Publications by authors named "Eric P F Chow"

279 Publications

Positivity and Risk Factors for Trichomonas Vaginalis Among Women Attending a Sexual Health Clinic in Melbourne, 2006-2019.

Sex Transm Dis 2022 Aug 10. Epub 2022 Aug 10.

Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia.

Background: Trichomonas vaginalis is not a notifiable disease in Australia in most states, resulting in limited Australian epidemiological studies. This study aimed to examine the positivity of T. vaginalis in women attending the Melbourne Sexual Health Centre (MSHC) and identify associated factors.

Methods: All women aged ≥16 years who were tested for T. vaginalis at MSHC from 2006-2019 were included. The diagnostic method changed from culture to nucleic acid amplification test (NAAT) in August 2018. The annual positivity of T. vaginalis was calculated. Due to the data completeness, we performed a generalised estimating equations multivariable logistic regression using data from 2011-2019 to examine factors associated with T. vaginalis positivity.

Results: From 2006-2019, 69,739 tests for T. vaginalis were conducted, and 294 tested positive (0.42%, 95% CI 0.37-0.47). Approximately 60% of women tested reported symptoms. After adjusting for potential confounders including the change in diagnostic method, there was a 21% (95% CI 12-31%) annual increase in T. vaginalis positivity between 2011 and 2019. Women with concurrent syphilis had the highest odds of testing positive for T. vaginalis (aOR 21.55; 95% CI 6.96-66.78); followed by women who had injected drugs in the last 12 months (aOR 6.99; 95% CI 4.11-11.87), were aged ≥35 years (aOR 3.47; 95% CI 2.26-5.35), or with concurrent chlamydia (aOR 1.77; 95% CI 1.05-2.99).

Conclusion: The rising positivity of T. vaginalis at MSHC irrespective of change in diagnostic method suggests a concurrent community-wide rise in Melbourne. Given the rising positivity, testing informed by risk factors should be considered.
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http://dx.doi.org/10.1097/OLQ.0000000000001690DOI Listing
August 2022

Applying Behavioural Insights to HIV Prevention and Management: a Scoping Review.

Curr HIV/AIDS Rep 2022 Aug 5. Epub 2022 Aug 5.

Central Clinical School, Monash University, Melbourne, Australia.

Purpose Of Review: This scoping review summarises the literature on HIV prevention and management interventions utilizing behavioural economic principles encapsulated in the MINDSPACE framework.

Recent Findings: MINDSPACE is an acronym developed by the UK's behavioural insights team to summarise nine key influences on human behaviour: Messenger, Incentives, Norms, Default, Salience, Priming, Affect, Commitment, and Ego. These effects have been used in various settings to design interventions that encourage positive behaviours. Currently, over 200 institutionalised behavioural insight teams exist internationally, which may draw upon the MINDSPACE framework to inform policy and improve public services. To date, it is not clear how behavioural insights have been applied to HIV prevention and management interventions. After screening 899 studies for eligibility, 124 were included in the final review. We identified examples of interventions that utilised all the MINDSPACE effects in a variety of settings and among various populations. Studies from high-income countries were most common (n = 54) and incentives were the most frequently applied effect (n = 100). The MINDSPACE framework is a useful tool to consider how behavioural science principles can be applied in future HIV prevention and management interventions. Creating nudges to enhance the design of HIV prevention and management interventions can help people make better choices as we strive to end the HIV/AIDS pandemic by 2030.
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http://dx.doi.org/10.1007/s11904-022-00615-zDOI Listing
August 2022

Kissing, fellatio, and analingus as risk factors for oropharyngeal gonorrhoea in men who have sex with men: A cross-sectional study.

EClinicalMedicine 2022 Sep 14;51:101557. Epub 2022 Jul 14.

Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia.

Background: Our aim was to determine whether exposure to the anatomical sites (oropharynx, penis, or anus) of male partners of men who have sex with men (MSM) were independent risk factors for oropharyngeal gonorrhoea after adjusting for exposures to these sites.

Methods: In this cross-sectional study, we invited MSM who attended the Melbourne Sexual Health Centre (MSHC) in Victoria, Australia between 26-November 2018 and 31-December 2020 to complete a survey of their sexual practices in the past three months. We collected data on the number of male partners with whom men engaged in sexual activities that exposed their oropharynx to their partners' oropharynx (kissing), penis (fellatio), and anus (rimming or analingus). Only men who were aged 16 years, tested for oropharyngeal gonorrhoea and did not have indeterminate or invalid results were included in the final analysis. We conducted univariable and multivariable logistic regression analyses to investigate associations between oropharyngeal gonorrhoea and the three exposures to the oropharynx.

Findings: The median age of the 2,322 men who completed the survey was 31 years (IQR: 26-40), and 5·2% ( = 120) were diagnosed with oropharyngeal gonorrhoea. Our univariate analysis showed that oropharyngeal gonorrhoea was significantly associated with increasing number of kissing ( <0·0001), rimming ( <0·0001) and fellatio ( <0·0001) partners. After adjusting for all three exposures, oropharyngeal gonorrhoea was associated with increasing number of kissing ( 0·014) and rimming partners ( = 0·037) but not fellatio ( = 0·61).

Interpretation: Our data suggest kissing and rimming are important practices in oropharyngeal gonorrhoea transmission in MSM Novel interventions which target the oropharynx are required for gonorrohoea prevention.

Funding: Australian National Health and Medical Research Council.
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http://dx.doi.org/10.1016/j.eclinm.2022.101557DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9294476PMC
September 2022

HIV Testing Uptake According to Opt-In, Opt-Out or Risk-Based Testing Approaches: a Systematic Review and Meta-Analysis.

Curr HIV/AIDS Rep 2022 Jul 13. Epub 2022 Jul 13.

Melbourne Sexual Health Centre, Alfred Health, Melbourne, Australia.

Purpose Of Review: Improving HIV testing uptake is essential to ending the HIV pandemic. HIV testing approaches can be opt-in, opt-out or risk-based. This systematic review examines and compares the uptake of HIV testing in opt-in, opt-out and risk-based testing approaches.

Recent Findings: There remain missed opportunities for HIV testing in a variety of settings using different approaches: opt-in (a person actively accepts to be tested for HIV), opt-out (a person is informed that HIV testing is routine/standard of care, and they actively decline if they do not wish to be tested for HIV) or risk-based (using risk-based screening tools to focus testing on certain individuals or sub-populations at greater risk of HIV). It is not clear how the approach could impact HIV test uptake when adjusted for other factors (e.g. rapid testing, country-income level, test setting and population tested). We searched four databases for studies reporting on HIV test uptake. In total, 18,238 records were screened, and 150 studies were included in the review. Most studies described an opt-in approach (87 estimates), followed by opt-out (76) and risk-based (19). Opt-out testing was associated with 64.3% test uptake (I = 99.9%), opt-in testing with 59.8% (I = 99.9%) and risk-based testing with 54.4% (I = 99.9%). When adjusted for settings that offered rapid testing, country income level, setting and population tested, opt-out testing had a significantly higher uptake (+ 12% (95% confidence intervals: 3-21), p = 0.007) than opt-in testing. We also found that emergency department patients and hospital outpatients had significantly lower HIV test uptake than other populations.
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http://dx.doi.org/10.1007/s11904-022-00614-0DOI Listing
July 2022

Patterns of Sexual Practices, Sexually Transmitted Infections and Other Genital Infections in Women Who Have Sex with Women Only (WSWO), Women Who Have Sex with Men Only (WSMO) and Women Who Have Sex with Men and Women (WSMW): Findings from a Sexual Health Clinic in Melbourne, Australia, 2011-2019.

Arch Sex Behav 2022 07 1;51(5):2651-2665. Epub 2022 Jul 1.

Melbourne Sexual Health Centre, Alfred Health, 580 Swanston Street, Carlton, VIC, 3053, Australia.

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 < .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 = .014), and syphilis positivity in WSMW increased (from 0.0% to 0.7%, p = .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.
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http://dx.doi.org/10.1007/s10508-022-02311-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9293838PMC
July 2022

Evidence supports use of on-demand PrEP for HIV prevention.

Lancet HIV 2022 08 27;9(8):e524-e526. Epub 2022 Jun 27.

Melbourne Sexual Health Centre, Alfred Health, Melbourne, VIC 3053, Australia; Central Clinical School, Faculty of Medicine, Nursing, and Health Sciences, Monash University, Melbourne, VIC, Australia.

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http://dx.doi.org/10.1016/S2352-3018(22)00158-8DOI Listing
August 2022

How is cervical cancer screening discussed with clients at a sexual health clinic in Melbourne, Australia?

Sex Health 2022 Jun 30. Epub 2022 Jun 30.

We conducted a survey among 40 clinicians working at the Melbourne Sexual Health Centre in November 2021. We asked clinicians how they discussed cervical screening with their clients. All clinicians used the term 'Cervical Screening Test (CST)' when discussing cervical cancer screening with clients. However, 19 clinicians (48%) also used the term 'Pap smear', particularly among older women as they were more familiar with Pap smear than CST. Twenty-five (63%) clinicians believed that clients did not understand the difference between Pap smears and CST. Further education is required to improve the understanding between the terminologies.
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http://dx.doi.org/10.1071/SH22093DOI Listing
June 2022

Accessible health care is critical to the effective control of sexually transmitted infections.

Sex Health 2022 Jun 28. Epub 2022 Jun 28.

Bacterial sexually transmitted infections (STIs) are rising relentlessly in virtually every country and among most risk groups. These infections have substantial individual and community consequences and costs. This review summarises the evidence for the effectiveness of different strategies to control STIs and assumes countries have sufficient financial resources to provide accessible health care. Reducing the probability of transmission essentially involves increasing condom use, which is problematic given that condom use is currently falling in most risk groups. Interventions to increase condom use are expensive and hard to sustain. Only a limited number of studies have shown it is possible to reduce the rate of partner change and sustained changes are difficult. In contrast, the provision of accessible health care has a powerful effect on the incidence rate of STIs, with dramatic falls in STIs in virtually all countries following the discovery of antibiotics. More recent studies support the powerful role of accessible health care as a strategy for putting substantial downward pressure on STI rates. Accessible health care has a powerful effect on the incidence of STIs. The professionals who are responsible for funding these services need to appreciate that they are ultimately responsible for the rates of STIs in their communities. In contrast, personal behaviour plays a less powerful role in determining the incidence of STIs and is hard to change and sustain at a population level. The public needs to appreciate that it is the governments they elect and not individuals who are responsible for the rates of STIs in their communities.
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http://dx.doi.org/10.1071/SH22042DOI Listing
June 2022

Clinical and laboratory aspects of condylomata lata lesions of syphilis.

Sex Transm Infect 2022 Jun 22. Epub 2022 Jun 22.

Melbourne Sexual Health Centre, Alfred Health, Carlton, Victoria, Australia.

Objectives: Condylomata lata are a less common but distinctive syphilitic lesion. Variable theories as to their nature and origin exist. The aim of this study was to determine the clinical and laboratory characteristics of condylomata lata by determining (1): the most closely aligned stage of syphilis, based on the rapid plasma reagin (RPR) titre; (2) symptom duration and (3) PCR cycle threshold (C) values, as an indicator of organism load.

Methods: This was a retrospective study of patients with PCR-positive condylomata lata lesions, attending a clinic in Melbourne, Australia, between 2011 and 2021. Syphilis serology was undertaken and RPR titres compared between condylomata lata, primary and secondary syphilis cases.

Results: 51 cases with PCR-positive condylomata lata were included. 41 cases were in men, 40 of whom were men who have sex with men (MSM), and 10 in women. Twelve of 51 (24%) cases were in HIV-positive MSM. Thirty-three of 51 (65%) had other mucocutaneous signs of secondary syphilis; 18 (35%) had no other signs of secondary syphilis. The median RPR titre among the 51 condylomata lata cases was 1:128, compared with the median RPR titre of primary syphilis (1:4) and of secondary syphilis (1:128). The median duration of lesions was 24 (IQR 10-60) days, with no significant difference between those with and without other signs of secondary syphilis (p=0.75). Median C values for condylomata lata (C=31) and primary syphilis (C=31) were significantly lower than for other secondary syphilis lesion types (C=33), indicating higher loads for condylomata lata and primary lesions compared with other secondary syphilis lesion types.

Discussion: These findings support condylomata lata as lesions that occur during the secondary stage of syphilis and which are likely to be highly infectious.
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http://dx.doi.org/10.1136/sextrans-2021-055385DOI Listing
June 2022

Human papillomavirus vaccine coverage in male-male partnerships attending a sexual health clinic in Melbourne, Australia.

Hum Vaccin Immunother 2022 Nov 17;18(5):2068929. Epub 2022 Jun 17.

Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia.

We aimed to investigate the sexual mixing by human papillomavirus (HPV) vaccination status in male-male partnerships and estimate the proportion of male-male partnerships protected against HPV. We analyzed male-male partnerships attending the Melbourne Sexual Health Center between 2018 and 2019. Data on self-reported HPV vaccination status were collected. Newman's assortativity coefficient was used to examine the sexual mixing by HPV vaccination status. Assortativity refers to the tendency of individuals to have partners with similar characteristics (i.e. same vaccination status). Of 321 male-male partnerships where both men reported their HPV vaccination status, 52.6% (95% CI: 47.0-58.2%) partnerships had both men vaccinated, 32.1% (95% CI: 27.0-37.5%) partnerships had only one man vaccinated, and 15.3% (95% CI: 11.5-19.7%) had both men unvaccinated. The assortativity on HPV vaccination status was moderate (assortativity coefficient = 0.265, 95% CI: 0.196-0.335). There were about 15% of male-male partnerships where both men were not protected against HPV. Interventions targeting vaccinated individuals to encourage their unvaccinated partners to be vaccinated might increase the HPV vaccine coverage.
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http://dx.doi.org/10.1080/21645515.2022.2068929DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9302508PMC
November 2022

Exploring the Use of "Nudges" to Improve HIV and Other Sexually Transmitted Infection Testing Among Men Who Have Sex with Men.

Arch Sex Behav 2022 07 16;51(5):2641-2650. Epub 2022 Jun 16.

Melbourne Sexual Health Centre, Alfred Health, 580 Swanston Street, Melbourne, VIC, 3053, Australia.

Behavioral economics and its applied branch "nudging" can improve individual choices in various health care settings. However, there is a paucity of research using nudges to improve regular testing for HIV and other sexually transmitted infections (STIs). The study examined which reminder system and message type men who have sex with men (MSM) preferred to remind them to undergo regular 3-monthly HIV and STI testing. A cross-sectional survey study was conducted among MSM attending a sexual health clinic in Melbourne, Australia between 13 January and 5 March 2020, exploring the preferred method of reminder and framing of the message. Descriptive statistics and logistic regression were used to analyze the data. A total of 309 responses were received. The majority of the participants (90%) preferred short messaging service (SMS) as the reminder method for HIV/STI testing compared to other types (e.g., email or instant messaging). More than a third of the participants (45%) showed a preference for a neutrally framed reminder message (Your next check-up is now due. Please phone for an appointment), while one-third (35%) preferred a personalized message (Hi [first name], you are due for your next check-up. Please phone for an appointment). Younger men were more likely to favor positive framed messages than older men who favored neutrally framed messages (p < .01). SMS was the preferred reminder method for regular HIV/STI testing. Reminder messages that were neutrally framed, personalized or positive framed messages were preferred over negative or social norm messages.
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http://dx.doi.org/10.1007/s10508-022-02321-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9202328PMC
July 2022

Characterisation of Treponema pallidum lineages within the contemporary syphilis outbreak in Australia: a genomic epidemiological analysis.

Lancet Microbe 2022 Jun 20;3(6):e417-e426. Epub 2022 Apr 20.

Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia; Victorian Infectious Diseases Reference Laboratory, Royal Melbourne Hospital, Melbourne, VIC, Australia. Electronic address:

Background: The incidence of syphilis has increased markedly in the past decade in high-income countries, including Australia. To date, however, genomic studies of Treponema pallidum have focused mainly on the northern hemisphere. Here, we aimed to characterise the lineages of T pallidum driving the current syphilis epidemic in Australia.

Methods: In this genomic epidemiological analysis, using phylogenomic and phylodynamic analyses, we analysed 456 high-quality T pallidum genomes collected from clinical samples in Australia between Oct 19, 2005, and Dec 31, 2020, and contextualised this information with publicly available sequence data. We also performed detailed genomic characterisation of putative antimicrobial resistance determinants, in addition to correlating single-locus typing of the TP0548 allele with the T pallidum phylogeny.

Findings: Phylogenomic analyses identified four major sublineages circulating in Australia and globally, two belonging to the SS14 lineage, and two belonging to the Nichols lineage. Australian sublineages were further delineated into twelve subgroups, with five of the six largest subgroups associated with men who have sex with men, and the sixth lineage was predominantly associated with heterosexual people. Most Australian T pallidum genomes (398 [87%] of 456) were genotypically macrolide resistant, and TP0548 typing correlated significantly with T pallidum genomic subgroups.

Interpretation: These findings show that the current syphilis epidemic in Australia is driven by multiple lineages of T pallidum, rather than one distinct outbreak. Major subgroups of T pallidum in Australia have emerged within the past 30 years, are closely related to global lineages, and circulate across different sexual networks. In conjunction with improved testing and treatment, these data could better inform the control of syphilis in Australia.

Funding: National Health and Medical Research Council, Australian Research Council.
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http://dx.doi.org/10.1016/S2666-5247(22)00035-0DOI Listing
June 2022

Real-world trends in incidence of bacterial sexually transmissible infections among gay and bisexual men using HIV pre-exposure prophylaxis (PrEP) in Australia following nationwide PrEP implementation: an analysis of sentinel surveillance data.

Lancet Infect Dis 2022 08 25;22(8):1231-1241. Epub 2022 May 25.

Burnet Institute, Melbourne, VIC, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.

Background: Although data from large implementation trials suggest that sexually transmissible infection (STI) risk increases among gay and bisexual men who initiate HIV pre-exposure prophylaxis (PrEP), there are few data on the trends in population-level STI incidence in the years following widespread PrEP implementation. We aimed to describe trends in bacterial STI incidence among gay and bisexual men using PrEP across Australia in the context of broad PrEP availability through Australia's subsidised medicines scheme.

Methods: We analysed linked clinical data from HIV-negative gay and bisexual men aged 16 years or older who had been prescribed PrEP across a sentinel surveillance clinical network, including 37 clinics in Australia, between Jan 1, 2016, and Dec 31, 2019. Patients were included if they had STI testing at least twice during the observation period. Repeat testing methods were used to calculate chlamydia, gonorrhoea, syphilis, and any STI incidence rates during individuals' periods of PrEP use. Incidence rate ratios (IRRs) for estimated change in incidence per half calendar year (6-month) period were calculated using negative binomial regression. Secondary analyses compared STI incidence rates across individuals initiating PrEP in each year from 2016 to 2019, as well as by length of time using PrEP (per each additional 6 months of PrEP use).

Findings: 22 730 men were included in the analyses. During the observation period, 11 351 chlamydia infections were diagnosed in 6630 (30·1%) of 22 034 men over 25 991·2 person-years of PrEP use (incidence rate 43·7 cases [95% CI 42·9-44·5] per 100 person-years). Chlamydia incidence decreased from 48·7 cases per 100 person-years in July-December, 2016, to 42·0 cases per 100 person-years in July-December, 2019 (IRR for estimated change per 6-month period 0·98 [95% CI 0·97-0·99]; p=0·0031). 9391 gonorrhoea infections were diagnosed in 5885 (26·9%) of 21 845 men over 24 858·7 person-years of PrEP use (incidence rate 37·8 cases [95% CI 37·0-38·5] per 100 person-years). Gonorrhoea incidence decreased from 45·5 cases per 100 person-years in July-December, 2016, to 37·2 cases per 100 person-years in July-December, 2019 (IRR 0·97 [95% CI 0·96-0·98]; p<0·0001). Declines in chlamydia and gonorrhoea incidence were most prominent in the first 18 months of observation and incidence was stable thereafter. 2062 syphilis infections were diagnosed in 1488 (7·7%) of 19 262 men over 21 978·9 person-years of PrEP use (incidence rate 9·4 cases [95% CI 9·0-9·8] per 100 person-years). Syphilis incidence increased from 6·2 cases per 100 person-years in July-December, 2016, to 9·8 cases per 100 person-years in July-December, 2019 (IRR 1·08 [95% CI 1·05-1·10]; p<0·0001).

Interpretation: Chlamydia and gonorrhoea incidence among gay and bisexual men using PrEP were highest in the early months of PrEP implementation in Australia and stabilised at slightly lower rates thereafter following wider PrEP uptake. Lower prospective STI risk among people initiating PrEP in later years contributed to the observed trends in STI incidence. Widespread PrEP implementation can contribute to increased STI screening and detection.

Funding: Australian Department of Health, National Health and Medical Research Council.
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http://dx.doi.org/10.1016/S1473-3099(22)00175-XDOI Listing
August 2022

Real-world trends in incidence of bacterial sexually transmissible infections among gay and bisexual men using HIV pre-exposure prophylaxis (PrEP) in Australia following nationwide PrEP implementation: an analysis of sentinel surveillance data.

Lancet Infect Dis 2022 08 25;22(8):1231-1241. Epub 2022 May 25.

Burnet Institute, Melbourne, VIC, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.

Background: Although data from large implementation trials suggest that sexually transmissible infection (STI) risk increases among gay and bisexual men who initiate HIV pre-exposure prophylaxis (PrEP), there are few data on the trends in population-level STI incidence in the years following widespread PrEP implementation. We aimed to describe trends in bacterial STI incidence among gay and bisexual men using PrEP across Australia in the context of broad PrEP availability through Australia's subsidised medicines scheme.

Methods: We analysed linked clinical data from HIV-negative gay and bisexual men aged 16 years or older who had been prescribed PrEP across a sentinel surveillance clinical network, including 37 clinics in Australia, between Jan 1, 2016, and Dec 31, 2019. Patients were included if they had STI testing at least twice during the observation period. Repeat testing methods were used to calculate chlamydia, gonorrhoea, syphilis, and any STI incidence rates during individuals' periods of PrEP use. Incidence rate ratios (IRRs) for estimated change in incidence per half calendar year (6-month) period were calculated using negative binomial regression. Secondary analyses compared STI incidence rates across individuals initiating PrEP in each year from 2016 to 2019, as well as by length of time using PrEP (per each additional 6 months of PrEP use).

Findings: 22 730 men were included in the analyses. During the observation period, 11 351 chlamydia infections were diagnosed in 6630 (30·1%) of 22 034 men over 25 991·2 person-years of PrEP use (incidence rate 43·7 cases [95% CI 42·9-44·5] per 100 person-years). Chlamydia incidence decreased from 48·7 cases per 100 person-years in July-December, 2016, to 42·0 cases per 100 person-years in July-December, 2019 (IRR for estimated change per 6-month period 0·98 [95% CI 0·97-0·99]; p=0·0031). 9391 gonorrhoea infections were diagnosed in 5885 (26·9%) of 21 845 men over 24 858·7 person-years of PrEP use (incidence rate 37·8 cases [95% CI 37·0-38·5] per 100 person-years). Gonorrhoea incidence decreased from 45·5 cases per 100 person-years in July-December, 2016, to 37·2 cases per 100 person-years in July-December, 2019 (IRR 0·97 [95% CI 0·96-0·98]; p<0·0001). Declines in chlamydia and gonorrhoea incidence were most prominent in the first 18 months of observation and incidence was stable thereafter. 2062 syphilis infections were diagnosed in 1488 (7·7%) of 19 262 men over 21 978·9 person-years of PrEP use (incidence rate 9·4 cases [95% CI 9·0-9·8] per 100 person-years). Syphilis incidence increased from 6·2 cases per 100 person-years in July-December, 2016, to 9·8 cases per 100 person-years in July-December, 2019 (IRR 1·08 [95% CI 1·05-1·10]; p<0·0001).

Interpretation: Chlamydia and gonorrhoea incidence among gay and bisexual men using PrEP were highest in the early months of PrEP implementation in Australia and stabilised at slightly lower rates thereafter following wider PrEP uptake. Lower prospective STI risk among people initiating PrEP in later years contributed to the observed trends in STI incidence. Widespread PrEP implementation can contribute to increased STI screening and detection.

Funding: Australian Department of Health, National Health and Medical Research Council.
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http://dx.doi.org/10.1016/S1473-3099(22)00175-XDOI Listing
August 2022

Anal and oral detection of in men who have sex with men with early syphilis infection.

Sex Transm Infect 2022 May 26. Epub 2022 May 26.

Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia.

Objectives: We aimed to characterise patterns of anal and oral detection of among men who have sex with men (MSM) with early syphilis.

Methods: 200 MSM with serologically confirmed primary, secondary and early latent syphilis were tested with PCR using an anal canal swab, oral rinse, plus swabs from any anal and oral lesions in a prospective, cross-sectional study. Anal and oral cycle threshold values were compared between subsets of men and according to rapid plasma reagin (RPR) titre.

Results: Of 200 men with early syphilis, 45 and 48 had anal and oral detected, respectively. Cycle threshold values were lower with anal compared with oral whether lesions were present or not. Among 27 and 42 men with anal and oral detected, respectively, and no anal or oral primary lesion, frequency of detection increased with increasing RPR titre, with 95% (25/27) and 98% (41/42) of shedding from respective sites occurring with RPR titres ≥1:16. 6.5% (13/200) of men with syphilis had concurrent detection of from both anal and oral sites: 9/13 with secondary syphilis, 7/9 of whom had anal lesions with a median duration of 30 days (range 7-180 days).

Conclusions: These data suggest load at the anus is higher than at the oral cavity and that a subset of men with secondary syphilis and prolonged anal lesions may be relatively infectious. Earlier detection and treatment of syphilis, when RPR titres are lower than 1:16, could potentially reduce infectiousness from anal and oral sites.
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http://dx.doi.org/10.1136/sextrans-2021-055370DOI Listing
May 2022

Using machine learning approaches to predict timely clinic attendance and the uptake of HIV/STI testing post clinic reminder messages.

Sci Rep 2022 05 24;12(1):8757. Epub 2022 May 24.

Central Clinical School, Monash University, Melbourne, Australia.

Timely and regular testing for HIV and sexually transmitted infections (STI) is important for controlling HIV and STI (HIV/STI) among men who have sex with men (MSM). We established multiple machine learning models (e.g., logistic regression, lasso regression, ridge regression, elastic net regression, support vector machine, k-nearest neighbour, naïve bayes, random forest, gradient boosting machine, XGBoost, and multi-layer perceptron) to predict timely (i.e., within 30 days) clinic attendance and HIV/STI testing uptake after receiving a reminder message via short message service (SMS) or email). Our study used 3044 clinic consultations among MSM within 12 months after receiving an email or SMS reminder at the Melbourne Sexual Health Centre between April 11, 2019, and April 30, 2020. About 29.5% [899/3044] were timely clinic attendance post reminder messages, and 84.6% [761/899] had HIV/STI testing. The XGBoost model performed best in predicting timely clinic attendance [mean [SD] AUC 62.8% (3.2%); F1 score 70.8% (1.2%)]. The elastic net regression model performed best in predicting HIV/STI testing within 30 days [AUC 82.7% (6.3%); F1 score 85.3% (1.8%)]. The machine learning approach is helpful in predicting timely clinic attendance and HIV/STI re-testing. Our predictive models could be incorporated into clinic websites to inform sexual health care or follow-up service.
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http://dx.doi.org/10.1038/s41598-022-12033-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9128330PMC
May 2022

Inhibitory Activity of Antibacterial Mouthwashes and Antiseptic Substances against Neisseria gonorrhoeae.

Antimicrob Agents Chemother 2022 06 17;66(6):e0004222. Epub 2022 May 17.

Department of Infectious Diseases, University of Melbourne at the Peter Doherty Institute, Melbourne, Victoria, Australia.

Improved treatment and prevention strategies, such as antimicrobial mouthwashes, may be important for addressing the public health threat of antimicrobial-resistant Neisseria gonorrhoeae. Here, we describe the activity of seven common antibacterial mouthwashes and antiseptics against N. gonorrhoeae isolates, incorporating the use of a human saliva test matrix. Our data demonstrate that antibacterial mouthwashes and antiseptics vary in their ability to inhibit the growth of N. gonorrhoeae and saliva may impact this inhibitory activity.
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http://dx.doi.org/10.1128/aac.00042-22DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9211398PMC
June 2022

Understanding the duration of tongue kissing among female sex workers for potential oropharyngeal-oropharyngeal gonorrhoea transmission.

Sex Transm Infect 2022 May 6. Epub 2022 May 6.

Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia.

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http://dx.doi.org/10.1136/sextrans-2022-055444DOI Listing
May 2022

Preferences for HIV Testing Services and HIV Self-Testing Distribution Among Migrant Gay, Bisexual, and Other Men Who Have Sex With Men in Australia.

Front Med (Lausanne) 2022 19;9:839479. Epub 2022 Apr 19.

Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia.

Background: In Australia, undiagnosed HIV rates are much higher among migrant gay, bisexual, or other men who have sex with men (GBMSM) than Australian-born GBMSM. HIV self-testing is a promising tool to overcome barriers to HIV testing and improve HIV testing uptake among migrant GBMSM. We compared the preferences for HIV testing services, including HIV self-testing, among migrant and Australian-born GBMSM.

Methods: Preferences were assessed two discrete choice experiments (DCEs). Participants were recruited between December 2017 and January 2018 using online and offline advertising and randomly assigned to complete one of two online DCE surveys. Migrant GBMSM were classified as being born in a country with a reciprocal healthcare agreement (RHCA) with Australia (providing free or subsided health care) or not. Latent class analysis and mixed logit models were used to explore heterogeneity in preferences.

Findings: We recruited 1,606 GBMSM, including 583 migrant men of whom 419 (72%) were born in non-RHCA countries. Most participants preferred a free or cheap oral test with higher accuracy and a shorter window period to facilitate early detection of infections. Cost was more important for men born in non-RHCA countries than for men from RHCA countries or Australia. All groups preferred accessing kits through online distributers or off the shelf purchasing from pharmacies. Men born in RHCA countries least preferred accessing HIV self-testing kits from a medical clinic, while more than half of men from non-RHCA countries most preferred sourcing kits from a clinic. Sex-on-premises venues were the least preferred location to access test kits among all groups. In addition, two latent class analyses explored heterogeneity in preferences among men from non-RHCA countries and we found four latent classes for HIV testing services and two latent classes for HIVST distribution.

Interpretation: Our findings emphasise the need for high-performing and low-cost HIV self-testing kits that are accessible from a variety of distribution points as a component of Australia's HIV response, especially for those who do not have access to free or subsidised health care in Australia.
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http://dx.doi.org/10.3389/fmed.2022.839479DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9063480PMC
April 2022

Correction to: Human Papillomavirus Antibody Levels Following Vaccination or Natural Infection Among Young Men Who Have Sex With Men.

Clin Infect Dis 2022 Apr 27. Epub 2022 Apr 27.

Central Clinical School, Faculty of Medicine, Nursing, and Health Sciences, Monash University, Melbourne, Victoria, Australia.

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http://dx.doi.org/10.1093/cid/ciac245DOI Listing
April 2022

Sampling time for self-taking an oropharyngeal swab for gonorrhoea and chlamydia testing.

Sex Health 2022 Apr 28. Epub 2022 Apr 28.

Self-taking oropharyngeal swabs for sexually transmitted infections such as gonorrhoea and chlamydia has become more common during the COVID-19 pandemic to minimise the risk to healthcare workers. However, there have been no standardised guidelines on sampling time for taking an oropharyngeal swab for gonorrhoea and chlamydia testing. We recruited 215 participants at the Melbourne Sexual Health Centre, Australia, between November 2021 and January 2022. We asked participants to report the time they spent on self-taking the oropharyngeal swab. The median self-taking sampling time was 8s (IQR=5-12), and the time did not differ between oropharyngeal gonorrhoea positivity (P=0.570) and oropharyngeal chlamydia positivity (P=0.457).
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http://dx.doi.org/10.1071/SH22034DOI Listing
April 2022

Sexual Activities and Changes in Condom Use in Group Sex Events Among Female Sex Workers in Melbourne, Australia.

Front Public Health 2022 6;10:834901. Epub 2022 Apr 6.

Melbourne Sexual Health Centre, Alfred Health, Melbourne, VIC, Australia.

Background: There are few studies investigating group sex among female sex workers (FSWs). This study aimed to examine the typical number of group sex participants, sexual activities and condom use in group sex among FSWs attending a sexual health clinic in Melbourne, Australia.

Methods: We conducted a cross-sectional survey between May 1, 2019 and March 13, 2020 among FSWs in Melbourne. Participants were asked whether they had participated in group sex (sex involving more than two participants) within the past 3 months, the size of the most recent group sex event, sexual activities they engaged in and condom use. It is unknown whether this was a paid or unpaid event in our study.

Results: Of the 247 FSWs surveyed, the mean age was 28.9 years and 51.8% were born in Australia. More than a quarter (27.5%, = 68) had had group sex in the past 3 months with the number of events ranging from 1 to 10 times. The median size of the group was 3 participants with one man and two women (including the FSW) being the most common combination. Kissing was the most common activity in group sex. Of 58 FSWs who had vaginal sex during group sex, 77.3% (51/58) reported their male partners always used condoms but 13.7% (7/51) of these did not change condoms between women.

Conclusion: This study finds that group sex is common among FSWs. Although condoms are always used during group sex, one in six men did not change their condoms between partners, which may increase STI transmission between partners.
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http://dx.doi.org/10.3389/fpubh.2022.834901DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9019149PMC
April 2022

Comparison of gastrointestinal side effects from different doses of azithromycin for the treatment of gonorrhoea.

J Antimicrob Chemother 2022 06;77(7):2011-2016

Central Clinical School, Monash University, Melbourne, Australia.

Objectives: Azithromycin is commonly used to treat Neisseria gonorrhoeae. We compared its gastrointestinal side effects using 1 g single, 2 g single or 2 g split (i.e. 1 g plus 1 g 6-12 h later) dosing, representing our clinic's changing guidelines over the study period.

Methods: We recruited consecutive sexual health clinic patients who received azithromycin (and 500 mg ceftriaxone) for uncomplicated gonorrhoea. Each patient received a text message 48 h after their attendance to complete a questionnaire.

Results: Patients received 1 g single (n = 271), 2 g single (218) or 2 g split (105) doses. Vomiting was less common for 1 g versus 2 g single dose [1.1% versus 3.7%; risk difference (RD): -2.6%; 95% CI: -0.2 to -5.4] and 2 g split versus 2 g single dose (0.9% versus 3.7%; RD: -2.8%; 95% CI: -0.3 to -5.8). Nausea was less common for 1 g versus 2 g single dose (13.7% versus 43.1%; RD: -29.5%; 95% CI: -21.7 to -37.2) and 2 g split versus 2 g single dose (16.4% versus 43.1%; RD: -26.8; 95% CI: -17.2 to -36.3). Diarrhoea was less common for 1 g versus 2 g single dose (25.5% versus 50.9%; RD: -25.5%; 95% CI: -17.0 to -33.9) and 2 g split versus 2 g single dose (30.9% versus 50.9%; RD: -20.0; 95% CI: -9.1 to -30.9). Almost all were willing to retake the same dosing for gonorrhoea in the future: 97% for 1 g single; 94% for 2 g single; and 97% for 2 g split dose.

Conclusions: Azithromycin 2 g split dose for gonorrhoea resulted in significantly less vomiting, nausea and diarrhoea than a 2 g single dose.
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http://dx.doi.org/10.1093/jac/dkac118DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9244214PMC
June 2022

Is SMS text or email more effective for recruitment into sexual health research?

Sex Transm Infect 2022 08 11;98(5):390. Epub 2022 Apr 11.

Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia.

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http://dx.doi.org/10.1136/sextrans-2022-055436DOI Listing
August 2022

Improving Access to Sexual Health Services in General Practice Using a Hub-and-Spoke Model: A Mixed-Methods Evaluation.

Int J Environ Res Public Health 2022 03 25;19(7). Epub 2022 Mar 25.

Melbourne Sexual Health Centre, Alfred Health, Melbourne 3053, Australia.

Improving access to sexual health services is critical in light of rising sexually transmitted infections (STIs). We evaluated a hub-and-spoke model for improving access to sexual health services in three general practices in Victoria, Australia. The primary outcome was the impact on HIV and STI (chlamydia, gonorrhoea, syphilis) testing. Segmented linear regression analysis was conducted to examine the trends in the total HIV/STI tests pre- (from January 2019 to June 2020) and post-implementation (from July 2020 to July 2021). We evaluated the feasibility and acceptability of integrating this model into the general practices using semi-structured individual interviews. There was a statistically significant rise in testing for HIV and STIs in all general practices: post-implementation, there was an increase of an average of 11.2 chlamydia tests per month ( = 0.026), 10.5 gonorrhoea tests per month ( = 0.001), 4.3 syphilis tests per month ( = 0.010), and 5.6 HIV tests per month ( = 0.010). Participants reported increases in knowledge level and confidence in offering STI testing and managing a greater variety of sexual health cases. This study demonstrates the feasibility of implementing a hub-and-spoke model to enable GPs to deliver sexual health care with support from a sexual health specialist service.
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http://dx.doi.org/10.3390/ijerph19073935DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8998128PMC
March 2022

A Machine-Learning-Based Risk-Prediction Tool for HIV and Sexually Transmitted Infections Acquisition over the Next 12 Months.

J Clin Med 2022 Mar 25;11(7). Epub 2022 Mar 25.

Melbourne Sexual Health Centre, Alfred Health, Melbourne, VIC 3053, Australia.

Background: More than one million people acquire sexually transmitted infections (STIs) every day globally. It is possible that predicting an individual's future risk of HIV/STIs could contribute to behaviour change or improve testing. We developed a series of machine learning models and a subsequent risk-prediction tool for predicting the risk of HIV/STIs over the next 12 months.

Methods: Our data included individuals who were re-tested at the clinic for HIV (65,043 consultations), syphilis (56,889 consultations), gonorrhoea (60,598 consultations), and chlamydia (63,529 consultations) after initial consultations at the largest public sexual health centre in Melbourne from 2 March 2015 to 31 December 2019. We used the receiver operating characteristic (AUC) curve to evaluate the model's performance. The HIV/STI risk-prediction tool was delivered via a web application.

Results: Our risk-prediction tool had an acceptable performance on the testing datasets for predicting HIV (AUC = 0.72), syphilis (AUC = 0.75), gonorrhoea (AUC = 0.73), and chlamydia (AUC = 0.67) acquisition.

Conclusions: Using machine learning techniques, our risk-prediction tool has acceptable reliability in predicting HIV/STI acquisition over the next 12 months. This tool may be used on clinic websites or digital health platforms to form part of an intervention tool to increase testing or reduce future HIV/STI risk.
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http://dx.doi.org/10.3390/jcm11071818DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8999359PMC
March 2022

Factors associated with group sex in heterosexual males and females attending a sexual health clinic in Melbourne, Australia: a cross-sectional survey.

Sex Health 2022 03;19(1):39-45

Melbourne Sexual Health Centre, Alfred Health, Melbourne, Vic. 3053, Australia; and Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Vic. 3004, Australia; and Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Vic. 3053, Australia.

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.
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http://dx.doi.org/10.1071/SH21224DOI Listing
March 2022

The diagnostic accuracy of pooled testing from multiple individuals for the detection of Chlamydia trachomatis and Neisseria gonorrhoeae: a systematic review.

Int J Infect Dis 2022 May 10;118:183-193. Epub 2022 Mar 10.

Central Clinical School, Monash University, Melbourne, Australia; Melbourne Sexual Health Centre, Alfred Health, Melbourne, Australia; Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom.

Objectives: Molecular testing for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) is costly. Therefore, we appraised the evidence regarding pooling samples from multiple individuals to test for CT/NG.

Methods: In this systematic review, we searched 5 databases (2000-2021). Studies were included if they contained primary data describing pooled testing. We calculated the pooled sensitivities and specificities for CT and NG using a bivariate mixed-effects logistic regression model.

Results: We included 22 studies: most were conducted in high-income countries (81.8%, 18 of 22), among women (73.3%, 17 of 22), and pooled urine samples (63.6%, 14 of 22). Eighteen studies provided 25 estimates for the meta-analysis of diagnostic accuracy, with data from 6,913 pooled specimens. The pooled sensitivity for CT was 98.4% (95% confidence intervals [CI]: 96.8-99.2%, I=77.5, p<0.001), and pooled specificity was 99.9% (95% CI: 99.6-100.0%, I=62.6, p<0.001). Only 2 studies reported pooled testing for NG, and both reported similarly high sensitivity and specificity as for CT. Sixteen studies provided data on the cost of pooling, reporting cost-savings ranging from 39%-90%.

Conclusions: Pooled testing from multiple individuals for CT is highly sensitive and specific compared with individual testing. This approach has the potential to reduce the cost of screening in populations for which single anatomic site screening is recommended.
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http://dx.doi.org/10.1016/j.ijid.2022.03.009DOI Listing
May 2022

HIV and STI Testing Preferences for Men Who Have Sex with Men in High-Income Countries: A Scoping Review.

Int J Environ Res Public Health 2022 03 4;19(5). Epub 2022 Mar 4.

Central Clinical School, Monash University, Melbourne, VIC 3800, Australia.

Regular testing for HIV and other sexually transmitted infections (STI) is recommended at least annually for sexually active men who have sex with men (MSM) in most high-income countries. To encourage regular use of HIV and STI testing and treatment services for MSM, we reviewed the literature to summarise the attributes of an HIV/STI testing service that MSM prefer. We conducted a scoping review, searching PubMed, EMBASE, PsycINFO and CINAHL in January 2020 for articles reporting primary data on the preferences of MSM (living in high-income countries) for HIV/STI testing services. Two reviewers independently screened titles and abstracts and any discrepancies were resolved by a third reviewer. We extracted data on the service attributes that MSM preferred and summarised these thematically using a socioecological framework. In total, 1464 publications were identified, 220 full texts were read and 57 were included in the final analysis. We found 21 articles addressing 'individual' attributes, 50 articles addressing 'service' attributes and 17 articles addressing 'societal' attributes. The key themes of preferences for HIV/STI testing services were: (1) the appeal of self-testing due to convenience and privacy; (2) the need to provide a variety of testing options; and (3) the influence of the testing experience, including confidentiality and privacy, tester characteristics and stigma. There were distinct patterns of preferences for subpopulations of MSM across studies, such as the preference of self-testing for young MSM, and of in-clinic testing for those who perceived themselves as high risk (i.e., with symptoms of STIs or exposed to a partner living with HIV). To make HIV/STI testing more accessible for MSM and encourage regular screening, it is important to address 'individual', 'service' and 'societal' attributes, such as enhancing the convenience of testing through self-testing, and providing a service that men feel comfortable and safe accessing. Furthermore, services should accommodate the preferences of diverse sub-populations within the MSM community.
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http://dx.doi.org/10.3390/ijerph19053002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8910668PMC
March 2022

Response time to an SMS link for a sexual health survey.

Sex Health 2022 Mar 10. Epub 2022 Mar 10.

In November 2021, clients attending the Melbourne Sexual Health Centre were invited to participate in the Annual Client Satisfaction Survey by receiving an SMS link at 5:15pm on the day they attended the clinic. We analysed the response time data and found that most (60%; 168/278) individuals responded to the survey during the time period 5:00-5:59pm, which wasaround the time when they received the SMS. We concluded that individuals responded quickly to the survey via an SMS link.
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http://dx.doi.org/10.1071/SH22021DOI Listing
March 2022
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