Publications by authors named "Fengyi Jin"

126 Publications

Qualitative Findings on the Impact of COVID-19 Restrictions on Australian Gay and Bisexual Men: Community Belonging and Mental Well-being.

Qual Health Res 2021 Aug 25:10497323211039204. Epub 2021 Aug 25.

La Trobe University, Bundoora, Victoria, Australia.

COVID-19 may threaten the already poor mental health outcomes of Australian gay and bisexual men and cut ties to important social/sexual networks and community. Qualitative research into the experiences of gay and bisexual men during COVID-19 regulations is currently sparse. We report on 489 responses to a qualitative free-text question asking Australian gay and bisexual men about the impacts of COVID-19 during April 2020. Issues pertinent to gay and bisexual men include lost ties to gay and bisexual social/sexual communities, spaces, and activities, which can reduce a sense of belonging to important sexual identity spaces, as well as significant mental well-being vulnerabilities. Reminiscing the collective response to HIV/AIDS, findings reinforce the value of gay and bisexual community organizations, spaces, and networks as supports for gay and bisexual men and emphasize the need for delivering mental health services.
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http://dx.doi.org/10.1177/10497323211039204DOI Listing
August 2021

Renal impairment in a large-scale HIV pre-exposure prophylaxis implementation cohort.

AIDS 2021 Jul 22. Epub 2021 Jul 22.

Central Clinical School, University of Sydney, Camperdown, NSW 2050, Australia Wagga Wagga Base Hospital, Wagga Wagga, NSW, 2650 Australia Kirby Institute, UNSW Sydney, Sydney, NSW 2052, Australia Department of Renal Medicine, Royal Prince Alfred Hospital, Camperdown, NSW, Australia Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Westmead, NSW 2145, Australia Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Westmead, NSW 2145, Australia Western Sydney Sexual Health Centre, Western Sydney Local Health District, Parramatta, NSW, 2150, Australia Holdsworth House Medical Practice, Darlinghurst, NSW 2010, Australia.

Background: HIV pre-exposure prophylaxis (PrEP) with fixed-dose tenofovir disoproxil fumarate (TDF) and emtricitabine has been associated with low rates of renal impairment in clinical trials. Large-scale PrEP implementation may result in higher rates, as the prevalence of associated risk factors may be higher than in trial populations.

Methods: A post-hoc analysis of EPIC-NSW, a large Australian multi-centre PrEP implementation trial for patients at high-risk of HIV infection. Participants were eligible for inclusion if they commenced PrEP between 1 March 2016 and of 30 April 2018, and had renal function assessed at baseline and at least once more before the censor date. The primary outcome was new onset renal impairment, defined as an estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73m2.

Results: 6808 participants were eligible for inclusion. Almost all were male (99%), with a median age of 35 years (IQR: 28 to 44). Approximately one-quarter (26%) had a baseline eGFR < 90 mL/min/1.73m2. Over a median follow-up period of 1.2 years (IQR 0.6 to 1.7), the rate of renal impairment was 5.8 episodes per 1000 person years (95%CI: 4.0 to 7.8). In multivariable Cox regression, there was higher risk of renal impairment in participants aged ≥50 years (HR 14.7, 95%CI: 5.0 to 43.3, p< 0.001) and those with an eGFR < 90 mL/min/1.73m2 (HR 28.9, 95%CI: 6.9 to 121.9) at baseline.

Conclusion: In a large-scale implementation study, TDF-containing PrEP was associated with a low risk of renal impairment overall, while older patients and those with pre-existing renal dysfunction were at substantially increased risk.
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http://dx.doi.org/10.1097/QAD.0000000000003035DOI Listing
July 2021

Long-term protection from HIV infection with oral HIV pre-exposure prophylaxis in gay and bisexual men: findings from the expanded and extended EPIC-NSW prospective implementation study.

Lancet HIV 2021 08 1;8(8):e486-e494. Epub 2021 Jul 1.

Clinic 16, St Leonards, NSW, Australia.

Background: Daily pre-exposure prophylaxis (PrEP) is effective in preventing HIV, but few long-term data are available on effectiveness and adherence in real-world settings. Here, we report trends in HIV incidence over 3 years in individuals at high risk who were prescribed PrEP in New South Wales (NSW), as well as adherence before the transition to subsidised PrEP.

Methods: Expanded PrEP Implementation in Communities-New South Wales (EPIC-NSW) was a pragmatic, prospective, single-arm, implementation study of daily, oral PrEP in 31 sites (sexual health clinics, general practices, and a hospital) in NSW, Australia. Eligible participants were HIV-negative adults (aged ≥18 years) who were at high risk of HIV infection as defined in local PrEP guidelines. Participants were prescribed coformulated (once-daily, oral tablet) tenofovir disoproxil fumarate (300 mg) and emtricitabine (200 mg) as HIV PrEP and were followed up with HIV testing, sexually transmitted infection testing, and PrEP dispensing. Originally planned for 3700 participants followed for 1 year, the study was expanded so that all eligible participants in the state could obtain PrEP and extended until publicly subsidised PrEP became available in Australia. The primary outcome was new HIV infection among all participants who were dispensed PrEP at least once and had at least one follow-up HIV test result. Adherence was estimated by medication possession ratio (MPR), defined as the proportion of PrEP pills dispensed in 90 days, assuming daily dosing. This study is registered with ClinicalTrials.gov, NCT02870790.

Findings: Between March 1, 2016, and April 30, 2018, we enrolled 9709 participants. 9596 participants were dispensed PrEP, of whom 9448 (98·3%) were gay or bisexual men. Participants were followed up until March 31, 2019, with at least one follow-up HIV test available in 9520 (99·2%) participants. Mean MPR declined from 0·93 to 0·64 from the first to the ninth quarter. There were 30 HIV seroconversions over 18 628 person-years, an incidence of 1·61 per 1000 person-years (95% CI 1·13-2·30). Being younger, living in a postcode with fewer gay men, reporting more risk behaviours at baseline, and having an MPR of less than 0·6 were each univariately associated with increased HIV incidence. In the final year of follow-up, when PrEP was mostly purchased rather than provided free by the study, HIV incidence remained low at 2·24 per 1000 person-years (1·46-3·44).

Interpretation: HIV incidence remained low over up to 3 years of follow-up, including during a transition from study-provided to publicly subsidised PrEP. In a setting of affordable PrEP and associated health-care services, very low HIV incidence of 1 to 2 per 1000 person-years can be maintained in gay and bisexual men who were previously at high risk.

Funding: New South Wales Ministry of Health, Australian Capital Territory Health Directorate, Gilead Sciences.
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http://dx.doi.org/10.1016/S2352-3018(21)00074-6DOI Listing
August 2021

Long-term protection from HIV infection with oral HIV pre-exposure prophylaxis in gay and bisexual men: findings from the expanded and extended EPIC-NSW prospective implementation study.

Lancet HIV 2021 08 1;8(8):e486-e494. Epub 2021 Jul 1.

Clinic 16, St Leonards, NSW, Australia.

Background: Daily pre-exposure prophylaxis (PrEP) is effective in preventing HIV, but few long-term data are available on effectiveness and adherence in real-world settings. Here, we report trends in HIV incidence over 3 years in individuals at high risk who were prescribed PrEP in New South Wales (NSW), as well as adherence before the transition to subsidised PrEP.

Methods: Expanded PrEP Implementation in Communities-New South Wales (EPIC-NSW) was a pragmatic, prospective, single-arm, implementation study of daily, oral PrEP in 31 sites (sexual health clinics, general practices, and a hospital) in NSW, Australia. Eligible participants were HIV-negative adults (aged ≥18 years) who were at high risk of HIV infection as defined in local PrEP guidelines. Participants were prescribed coformulated (once-daily, oral tablet) tenofovir disoproxil fumarate (300 mg) and emtricitabine (200 mg) as HIV PrEP and were followed up with HIV testing, sexually transmitted infection testing, and PrEP dispensing. Originally planned for 3700 participants followed for 1 year, the study was expanded so that all eligible participants in the state could obtain PrEP and extended until publicly subsidised PrEP became available in Australia. The primary outcome was new HIV infection among all participants who were dispensed PrEP at least once and had at least one follow-up HIV test result. Adherence was estimated by medication possession ratio (MPR), defined as the proportion of PrEP pills dispensed in 90 days, assuming daily dosing. This study is registered with ClinicalTrials.gov, NCT02870790.

Findings: Between March 1, 2016, and April 30, 2018, we enrolled 9709 participants. 9596 participants were dispensed PrEP, of whom 9448 (98·3%) were gay or bisexual men. Participants were followed up until March 31, 2019, with at least one follow-up HIV test available in 9520 (99·2%) participants. Mean MPR declined from 0·93 to 0·64 from the first to the ninth quarter. There were 30 HIV seroconversions over 18 628 person-years, an incidence of 1·61 per 1000 person-years (95% CI 1·13-2·30). Being younger, living in a postcode with fewer gay men, reporting more risk behaviours at baseline, and having an MPR of less than 0·6 were each univariately associated with increased HIV incidence. In the final year of follow-up, when PrEP was mostly purchased rather than provided free by the study, HIV incidence remained low at 2·24 per 1000 person-years (1·46-3·44).

Interpretation: HIV incidence remained low over up to 3 years of follow-up, including during a transition from study-provided to publicly subsidised PrEP. In a setting of affordable PrEP and associated health-care services, very low HIV incidence of 1 to 2 per 1000 person-years can be maintained in gay and bisexual men who were previously at high risk.

Funding: New South Wales Ministry of Health, Australian Capital Territory Health Directorate, Gilead Sciences.
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http://dx.doi.org/10.1016/S2352-3018(21)00074-6DOI Listing
August 2021

Adherence to daily HIV pre-exposure prophylaxis in a large-scale implementation study in New South Wales, Australia.

AIDS 2021 Oct;35(12):1987-1996

The Kirby Institute, UNSW Sydney.

Objectives: To examine patterns of long-term pre-exposure prophylaxis (PrEP) adherence and its association with HIV seroconversion in NSW, Australia.

Design: Population-based HIV PrEP implementation study.

Methods: Expanded PrEP Implementation in Communities in New South Wales was an open-label study of daily oral PrEP which recruited participants from March 2016 to April 2018. Adherence was measured using dispensing records. PrEP discontinuation was defined as an at least 120-day period without PrEP coverage. Long-term adherence patterns were identified using group-based trajectory modelling.

Results: Participants dispensed at least once (n = 9586) were almost all male (98.5%), identified as gay (91.3%), with a median age of 34 years (range: 18-86). Of the 6460 (67.4%) participants who had at least 9 months of follow-up since first dispensing, 1942 (30.1%) discontinued. Among these, 292 (15.0%) restarted later. Four distinct groups were identified ['Steep decline' in adherence (15.8%), 'Steady decline' (11.6%), 'Good adherence' (37.4%), and 'Excellent adherence' (35.2%)]. Older (P < 0.001) and gay-identified (P < 0.001) participants were more likely to have higher adherence, so were those living in postcodes with a higher proportion of gay-identified male residents (P < 0.001). Conversely, those who at baseline reported recent crystal methamphetamine use and had a recent diagnosis of sexually transmitted infection (STI) had lower adherence (P < 0.001). Overall HIV incidence was 0.94 per 1000 person-years (95% confidence interval: 0.49-1.81; n = 9) and was highest in the 'steep decline' group (5.45 per 1000 person-years; P = 0.001).

Conclusion: : About 15% of participants stopped PrEP during study follow-up and were at increased risk of HIV infection. They were more likely to be younger and report a recent STI or methamphetamine use prior to PrEP initiation.
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http://dx.doi.org/10.1097/QAD.0000000000002970DOI Listing
October 2021

Adherence to daily HIV pre-exposure prophylaxis in a large-scale implementation study in New South Wales, Australia.

AIDS 2021 Oct;35(12):1987-1996

The Kirby Institute, UNSW Sydney.

Objectives: To examine patterns of long-term pre-exposure prophylaxis (PrEP) adherence and its association with HIV seroconversion in NSW, Australia.

Design: Population-based HIV PrEP implementation study.

Methods: Expanded PrEP Implementation in Communities in New South Wales was an open-label study of daily oral PrEP which recruited participants from March 2016 to April 2018. Adherence was measured using dispensing records. PrEP discontinuation was defined as an at least 120-day period without PrEP coverage. Long-term adherence patterns were identified using group-based trajectory modelling.

Results: Participants dispensed at least once (n = 9586) were almost all male (98.5%), identified as gay (91.3%), with a median age of 34 years (range: 18-86). Of the 6460 (67.4%) participants who had at least 9 months of follow-up since first dispensing, 1942 (30.1%) discontinued. Among these, 292 (15.0%) restarted later. Four distinct groups were identified ['Steep decline' in adherence (15.8%), 'Steady decline' (11.6%), 'Good adherence' (37.4%), and 'Excellent adherence' (35.2%)]. Older (P < 0.001) and gay-identified (P < 0.001) participants were more likely to have higher adherence, so were those living in postcodes with a higher proportion of gay-identified male residents (P < 0.001). Conversely, those who at baseline reported recent crystal methamphetamine use and had a recent diagnosis of sexually transmitted infection (STI) had lower adherence (P < 0.001). Overall HIV incidence was 0.94 per 1000 person-years (95% confidence interval: 0.49-1.81; n = 9) and was highest in the 'steep decline' group (5.45 per 1000 person-years; P = 0.001).

Conclusion: : About 15% of participants stopped PrEP during study follow-up and were at increased risk of HIV infection. They were more likely to be younger and report a recent STI or methamphetamine use prior to PrEP initiation.
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http://dx.doi.org/10.1097/QAD.0000000000002970DOI Listing
October 2021

High Levels of Prevention-Effective Adherence to HIV PrEP: An Analysis of Substudy Data From the EPIC-NSW Trial.

J Acquir Immune Defic Syndr 2021 08;87(4):1040-1047

Kirby Institute, UNSW Sydney, Sydney, Australia.

Background: Preexposure prophylaxis (PrEP) prevents HIV infection but relies on good adherence at times of risk, termed "prevention-effective adherence." Most studies assess adherence without reference to sexual behaviur, making it challenging to determine if poor adherence coincides with HIV risk.

Setting: We examined data from a behavioral substudy of a large-scale PrEP implementation trial in New South Wales, Australia.

Methods: Trial participants completed optional brief quarterly surveys, reporting the number of pills taken and sexual behavior with male partners for each day of the "last full week" before each survey. Condomless sex (CLS) was defined as "higher risk" for HIV when with HIV-positive men with detectable/unknown viral loads or unknown HIV status men. Adequate PrEP protection was defined as ≥4 pills for participants assigned male sex at birth and ≥6 pills for participants assigned female sex at birth (including transgender men).

Results: Of 9596 participants dispensed PrEP, 4401 completed baseline and ≥1 follow-up survey. Participants reported on 12,399 "last full weeks": 7485 weeks (60.4%) involved CLS and 2521 weeks (33.7% of CLS-weeks) involved higher risk CLS. There were 103 weeks in which participants did not have adequate PrEP protection and had higher risk CLS: 4.1% of higher-risk CLS weeks (n = 103/2521), 1.4% of all CLS weeks (n = 103/7485), and 0.8% of all observed weeks (n = 103/12,399).

Conclusions: In a large PrEP trial, prevention-effective adherence to PrEP was very high at 99%. Our findings illustrate the importance of measuring pill-taking and sexual behavior in the same period so that prevention-effective adherence can be better estimated.
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http://dx.doi.org/10.1097/QAI.0000000000002691DOI Listing
August 2021

Changes in Sexual Behaviour Following PrEP Initiation Among Australian Gay and Bisexual Men in Relationships: Results from a Prospective Observational Study.

AIDS Behav 2021 Mar 29. Epub 2021 Mar 29.

Kirby Institute, UNSW Sydney, Level 6, Wallace Wurth Building, Sydney, NSW, 2052, Australia.

Few studies have examined changes in sexual behaviour following HIV pre-exposure prophylaxis (PrEP) initiation among gay, bisexual and other men who have sex with men (GBM) in relationships. In a national, online, prospective study of GBM in Australia, we compared sexual behaviours prior to and after PrEP initiation among HIV-negative and unknown-HIV-status men (recruited 2014-2017) not taking PrEP at baseline and who completed at least one six-monthly follow-up by July 2018. Among men in relationships who did not initiate PrEP (n = 339), we compared their most recent survey to their prior one, while among men in relationships who initiated PrEP (n = 81), we compared follow-ups before and after PrEP initiation. Among the 81 PrEP-initiators who were in a relationship both before and after initiation, the proportion reporting their regular partner was on PrEP increased from 8.3 to 44.4% (p < 0.001) and the proportion reporting receptive CLAIC increased from 27.2 to 44.4% (p = 0.009). Overall, men who initiated PrEP were more likely to be in a relationship with a partner on PrEP, and it appeared they started PrEP around the same time. Receptive CLAIC also became more common.
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http://dx.doi.org/10.1007/s10461-021-03232-wDOI Listing
March 2021

Sexual behaviours associated with incident high-risk anal human papillomavirus among gay and bisexual men.

Sex Transm Infect 2021 Mar 16. Epub 2021 Mar 16.

The Kirby Insitute, UNSW Sydney, Sydney, New South Wales, Australia.

Objective: High-risk human papillomavirus (HRHPV) causes anal cancer, which disproportionately affects gay and bisexual men (GBM). We examined sexual behaviours associated with incident anal HRHPV in an observational cohort study of GBM in Sydney, Australia.

Methods: GBM aged 35 years and above were enrolled in the Study of the Prevention of Anal Cancer. Detailed information on sexual practices in the last 6 months, including receptive anal intercourse (RAI) and non-intercourse receptive anal practices, was collected. Anal human papillomavirus (HPV) testing was performed at the baseline and three annual follow-up visits. Risk factors for incident HRHPV were determined by Cox regression using the Wei-Lin-Weissfeld method.

Results: Between 2010 and 2015, 617 men were recruited and 525 who had valid HPV results at baseline and at least one follow-up visit were included in the analysis. The median age was 49 years (IQR 43-56) and 188 (35.8%) were HIV-positive. On univariable analysis, incident anal HRHPV was associated with being HIV-positive (p<0.001), having a higher number of recent RAI partners regardless of condom use (p<0.001 for both), preference for the receptive position during anal intercourse (p=0.014) and other non-intercourse receptive anal sexual practices, including rimming, fingering and receptive use of sex toys (p<0.05 for all). In multivariable analyses, being HIV-positive (HR 1.46, 95% CI 1.09 to 1.85, p=0.009) and reporting condom-protected RAI with a higher number of sexual partners (p<0.001) remained significantly associated with incident HRHPV. When stratified by recent RAI, non-intercourse receptive anal practices were not associated with incident HRHPV in men who reported no recent RAI.

Conclusion: GBM living with HIV and those who reported RAI were at increased of incident anal HRHPV. Given the substantial risk of anal cancer and the difficulty in mitigating the risk of acquiring anal HRHPV, HPV vaccination should be considered among sexually active older GBM.

Trial Registration Number: ANZCTR365383.
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http://dx.doi.org/10.1136/sextrans-2020-054851DOI Listing
March 2021

Comparison of Trends in Rates of Sexually Transmitted Infections Before vs After Initiation of HIV Preexposure Prophylaxis Among Men Who Have Sex With Men.

JAMA Netw Open 2020 12 1;3(12):e2030806. Epub 2020 Dec 1.

Kirby Institute, University of New South Wales Sydney, Sydney, New South Wales, Australia.

Importance: There have been concerns that HIV preexposure prophylaxis (PrEP) may be associated with increases in sexually transmitted infections (STIs) because of subsequent reductions in condom use and/or increases in sexual partners.

Objective: To determine trends in STI test positivity among high-risk men who have sex with men (MSM) before and after the start of HIV PrEP.

Design, Setting, And Participants: A before-after analysis was conducted using a subcohort of a single-group PrEP implementation study cohort in New South Wales, Australia (Expanded PreEP Implementation in Communities in New South Wales [EPIC-NSW]), from up to 1 year before enrollment if after January 1, 2015, and up to 2 years after enrollment and before December 31, 2018. STI testing data were extracted from a network of 54 sexual health clinics and 6 primary health care clinics Australia-wide, using software to deidentify, encrypt, and anonymously link participants between clinics. A cohort of MSM dispensed PrEP for the first time during the study, with 2 or more STI tests in the prior year and who tested during follow-up, were included from the EPIC-NSW cohort of HIV-negative participants with high-risk sexual behavior. Data analysis was performed from June to December 2019.

Exposures: Participants were dispensed coformulated tenofovir disoproxil fumarate (300 mg) and emtricitabine (200 mg) as HIV PrEP.

Main Outcomes And Measures: The main outcome was STI, measured using test positivity, defined as the proportion of participants testing positive for an STI at least once per quarter of follow-up. Outcomes were calculated for Chlamydia trachomatis and Neisseria gonorrhoea by site of infection (anorectal, pharyngeal, urethral, or any) and for syphilis.

Results: Of the EPIC-NSW cohort of 9709 MSM, 2404 were included in the before-after analysis. The mean (SD) age of the participants was 36 (10.4) years, and 1192 (50%) were Australia-born. STI positivity was 52% in the year after PrEP (23.3% per quarter; 95% CI, 22.5%-24.2% per quarter) with no significant trend (mean rate ratio [RR] increase of 1.01 per quarter [95% CI, 0.99-1.02]; P = .29), compared with 50% positivity in the year prior to PrEP (20.0% per quarter [95% CI, 19.04%-20.95% per quarter]; RR for overall STI positivity, 1.17 [95% CI, 1.10-1.24]; P < .001), with an increase in quarterly STI positivity (mean RR of 1.08 per quarter, or an 8% increase per quarter [95% CI, 1.05-1.11]; P < .001; RR, 0.93 [95% CI, 0.90-0.96]; P < .001). Findings were similar when stratified by specific STIs and anatomical site.

Conclusions And Relevance: STI rates were high but stable among high-risk MSM while taking PrEP, compared with a high but increasing trend in STI positivity before commencing PrEP. These findings suggest the importance of considering trends in STIs when describing how PrEP use may be associated with STI incidence.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.30806DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7758809PMC
December 2020

Effect of age on the association between recreational drug use and sexual risk behaviour: a cross-sectional observational analysis.

Sex Health 2020 12;17(6):538-542

Sexual Health Service, Sydney Local Health District, Camperdown, NSW 2050, Australia; and The Kirby Institute, UNSW Australia, Sydney, NSW 2052, Australia; and Central Clinical School, The University of Sydney, Sydney, NSW 2006, Australia.

Recreational drug use (RDU) among gay and bisexual men (GBM) is associated with higher-risk sexual behaviours, however this has not been well defined among older GBM. We investigated the association between RDU and sexual behaviours among older GBM in Sydney, Australia. 617 GBM aged 35-79 years self-reported their RDU in the past 6 months and sexual behaviours. Age-stratified univariable associations between RDU and behaviour were examined. GBM aged 35-44 years were the most likely to report RDU, with rates decreasing with increasing age (Ptrend < 0.001). Associations between RDU and higher-risk sexual behaviours were most consistently found among GBM aged 35-54 years.
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http://dx.doi.org/10.1071/SH20115DOI Listing
December 2020

HIV, Immune Dysfunction, and the Natural History of Anal High-Risk Human Papillomavirus Infection in Gay and Bisexual Men.

J Infect Dis 2021 Jul;224(2):246-257

The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia.

Background: Incidence of anal cancer is highest in gay and bisexual men (GBM). Better understanding of the natural history of anal high-risk human papillomavirus (hrHPV) infection is needed for anal cancer prevention.

Methods: The Study of the Prevention of Anal Cancer was a 3-year study of Australian GBM, aged 35 years or older. We examined incidence, clearance, and risk factors for 13 hrHPV types at baseline and 3 annual visits.

Results: In 525 men with ≥ 2 visits, 348 (66.3%) acquired ≥ 1 incident hrHPV infection. HPV16 incidence rates were similar, but non-16 hrHPV incidence was higher in HIV-positive (51.8/100 person years [PY]) than HIV-negative men (36.5/100 PY, P < .001). Annual clearance rates of HPV16 (13.21/100 PY, 95% confidence interval, 10.53-16.56) were lower than for other hrHPV types. hrHPV clearance rates were not associated with HIV overall but were significantly lower in those with a lower nadir CD4 (<200 cells/µL) for HPV16 (P = .015) and other hrHPV types (P = .007).

Conclusions: Higher incidence of non-16 hrHPV types, coupled with lower clearance of non-16 hrHPV types in those with past impaired immune function, is consistent with the greater role of non-16 hrHPV in anal cancer in HIV-positive people.

Australia New Zealand Clinical Trials Registry: ANZCTR365383.
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http://dx.doi.org/10.1093/infdis/jiaa723DOI Listing
July 2021

Prevalence and incidence of hepatitis C virus infection in men who have sex with men: a systematic review and meta-analysis.

Lancet Gastroenterol Hepatol 2021 01 18;6(1):39-56. Epub 2020 Nov 18.

The Kirby Institute, University of New South Wales, Sydney, NSW, Australia.

Background: WHO has set targets for hepatitis C virus (HCV) elimination by 2030. We did a global systematic review of HCV prevalence and incidence in men who have sex with men (MSM) to provide updated estimates that can guide community education and public health policy.

Methods: We did a systematic review and meta-analysis of studies published and listed on MEDLINE or Embase between Jan 1, 2000, and Oct 31, 2019, including conference proceedings. Studies were eligible if they reported measures of HCV prevalence or HCV incidence (or both) among MSM. Studies that relied on participants' self-reported HCV status with no laboratory confirmation were excluded. Pooled HCV estimates in MSM were stratified by HIV status and by injecting drug use, then by WHO region and by income level. Random-effects meta-analysis was done to account for between-study heterogeneity and examined using the I statistic. Pooled HCV prevalence was also compared with HCV estimates in the general population and presented as prevalence ratios (PRs). In HIV-negative MSM, incidence estimates were stratified by use of HIV pre-exposure prophylaxis (PrEP). The systematic review was registered with PROSPERO, number CRD42020156262.

Findings: Of 1221 publications identified, 194 were deemed to be eligible and included in the systematic review and meta-analysis. Overall, the pooled HCV prevalence in MSM was 3·4% (95% CI 2·8-4·0; I=98·0%) and was highest in Africa (5·8%, 2·5-10·4) and South-East Asia (5·0%, 0·0-16·6). Globally, HCV prevalence was 1·5% (1·0-2·1) in HIV-negative MSM and 6·3% (5·3-7·5) in HIV-positive MSM. Compared with the general population, HCV prevalence was slightly higher in HIV-negative MSM (PR 1·58, 95% CI 1·14-2·01) and markedly higher (6·22, 5·14-7·29) in HIV-positive MSM. Pooled HCV prevalence was substantially higher in MSM who had ever injected drugs (30·2%, 22·0-39·0) or currently injected drugs (45·6%, 21·6-70·7) than in those who never injected drugs (2·7%, 2·0-3·6). In HIV-negative MSM, the pooled HCV incidence was 0·12 per 1000 person-years (95% CI 0·00-0·72) in individuals not on PrEP and 14·80 per 1000 person-years (9·65-20·95) in individuals on PrEP. HCV incidence in HIV-positive MSM was 8·46 per 1000 person-years (6·78-10·32).

Interpretation: HIV-positive MSM are at substantially increased risk of HCV. Overall, HIV-negative MSM had a slightly higher prevalence of HCV than the general population but had a lower prevalence than HIV-positive MSM. High HCV incidence in more recent PrEP studies suggests that as PrEP use increases, greater HCV transmission might occur. HCV burden in MSM varies considerably by region, which is likely to be associated with variation in the prevalence of injecting drug use and HIV.

Funding: World Health Organization.
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http://dx.doi.org/10.1016/S2468-1253(20)30303-4DOI Listing
January 2021

Substantial Decline in Use of HIV Preexposure Prophylaxis Following Introduction of COVID-19 Physical Distancing Restrictions in Australia: Results From a Prospective Observational Study of Gay and Bisexual Men.

J Acquir Immune Defic Syndr 2021 01;86(1):22-30

Kirby Institute, UNSW Sydney, Kensington, Australia.

Background: In response to the novel coronavirus disease (COVID-19) pandemic, Australia introduced public health and physical distancing restrictions in late March 2020. We investigated the impact of these restrictions on HIV preexposure prophylaxis (PrEP) use among Australian gay and bisexual men (GBM).

Methods: Participants in an ongoing online cohort study previously reported PrEP use from 2014 to 2019. In April 2020, 847 HIV-negative and untested participants completed questionnaires assessing changes in PrEP use as a result of COVID-19 public health measures. Binary logistic multiple regression was used to estimate adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) to compare changes in PrEP use behaviors.

Results: Among 847 men, mean age was 44.1 years (SD: 12.7). PrEP use rose from 4.9% in 2015 to 47.2% in 2020. Among those, 41.8% (n = 167) discontinued PrEP use during COVID-19 restrictions. Discontinuing PrEP during COVID-19 restrictions was independently associated with being less likely to have recently tested for HIV (aOR: 0.17; 95% CI: 0.09 to 0.34; P < 0.001) and less likely to report sex with casual partners (aOR: 0.28; 95% CI: 0.14 to 0.54; P < 0.001).

Conclusions: By April 2020, following the introduction of COVID-19 restrictions, GBM dramatically reduced PrEP use, coinciding with a reduction in sexual activity. Longer-term impacts of COVID-19 restrictions on sexual behaviors among GBM need to be monitored because they may foreshadow fluctuations in prevention coverage and risk of HIV infection. Our findings indicate a potential need for clear, targeted information about resumption of PrEP and on-demand optimal dosing regimens in response to ongoing changes in restrictions.
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http://dx.doi.org/10.1097/QAI.0000000000002514DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7727320PMC
January 2021

Prevalence and Association of Perianal and Intra-Anal Warts with Composite High-Grade Squamous Intraepithelial Lesions Among Gay and Bisexual Men: Baseline Data from the Study of the Prevention of Anal Cancer.

AIDS Patient Care STDS 2020 10 21;34(10):436-443. Epub 2020 Sep 21.

The Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia.

Human papillomavirus (HPV) causes anal warts and anal squamous cell carcinoma (SCC). A higher incidence of anal cancer has been found among individuals previously diagnosed with anogenital warts. We aimed to investigate the association between anal warts and the presumed anal SCC precursor high-grade squamous intraepithelial lesion (HSIL), among participants in the Study of the Prevention of Anal Cancer (SPANC). SPANC was a longitudinal study of anal HPV infections and related lesions among gay and bisexual men (GBM) age 35 years and older, in Sydney, Australia. Anal cytology and high-resolution anoscopy were performed. Logistic regression was used to investigate the association between clinically diagnosed anal warts and intra-anal composite-HSIL (cytology and/or histology) at the baseline visit. The prevalence of HSIL within biopsies from intra-anal warts was calculated. Laser capture microdissection (LCM) and HPV-genotyping was performed on HSIL lesions. Among 616 participants at study entry, 165 (26.8%) and 51 (8.3%) had intra-anal and perianal warts, respectively. Warts were associated with composite-HSIL, even after adjustment for HIV status, age, lifetime receptive anal intercourse partner number, and smoking (perianal: aOR 2.13, 95% CI 1.17-3.87,  = 0.013; intra-anal: aOR 1.69, 95% CI 1.16-2.46,  = 0.006). HSIL was detected in 24 (14.5%) of 165 biopsies from intra-anal warts. Of 17 HSIL lesions, 16 (94.1%) had high-risk HPV detected by LCM. Anal warts were common. Prevalent anal warts were associated with composite-HSIL. HSIL may be detected within biopsies of intra-anal warts. Anal warts may be a useful addition to risk stratification for HSIL among GBM.
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http://dx.doi.org/10.1089/apc.2020.0067DOI Listing
October 2020

Physical Distancing Due to COVID-19 Disrupts Sexual Behaviors Among Gay and Bisexual Men in Australia: Implications for Trends in HIV and Other Sexually Transmissible Infections.

J Acquir Immune Defic Syndr 2020 Nov;85(3):309-315

Kirby Institute, UNSW Sydney, Kensington, Australia.

Introduction: In March 2020, Australian state and federal governments introduced physical distancing measures alongside widespread testing to combat COVID-19. These measures may decrease people's sexual contacts and thus reduce the transmission of HIV and other sexually transmissible infections (STIs). We investigated the impact of physical distancing measures due to COVID-19 on the sexual behavior of gay and bisexual men in Australia.

Methods: Between April 4, 2020, and April 29, 2020, 940 participants in an ongoing cohort study responded to questions to measure changes in sexual behaviors during the COVID-19 pandemic. Men reported the date they become concerned about COVID-19 and whether they engaged in sexual behavior with regular or casual partners or "fuckbuddies" in the 6 months before becoming concerned about COVID-19 (hereafter referred to as "before COVID-19"), and following the date, they become concerned about COVID-19 (hereafter referred to as "since COVID-19"). Before and since COVID-19 was based on individual participants' own perceived date of becoming concerned about COVID-19.

Results: The mean age of was 39.9 years (SD: 13.4). Most participants (88.3%) reported sex with other men during the 6 months before COVID-19. Of the 587 men (62.4%) who reported sex with casual partners before COVID-19, 93 (15.8%) continued to do so in the period since COVID-19, representing a relative reduction of 84.2%.

Conclusion: Gay and bisexual men in Australia have dramatically reduced their sexual contacts with other men since COVID-19. These behavioral changes will likely result in short-term reductions in new HIV and STI diagnoses. If sexual health screenings are undertaken before resuming sexual activity, this could present a novel opportunity to interrupt chains of HIV and STI transmission.
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http://dx.doi.org/10.1097/QAI.0000000000002462DOI Listing
November 2020

Human Papillomavirus Genotypes in Anal High-Grade Squamous Intraepithelial Lesion (HSIL): Anal Intraepithelial Neoplasia Grades 2 (AIN2) and 3 (AIN3) Are Different.

Cancer Epidemiol Biomarkers Prev 2020 10 30;29(10):2078-2083. Epub 2020 Jul 30.

Centre for Women's Infectious Diseases, The Royal Women's Hospital, Parkville, Melbourne, Victoria, Australia.

Background: Anal high-grade squamous intraepithelial lesion (HSIL) can be histomorphologically categorized into anal intraepithelial neoplasia (AIN) grade 2 (AIN2) and grade 3 (AIN3). Different risk factors for these two categories have been described. We investigated whether there were also differences in lesion-specific human papillomavirus (HPV) genotypes.

Methods: The Study of the Prevention of Anal Cancer (SPANC) recruited 617 gay and bisexual men (GBM); 36% of participants were HIV positive. At baseline, 196 men (31.8%) had histologic HSIL lesions. Tissue was available for genotyping in 171, with a total of 239 HSIL lesions (183 AIN3 and 56 AIN2). Using laser capture microdissection, each lesion revealed a maximum of one genotype.

Results: High-risk HPV (HR-HPV) genotypes were found in 220 (92.1%) HSIL lesions, with no significant difference between AIN3 (93.4%) and AIN2 (87.5%). AIN3 lesions had significantly more HPV16 (42.1%) than AIN2 lesions (12.5%; < 0.001) and AIN2 lesions had significantly more non-16 HR-HPV types (75.0%) than AIN3 lesions (51.4%; = 0.002). These associations were similar for HIV-negative men with HPV16 in 51.1% AIN3 and 18.2% AIN2 ( = 0.001) and non-16 HR-HPV in 40.0% AIN3 and 75.8% AIN2 ( < 0.001). For HIV-positive men, HPV16 remained more frequently detected in AIN3 (33.3% vs. 4.4% for AIN2; = 0.004), but there was no difference between AIN3 and AIN2 for non-16 HR-HPV (62.4% vs. 73.9%; = 0.300).

Conclusions: As HPV16 has the strongest link with anal cancer, the subcategorization of HSIL may enable stratification of lesions for anal cancer risk and guide anal HSIL management.

Impact: Stratification of anal cancer risk by histologic HSIL grade.
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http://dx.doi.org/10.1158/1055-9965.EPI-20-0664DOI Listing
October 2020

Human Papillomavirus Genotypes in Anal High-Grade Squamous Intraepithelial Lesion (HSIL): Anal Intraepithelial Neoplasia Grades 2 (AIN2) and 3 (AIN3) Are Different.

Cancer Epidemiol Biomarkers Prev 2020 10 30;29(10):2078-2083. Epub 2020 Jul 30.

Centre for Women's Infectious Diseases, The Royal Women's Hospital, Parkville, Melbourne, Victoria, Australia.

Background: Anal high-grade squamous intraepithelial lesion (HSIL) can be histomorphologically categorized into anal intraepithelial neoplasia (AIN) grade 2 (AIN2) and grade 3 (AIN3). Different risk factors for these two categories have been described. We investigated whether there were also differences in lesion-specific human papillomavirus (HPV) genotypes.

Methods: The Study of the Prevention of Anal Cancer (SPANC) recruited 617 gay and bisexual men (GBM); 36% of participants were HIV positive. At baseline, 196 men (31.8%) had histologic HSIL lesions. Tissue was available for genotyping in 171, with a total of 239 HSIL lesions (183 AIN3 and 56 AIN2). Using laser capture microdissection, each lesion revealed a maximum of one genotype.

Results: High-risk HPV (HR-HPV) genotypes were found in 220 (92.1%) HSIL lesions, with no significant difference between AIN3 (93.4%) and AIN2 (87.5%). AIN3 lesions had significantly more HPV16 (42.1%) than AIN2 lesions (12.5%; < 0.001) and AIN2 lesions had significantly more non-16 HR-HPV types (75.0%) than AIN3 lesions (51.4%; = 0.002). These associations were similar for HIV-negative men with HPV16 in 51.1% AIN3 and 18.2% AIN2 ( = 0.001) and non-16 HR-HPV in 40.0% AIN3 and 75.8% AIN2 ( < 0.001). For HIV-positive men, HPV16 remained more frequently detected in AIN3 (33.3% vs. 4.4% for AIN2; = 0.004), but there was no difference between AIN3 and AIN2 for non-16 HR-HPV (62.4% vs. 73.9%; = 0.300).

Conclusions: As HPV16 has the strongest link with anal cancer, the subcategorization of HSIL may enable stratification of lesions for anal cancer risk and guide anal HSIL management.

Impact: Stratification of anal cancer risk by histologic HSIL grade.
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http://dx.doi.org/10.1158/1055-9965.EPI-20-0664DOI Listing
October 2020

The Natural History of Anal High-grade Squamous Intraepithelial Lesions in Gay and Bisexual Men.

Clin Infect Dis 2021 03;72(5):853-861

The Kirby Institute, University of New South Wales, New South Wales, Australia.

Background: Gay and bisexual men (GBM) are disproportionately affected by anal cancer. Prevention is hindered by incomplete understanding of the natural history of its precursor, anal high-grade squamous intraepithelial lesions (HSIL).

Methods: The Study of the Prevention of Anal Cancer, conducted between 2010 and 2018, enrolled human immunodeficiency virus (HIV)-positive and HIV-negative GBM aged ≥35 years. Anal cytology and high-resolution anoscopy (HRA) were performed at baseline and 3 annual visits. A composite HSIL diagnosis (cytology ± histology) was used. Cytological high-grade squamous intraepithelial lesions (cHSIL) incidence and clearance rates were calculated with 95% confidence intervals (CIs). Predictors were calculated using Cox regression with hazard ratios (HRs) and 95% CIs.

Results: Among 617 men, 220 (35.7%) were HIV-positive, median age 49 years. And 124 incident cHSIL cases occurred over 1097.3 person-years (PY) follow-up (11.3, 95% CI 9.5-13.5 per 100 PY). Significant bivariate predictors of higher incidence included age <45 years (HR 1.64, 95% CI 1.11-2.41), HIV positivity (HR 1.43, 95% CI .99-2.06), prior SIL diagnosis (P-trend < .001) and human papillomavirus (HPV)16 (HR 3.39, 2.38-4.84). Over 695.3 PY follow-up, 153 HSIL cleared (clearance 22.0, 95% CI 18.8-25.8 per 100 PY). Predictors were age < 45 years (HR 1.52, 1.08-2.16), anal intraepithelial neoplasia (AIN)2 rather than AIN3 (HR 1.79, 1.29-2.49), smaller lesions (HR 1.62, 1.11-2.36) and no persistent HPV16 (HR 1.72, 1.23-2.41). There was 1 progression to cancer (incidence 0.224, 95% CI .006-1.25 per 100 PY).

Conclusion: These data strongly suggest that not all anal HSIL detected in screening requires treatment. Men with persistent HPV16 were less likely to clear HSIL and are more likely to benefit from effective HSIL treatments.

Clinical Trials Registration: Australia New Zealand Clinical Trials Registry (ANZCTR365383).
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http://dx.doi.org/10.1093/cid/ciaa166DOI Listing
March 2021

HIV treatment and anal cancer: emerging clarity.

Lancet HIV 2020 04 25;7(4):e220-e221. Epub 2020 Feb 25.

The Kirby Institute, University of New South Wales, Sydney, NSW 2052, Australia.

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http://dx.doi.org/10.1016/S2352-3018(20)30027-8DOI Listing
April 2020

HIV treatment and anal cancer: emerging clarity.

Lancet HIV 2020 04 25;7(4):e220-e221. Epub 2020 Feb 25.

The Kirby Institute, University of New South Wales, Sydney, NSW 2052, Australia.

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http://dx.doi.org/10.1016/S2352-3018(20)30027-8DOI Listing
April 2020

HIV treatment and anal cancer: emerging clarity.

Lancet HIV 2020 04 25;7(4):e220-e221. Epub 2020 Feb 25.

The Kirby Institute, University of New South Wales, Sydney, NSW 2052, Australia.

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http://dx.doi.org/10.1016/S2352-3018(20)30027-8DOI Listing
April 2020

HIV treatment and anal cancer: emerging clarity.

Lancet HIV 2020 04 25;7(4):e220-e221. Epub 2020 Feb 25.

The Kirby Institute, University of New South Wales, Sydney, NSW 2052, Australia.

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http://dx.doi.org/10.1016/S2352-3018(20)30027-8DOI Listing
April 2020

Psychological and utility-based quality of life impact of screening test results for anal precancerous lesions in gay and bisexual men: baseline findings from the Study of the Prevention of Anal Cancer.

Sex Transm Infect 2020 05 1;96(3):177-183. Epub 2019 Aug 1.

Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia

Objective: Gay, bisexual and other men who have sex with men (GBMSM), particularly HIV-positive GBMSM, are at increased anal cancer risk compared with the general population. This study examined the psychological and quality of life (QoL) impact of receiving abnormal anal cancer screening results during the baseline visit of the Study of the Prevention of Anal Cancer (SPANC).

Methods: SPANC was a prospective cohort study of the natural history of anal human papillomavirus (HPV) and associated abnormalities in GBM aged 35 years and over. Participants completed questionnaires including aspects of health-related QoL (HR-QoL) and psychosocial functioning at baseline. Participants underwent procedures including an anal swab for cytology, and high-resolution anoscopy with biopsy of any possibly HPV-related abnormality. Questionnaires were readministered 2 weeks and 3 months after participants were given cytology and histology results. Perceived test result served as the study factor.

Results: Participants with perceived abnormal results (n=232) reported poorer HR-QoL (mean difference=1.8; p=0.004) and lower utility-based QoL (mean difference=0.02; p=0.018) 2 weeks after screening than individuals with perceived normal results (n=268). These differences did not persist at 3-month follow-up. A greater proportion of participants who perceived their results as abnormal reported feeling worse than usual about their anal health and anal cancer fear (p's<0.001), experienced more intrusive thoughts about their results (p's≤0.006) and felt more likely to develop cancer than other gay men their age (p's≤0.025) at both time points than those with perceived normal results.

Conclusions: Providing abnormal results may cause psychological distress and impact HR-QoL, with sustained intrusive thoughts, increased cancer worry and perceived cancer risk. The potential for psychological harm needs to be considered when implementing anal cancer screening programmes.
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http://dx.doi.org/10.1136/sextrans-2019-054098DOI Listing
May 2020

Awareness and knowledge of anal cancer in a community-recruited sample of HIV-negative and HIV-positive gay and bisexual men.

Sex Health 2019 06;16(3):240-246

HIV, Immunology & Infectious Diseases, St Vincent's Hospital, 390 Victoria Street, Darlinghurst, NSW 2010, Australia; and Corresponding author. Email:

Background Anal cancer disproportionately affects people with HIV infection, especially gay and bisexual men (GBM). The awareness and understanding of human papillomavirus (HPV) and anal cancer in a community-based sample of people living with HIV and GBM was explored to inform future evidence-based public health interventions.

Methods: Following consultation with affected communities and relevant healthcare professionals, a questionnaire was developed that assessed knowledge, understanding and experience of anal HPV, HPV vaccination, screening and perceived personal risk of anal cancer. Participants were recruited through HIV community and GBM organisations and anonymously completed the questionnaire online.

Results: Of 1660 questionnaires returned, 1574 were analysed from men, of whom 1535 (97.5%) identified as GBM and 15.7% reported being HIV-positive. Most (51.8%) of the HIV-positive men and 68.1% of HIV-negative or unknown men thought their risk of anal cancer was the same, or lower, than that of the general population. Only a small minority (12.5%) reported ever having talked to their doctor about anal HPV and/or anal cancer and 11.6% reported ever having had an anal cancer examination. Less than one-third (31.5%) had heard of HPV vaccination and only 2.9% of men recollected receiving HPV vaccination.

Conclusions: Knowledge and awareness of anal cancer was generally poor in a sample of HIV-positive and HIV-negative GBM. Specific information targeted at these people could potentially raise awareness, leading to earlier diagnosis, reduced burden of disease among GBM and less demands on the healthcare system. Young GBM might benefit from education regarding the importance of HPV vaccination.
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http://dx.doi.org/10.1071/SH18219DOI Listing
June 2019

Prevalence, incidence and predictors of anal , anal and syphilis among older gay and bisexual men in the longitudinal Study for the Prevention of Anal Cancer (SPANC).

Sex Transm Infect 2019 11 24;95(7):477-483. Epub 2019 Apr 24.

HIV Epidemiology and Prevention Program, The Kirby Institute, Sydney, New South Wales, Australia.

Objectives: Sexually transmitted infection (STI) notifications are increasing among older individuals. Many older gay and bisexual men (GBM) are sexually active and have multiple partners. We aimed to investigate the prevalence, incidence and predictors of anal chlamydia, anal gonorrhoea and syphilis in older GBM.

Methods: The Study for the Prevention of Anal Cancer (SPANC) was a prospective cohort study of HPV infections and related anal lesions among community-recruited GBM age ≥ 35 years in Sydney, Australia. At baseline and subsequent annual visits, recent STI diagnoses were collected via questionnaire ('interval diagnoses') and STI testing occurred ('study visit diagnoses'). Baseline STI prevalence was calculated using study visit diagnoses. Incidence of anal chlamydia and gonorrhoea was calculated using interval and study visit diagnoses. Syphilis incidence was calculated using interval diagnoses. Univariate and multivariate analysis using Cox proportional hazards were undertaken to investigate the association between risk factors and incident STI.

Results: Among 617 GBM, the median age was 49 years (range 35-79) and 35.8% (n=221) were HIV-positive. At baseline, STI prevalence was: anal chlamydia 2.3% (n=14); anal gonorrhoea 0.5% (n=3) and syphilis 1.0% (n=6). During 1428 person-years of follow-up (PYFU), the incidence (per 100 PYFU) of anal chlamydia, anal gonorrhoea and syphilis was 10.40 (95% CI 8.82 to 12.25), 9.11 (95% CI 7.64 to 10.85) and 5.47 (95% CI 4.38 to 6.84), respectively. In multivariate analysis, HIV-positivity, higher number of recent condomless receptive anal intercourse partners and baseline methamphetamine use were associated with each STI. Sex with 'fuck-buddies' was associated with anal chlamydia and gonorrhoea. Age was not associated with any STI.

Discussion: There was a high incidence of STI among SPANC participants. Age should not be used as a proxy for sexual risk and older GBM require a detailed sexual behaviour and recreational drug use history. Interventions that specifically target STI risk among older GBM should be considered.
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http://dx.doi.org/10.1136/sextrans-2019-054011DOI Listing
November 2019

Prevalence, incidence and predictors of anal , anal and syphilis among older gay and bisexual men in the longitudinal Study for the Prevention of Anal Cancer (SPANC).

Sex Transm Infect 2019 11 24;95(7):477-483. Epub 2019 Apr 24.

HIV Epidemiology and Prevention Program, The Kirby Institute, Sydney, New South Wales, Australia.

Objectives: Sexually transmitted infection (STI) notifications are increasing among older individuals. Many older gay and bisexual men (GBM) are sexually active and have multiple partners. We aimed to investigate the prevalence, incidence and predictors of anal chlamydia, anal gonorrhoea and syphilis in older GBM.

Methods: The Study for the Prevention of Anal Cancer (SPANC) was a prospective cohort study of HPV infections and related anal lesions among community-recruited GBM age ≥ 35 years in Sydney, Australia. At baseline and subsequent annual visits, recent STI diagnoses were collected via questionnaire ('interval diagnoses') and STI testing occurred ('study visit diagnoses'). Baseline STI prevalence was calculated using study visit diagnoses. Incidence of anal chlamydia and gonorrhoea was calculated using interval and study visit diagnoses. Syphilis incidence was calculated using interval diagnoses. Univariate and multivariate analysis using Cox proportional hazards were undertaken to investigate the association between risk factors and incident STI.

Results: Among 617 GBM, the median age was 49 years (range 35-79) and 35.8% (n=221) were HIV-positive. At baseline, STI prevalence was: anal chlamydia 2.3% (n=14); anal gonorrhoea 0.5% (n=3) and syphilis 1.0% (n=6). During 1428 person-years of follow-up (PYFU), the incidence (per 100 PYFU) of anal chlamydia, anal gonorrhoea and syphilis was 10.40 (95% CI 8.82 to 12.25), 9.11 (95% CI 7.64 to 10.85) and 5.47 (95% CI 4.38 to 6.84), respectively. In multivariate analysis, HIV-positivity, higher number of recent condomless receptive anal intercourse partners and baseline methamphetamine use were associated with each STI. Sex with 'fuck-buddies' was associated with anal chlamydia and gonorrhoea. Age was not associated with any STI.

Discussion: There was a high incidence of STI among SPANC participants. Age should not be used as a proxy for sexual risk and older GBM require a detailed sexual behaviour and recreational drug use history. Interventions that specifically target STI risk among older GBM should be considered.
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November 2019

HIV Pre-exposure Prophylaxis (PrEP) Uptake Among Gay and Bisexual Men in Australia and Factors Associated With the Nonuse of PrEP Among Eligible Men: Results From a Prospective Cohort Study.

J Acquir Immune Defic Syndr 2019 07;81(3):e73-e84

The Kirby Institute, UNSW Sydney, Sydney, Australia.

Background: HIV pre-exposure prophylaxis (PrEP) is a highly effective biomedical HIV prevention strategy, yet some gay and bisexual men (GBM) who are eligible to access PrEP are not using it. We report the incidence of PrEP uptake, factors predicting its initiation, and identify characteristics associated with nonuptake of PrEP among Australian GBM who meet the eligibility criteria.

Methods: The Following Lives Undergoing Change (Flux) Study is a national, online, prospective observational study among GBM focusing on licit and illicit drug use. Participants (N = 1257) responded to baseline and 6-monthly follow-up questionnaires. Incidence per 100 person-years and incidence rate ratios of PrEP initiation are presented. Multivariate Poisson regression was used to examine associations with PrEP initiation and logistic regression to examine associations with nonuptake of PrEP among eligible GBM.

Results: Among GBM who met the eligibility criteria, 69.8% of men did not commence PrEP. Factors independently associated with nonuptake of PrEP were younger age, living in an Australian state without a PrEP trial, lower social engagement with other gay men, less use of illicit party drugs or use of illicit party drugs for sex, and less likely to have engaged in HIV sexual risk behaviors such as group sex or any condomless anal intercourse.

Conclusions: Despite meeting formal eligibility criteria for PrEP, men who were relatively less sexually active or less socially connected were less likely to initiate PrEP. Men who did not initiate PrEP may assess their risk as insufficient relative to others to warrant using PrEP because they engaged in less frequent "risky" behaviors.
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http://dx.doi.org/10.1097/QAI.0000000000002047DOI Listing
July 2019

Incidence and time trends of anal cancer among people living with HIV in Australia.

AIDS 2019 07;33(8):1361-1368

The Kirby Institute.

Background: Anal cancer incidence increased markedly in people living with HIV (PLWHIV) after the introduction of HAART, but in a few setting settings, recent declines have been reported. We report the incidence and time trends of anal cancer in PLWHIV in Australia.

Study Design: A data linkage study between the National HIV Registries and the Australian Cancer Database.

Methods: Cases of anal squamous cell carcinoma (ASCC) in Australians aged 16 years and above diagnosed with HIV between 1982 and 2012 were identified. Standardized incidence ratios (SIRs) were calculated to compare incidence with that of the general population. Poisson regression models were developed to describe the time trends of ASCC over time and to compare ASCC risk within subgroups of PLWHIV.

Results: Among 28 696 individuals, a total of 129 cases of ASCC were identified. The crude incidence was 36.3 per 100 000 person-years and it increased sharply from 14.8 to 62.1 per 100 000 person-years between 1982-1995 and 2009-2012 (P trend <0.001). The SIR was 35.3 (95% confidence interval 29.5-42.0), and there was an inverse association between SIR and increasing age (P trend <0.001). In multivariate analyses, ASCC incidence was significantly higher in recent years (P trend <0.001), in those who acquired HIV through male homosexual contact (P = 0.002), and in those who had a history of AIDS (P < 0.001).

Conclusion: PLWHIV in Australia are at markedly higher risk of anal cancer. Unlike in some industrialized countries with a mature HIV epidemic, the incidence of anal cancer is still increasing in this population in Australia.
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http://dx.doi.org/10.1097/QAD.0000000000002218DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7141812PMC
July 2019
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