that bacterial vaginosis is a sexually transmitted infection is still debated. To investigate whether bacterial vaginosis is associated with specific sexual practices or instead has features in common with a sexually transmitted infection, we compared behavioral associations in women with bacterial vaginosis to women with vaginal candidiasis., Methods: Women with symptoms of abnormal vaginal discharge or odor who attended Melbourne Sexual Health Centre between July 2003 and August 2004 were eligible for enrollment in the study. Information on demographics and behavioral and contraceptive practices were collected by self-completed questionnaire. Participants were tested for bacterial vaginosis, Candida spp (microscopy and culture), and sexually transmitted infections. Statistical comparisons were made between women with and without bacterial vaginosis and women with and without candidiasis, using univariate and multivariate analysis., Results: A total of 342 women were enrolled in the study; 157 were diagnosed with bacterial vaginosis, 51 had candidiasis by microscopy, and 95 had candidiasis by culture. Bacterial vaginosis was associated with indicators of high-risk sexual behavior such as a new sexual partner and greater number of male partners in the last year, increased number of lifetime sexual partners, less than 13 years of education, a past history of pregnancy, and smoking (P < .05). Candidiasis was not associated with these risk behaviors and was instead related to practices such as receptive anal and oral sex and douching., Conclusion: The association between bacterial vaginosis and practices that are associated with sexually transmitted infections, in contrast to those observed with candidiasis, suggests a possible sexually transmitted cause., Level of Evidence: II-2.

Background: Injecting drug users (IDUs) are a marginalised population, who infrequently access health services for screening for sexually transmitted infections (STIs) and blood borne viruses (BBVs), and are at high risk of these infections., Objectives: To use street outreach and self collection of samples for STI screening, to establish the prevalence of BBVs and STIs, and to identify risk behaviours among a group of culturally diverse street based IDUs., Methods: This was a cross sectional study of 314 IDUs in the central business district of Melbourne, Australia, conducted over 3 years (1999-2002). We used street outreach as the recruitment strategy with staff "on foot" in injecting and dealing locations, as well as self collected genital sampling to increase acceptance of screening for Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis by polymerase chain reaction (PCR). Individuals were screened for hepatitis A, B, and C, syphilis and HIV, and given the option of a self collected or clinician collected blood sample to increase acceptance of screening for BBVs., Results: Street outreach was highly effective and self directed STI sampling was more acceptable than practitioner directed sampling (76% versus 9% acceptance, p<0.001). There was a high prevalence of hepatitis C (74%, 95% CI 69 to 79), STIs (8% (5 to 13)), and chlamydia (6% (3 to 10)), and past exposure to hepatitis A and B was common. High rates of recent sharing of injecting equipment, unprotected sex and casual sexual partners, together with low levels of awareness of current hepatitis C infection were identified., Conclusion: Street outreach and self collected genital samples facilitate screening for STIs and BBVs in IDUs and revealed a high prevalence of infections and risk behaviours.