Publications by authors named "Martin Holt"

165 Publications

Sustaining success: a qualitative study of gay and bisexual men's experiences and perceptions of HIV self-testing in a randomized controlled trial.

BMC Public Health 2021 Nov 9;21(1):2048. Epub 2021 Nov 9.

Kirby Institute, UNSW Sydney, Sydney, NSW, Australia.

Background: HIV self-testing was proved as an effective tool for increasing testing frequency in gay and bisexual men at high risk of infection. Questions remain about understanding why HIVST encouraged testing and how such success can be translated to programmatic implementation.

Methods: We conducted a qualitative investigation of how FORTH participants experienced and perceived HIVST. Stratified sampling was used to recruit gay and bisexual men participating in the FORTH HIVST intervention to take part in interviews, focusing on infrequent testers and those who had received inaccurate HIVST results.

Results: Our analysis identified several prominent themes organized into two overarching domains from the 15 interviews: (i) aspects of HIVST contributing to HIV testing frequency, and (ii) sustaining HIVST into the future. Participants also believed that their use of HIVST in the future would depend on the test kit's reliability, particularly when compared with highly reliable clinic-based testing.

Conclusion: HIVST increases the frequency of HIV testing among gay and bisexual men due, in part, to the practical, psychological, and social benefits it offers. To capitalize fully on these benefits, however, strategies to ensure the availability of highly reliable HIVST are required to sustain benefits beyond the confines of a structured research study.
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http://dx.doi.org/10.1186/s12889-021-12011-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8576944PMC
November 2021

The longer-term effects of access to HIV self-tests on HIV testing frequency in high-risk gay and bisexual men: follow-up data from a randomised controlled trial.

Lancet Reg Health West Pac 2021 Sep 15;14:100214. Epub 2021 Jul 15.

Kirby Institute, UNSW Sydney, Sydney, NSW, Australia.

Background: A wait-list randomised controlled trial in Australia (FORTH) in high-risk gay and bisexual men (GBM) showed access to free HIV self-tests (HIVSTs) doubled the frequency of HIV testing in year 1 to reach guideline recommended levels of 4 tests per year, compared to two tests per year in the standard-care arm (facility-based testing). In year 2, men in both arms had access to HIVSTs. We assessed if the effect was maintained for a further 12 months.

Methods: Participants included GBM reporting condomless anal intercourse or > 5 male partners in the past 3 months. We included men who had completed at least one survey in both year 1 and 2 and calculated the mean tests per person, based on the validated self-report and clinic records. We used Poisson regression and random effects Poisson regression models to compare the overall testing frequency by study arm, year and testing modality (HIVST/facility-based test).

Findings: Overall, 362 men completed at least one survey in year 1 and 343 in year 2. Among men in the intervention arm (access to HIVSTs in both years), the mean number of HIV tests in year 2 (3⋅7 overall, 2⋅3 facility-based tests, 1⋅4 HIVSTs) was lower compared to year 1 (4⋅1 overall, 1⋅7 facility-based tests, 2⋅4 HIVSTs) (RR:0⋅84, 95% CI:0⋅75-0⋅95, p=0⋅002), but higher than the standard-care arm in year 1 (2⋅0 overall, RR:1⋅71, 95% CI:1⋅48-1.97, p<0⋅001). Findings were not different when stratified by sociodemographic characteristics or recent high risk sexual history.

Interpretation: In year 2, fewer HIVSTs were used on average compared to year 1, but access to free HIVSTs enabled more men to maintain higher HIV testing frequency, compared with facility-based testing only. HIV self-testing should be a key component of HIV testing and prevention strategies.

Funding: This work was supported by grant 568971 from the National Health and Medical Research Council of Australia.
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http://dx.doi.org/10.1016/j.lanwpc.2021.100214DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8484892PMC
September 2021

Rational design of mechanically robust Ni-rich cathode materials via concentration gradient strategy.

Nat Commun 2021 Oct 15;12(1):6024. Epub 2021 Oct 15.

Chemical Sciences and Engineering Division, Argonne National Laboratory, Lemont, IL, 60439, USA.

Mechanical integrity issues such as particle cracking are considered one of the leading causes of structural deterioration and limited long-term cycle stability for Ni-rich cathode materials of Li-ion batteries. Indeed, the detrimental effects generated from the crack formation are not yet entirely addressed. Here, applying physicochemical and electrochemical ex situ and in situ characterizations, the effect of Co and Mn on the mechanical properties of the Ni-rich material are thoroughly investigated. As a result, we successfully mitigate the particle cracking issue in Ni-rich cathodes via rational concentration gradient design without sacrificing the electrode capacity. Our result reveals that the Co-enriched surface design in Ni-rich particles benefits from its low stiffness, which can effectively suppress the formation of particle cracking. Meanwhile, the Mn-enriched core limits internal expansion and improve structural integrity. The concentration gradient design also promotes morphological stability and cycling performances in Li metal coin cell configuration.
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http://dx.doi.org/10.1038/s41467-021-26290-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8520018PMC
October 2021

Resourcefulness of homeless young people who practise sex work in Pakistan: a qualitative study.

Sex Health 2021 Nov;18(5):378-384

Centre for Social Research in Health, The University of New South Wales, Sydney, NSW, Australia.

Background Many homeless young people in Pakistan use sex work as a way to generate income, particularly if they have few other options for work. Because it is highly stigmatised, little attention has been paid to the strategies homeless young people use to practise sex work, and what this suggests about their capacities and strengths. Methods Semi-structured interviews were conducted with 29 homeless young people (aged 16-25years) from Rawalpindi, Pakistan, including nine cisgender heterosexual men, six cisgender heterosexual women, seven cisgender gay men, and seven transgender heterosexual women. Results Participants sought memberships in street-based peer groups where financial gains were contingent on dancing and sex work. To practise their work successfully, participants learned novel skills and mobilised material resources available to them on the streets. Participants talked about how they acquired and benefitted from skills related to beautification, dancing, communication, and sexual services to achieve the necessary standards for entertainment and sex work. Access to material resources like makeup, clothes, rented rooms, mobile phones and condoms made dancing and sex work possible and safer for participants. Conclusions Participants' improvisation with limited resources on the streets has important implications for policy and programs. Showcasing the resourcefulness and capacities of young people encourages a different way of thinking about them. This potential could be utilised in productive ways if they were given the chance to receive mainstream and technical education, better health support and access to the formal job market.
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http://dx.doi.org/10.1071/SH21024DOI Listing
November 2021

Clinician imaginaries of HIV PrEP users in and beyond the gay community in Australia.

Cult Health Sex 2021 Sep 10:1-15. Epub 2021 Sep 10.

Centre for Social Research in Health, UNSW Sydney, Sydney, Australia.

Through the development and implementation of HIV pre-exposure prophylaxis (PrEP), the characteristics of PrEP users have been configured in a range of ways. Drawing on the concept of 'imaginaries', we consider how clinicians imagine PrEP users and related communities. We conducted 28 semi-structured interviews in 2019-2020 with PrEP-providing clinicians based in New South Wales and Western Australia. Participants included general practitioners, sexual health nurses and sexual health doctors. We inductively developed three themes through a reflexive thematic analysis: 'PrEP users as 99% gay men/MSM', 'The informed and connected PrEP user', and 'Condom users in the PrEP era'. Participants imagined PrEP users primarily as gay men, and so we focused on how gay community was imagined in relation to PrEP users. Users were imagined as supporting one another to use PrEP effectively, but some were imagined as threatening norms of condom use amongst gay community. Analysing clinician imaginaries of PrEP users reveals insight into how clinicians speculate about and engage with changing community norms related to condom use and accessing PrEP. These imaginaries reveal ongoing tensions about who is believed to be best suited to PrEP, and PrEP's impact on norms of conduct in imagined biosocial communities like gay men.
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http://dx.doi.org/10.1080/13691058.2021.1957152DOI Listing
September 2021

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 11 25;31(13):2414-2425. 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
November 2021

The Complexities of Categorizing Gender: A Hierarchical Clustering Analysis of Data from the First Australian Trans and Gender Diverse Sexual Health Survey.

Transgend Health 2021 Apr 16;6(2):74-81. Epub 2021 Apr 16.

Kirby Institute, UNSW Sydney, Sydney, Australia.

This study used self-reported gender among trans and gender diverse people in Australia to identify and describe broad, overarching gender categories that encompass the expansive ways in which gender can be defined and expressed. Data were collected as part of the Australian Trans and Gender Diverse Sexual Health Survey hosted in October 2018. Participant self-identification with nonexclusive gender categories were analyzed using algorithm-based hierarchical clustering; factors associated with gender clusters were identified using logistic regression analyses. Usable data were collected from 1613 trans and gender diverse people in Australia, of whom 71.0% used two or more labels to describe their gender. Three nonexclusive clusters were identified: (i) women/trans women, (ii) men/trans men, and (iii) nonbinary. In total, 33.8% of participants defined their gender in exclusively binary terms (i.e., men/women, trans men/trans women), 40.1% in nonbinary terms, and 26.0% in both binary and nonbinary terms. The following factors were associated with selecting nonbinary versus binary gender labels: presumed female gender at birth (adjusted odds ratio [aOR]=2.02, 95% confidence interval [CI]=1.60-2.54, <0.001), having a majority of sexual and/or gender minority friends (aOR=2.46, 95% CI=1.49-3.10, <0.001), and having spent more than half of one's life identifying as trans and/or gender diverse (aOR=1.75, 95% CI=1.37-2.23, <0.001). Trans and gender diverse people take up diverse and often multiple gender labels, which can be broadly categorized as binary and nonbinary. Systems of health care and research must be adapted to include nonbinary people while remaining amenable to further adaptation.
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http://dx.doi.org/10.1089/trgh.2020.0050DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8364001PMC
April 2021

Cisgenderism and transphobia in sexual health care and associations with testing for HIV and other sexually transmitted infections: Findings from the Australian Trans & Gender Diverse Sexual Health Survey.

PLoS One 2021 21;16(7):e0253589. Epub 2021 Jul 21.

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

Transgender and gender diverse people have unique risks and needs in the context of sexual health, but little is known about sexual health care for this population. In 2018, a national, online survey of sexual health and well-being was conducted with trans and gender diverse people in Australia (n = 1,613). Data from this survey were analysed to describe uptake of sexual health care and experiences of interpersonal and structural cisgenderism and transphobia. Experiences of cisgenderism and transphobia in sexual health care were assessed using a new, four-item scale of 'gender insensitivity', which produced scores ranging from 0 (highly gender sensitive) to 4 (highly gender insensitive). Logistic and linear regression analyses were conducted to determine if experiences of gender insensitivity in sexual health care were associated with uptake and frequency of HIV/STI testing in the 12 months prior to participation. Trans and gender diverse participants primarily accessed sexual health care from general practice clinics (86.8%), followed by publicly funded sexual health clinics (45.6%), community-based services (22.3%), and general hospitals (14.9%). Experiences of gender insensitivity were common overall (73.2% of participants reported ≥2 negative experiences) but most common in hospitals (M = 2.9, SD = 1.3) and least common in community-based services (M = 1.3, SD = 1.4; p<0.001). When controlling for sociodemographic factors, social networks, general access to health care, and sexual practices, higher levels of gender insensitivity in previous sexual health care encounters were associated with a lower likelihood of recent HIV/STI testing (adjusted prevalence ratio = 0.92, 95% confidence interval [CI]:091,0.96, p<0.001) and less-frequent HIV/STI testing (B = -0.07, 95%CI:-0.10,-0.03, p = 0.007). Given the high rates of HIV and other STIs among trans and gender diverse people in Australia and overseas, eliminating cisgenderism and transphobia in sexual health care may help improve access to diagnostic testing to reduce infection rates and support the overall sexual health and well-being of these populations.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0253589PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8294496PMC
November 2021

Preferences for Current and Future PrEP Modalities Among PrEP-Experienced Gay and Bisexual Men in Australia.

AIDS Behav 2021 Jun 17. Epub 2021 Jun 17.

The Kirby Institute, UNSW Sydney, Sydney, NSW, 2052, Australia.

Alternatives to daily dosing of HIV pre-exposure prophylaxis (PrEP) are continuing to emerge. From October 2019 to March 2020, we conducted an online survey of PrEP-experienced gay and bisexual men in Australia about interest in and preference for four different PrEP modalities: daily dosing, event-driven dosing, long-acting injectable (LAI)-PrEP and subdermal PrEP implants. Using data from 1477 participants, we measured interest and preference of different modalities using multivariate logistic regression. High proportions of participants were interested in LAI-PrEP (59.7%), daily PrEP (52.0%), PrEP implants (45.3%) and event-driven PrEP (42.8%). LAI-PrEP was the most frequently selected preference (30.5%), followed by PrEP implants (26.3%), daily PrEP (21.4%) and event-driven PrEP (21.2%). Higher interest and preference for non-daily PrEP modalities were associated with being concerned about side effects and perceived difficulties with daily adherence. As novel modalities emerge, attitudes to them should be considered in public health messaging to facilitate informed decision-making.
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http://dx.doi.org/10.1007/s10461-021-03344-3DOI Listing
June 2021

Treatment outcomes of a lesbian, gay, bisexual, transgender and queer alcohol and other drug counselling service in Australia: A retrospective analysis of client records.

Drug Alcohol Rev 2021 Nov 5;40(7):1358-1368. Epub 2021 May 5.

Centre for Social Research in Health, UNSW Sydney, Sydney, Australia.

Introduction: Substance use disorders are more prevalent among lesbian, gay, bisexual, transgender and queer (LGBTQ) people than among their heterosexual and cisgender peers. There has been limited alcohol and other drug (AOD) treatment research with LGBTQ people outside of North America. This study aimed to examine the treatment outcomes of clients attending a LGBTQ-specific AOD counselling service in Australia (ACON's Substance Support Service) and compare their client profile and treatment outcomes with LGBTQ and non-LGBTQ clients of similar mainstream services.

Methods: This study was a retrospective analysis of the health records of 284 ACON clients and 1011 clients of five mainstream services in 2016-2018. Clients completed clinical interviews at treatment entry and periodically throughout treatment and completed measures of substance use, severity of dependence, psychological distress and quality of life.

Results: Most ACON clients were seeking treatment for methamphetamine (58%) and alcohol use (26%). Among ACON clients, there were reductions in past month days of substance use and severity of dependence between treatment entry and counselling sessions 4, 8 and 12 (all P < 0.001). There were statistically significant reductions in psychological distress and improved quality of life among ACON clients. Despite ACON and the mainstream services having similar treatment approaches, their client profiles were markedly different in terms of sociodemographic characteristics, substance use and source of referral, which precluded comparison of treatment outcomes.

Discussion And Conclusions: ACON's clients showed reduced substance use and improved psychosocial wellbeing during treatment. The findings support the provision of LGBTQ-specific AOD services.
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http://dx.doi.org/10.1111/dar.13303DOI Listing
November 2021

Challenges of providing HIV pre-exposure prophylaxis across Australian clinics: qualitative insights of clinicians.

Sex Health 2021 05;18(2):187-194

Centre for Social Research in Health, UNSW Sydney, New South Wales, Australia.

Background HIV pre-exposure prophylaxis (PrEP) has been rapidly implemented in Australia, initially through restricted access in demonstration studies, and then through prescribing across sexual health clinics and general practice settings. In 2018, PrEP was publicly subsidised for people with Medicare (universal health insurance for citizens, permanent residents and those from countries with reciprocal arrangements). There is little research examining the experiences of PrEP providers in Australia, and existing research has been primarily conducted before public subsidy.

Methods: In this qualitative study, we examine the challenges that have emerged for PrEP-providing clinicians after public subsidy for PrEP was introduced. We conducted 28 semi-structured interviews in 2019-20 with PrEP providers in two Australian states, and analysed data thematically. Participants included general practitioners (GPs), sexual health nurses and sexual health physicians.

Results: Sexual health services have been reconfigured to meet changing patient demand, with an emphasis on ensuring equitable financial access to PrEP. Restrictions to nurse-led PrEP frustrated some participants, given that nurses had demonstrated competence during trials. GPs were believed to be less effective at prescribing PrEP, but GP participants themselves indicated that PrEP was an easy intervention, but difficult to integrate into general practice. Participants expressed discomfort with on-demand PrEP.

Conclusions: Our findings indicate that supporting ways for patients without Medicare to access PrEP inexpensively, advocating for nurse-led PrEP, and developing guidelines adapted to general practice consultations could ensure that PrEP is delivered more effectively and equitably. Additionally, PrEP providers require encouragement to build confidence in providing on-demand PrEP.
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http://dx.doi.org/10.1071/SH20208DOI Listing
May 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 Nov 29;25(11):3704-3711. 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
November 2021

Stigma as understood by key informants: A social ecological approach to gay and bisexual men's use of crystal methamphetamine for sex.

Int J Drug Policy 2021 08 26;94:103229. Epub 2021 Mar 26.

Centre for Social Research in Health, UNSW Sydney, Sydney, NSW, 2052, Australia.

This paper explores the perceptions of 35 key informants (KIs) in a range of relevant health and community sectors regarding the stigmatisation of GBM's crystal methamphetamine use and sexual practice with view to informing stigma reduction efforts. A modified social ecological model was used to guide analysis and interpretation. At the individual level, KI participants indicated that crystal methamphetamine was used by some GBM to reduce the effects of internalised stigma. At the network level, KIs thought that some drugs and types of use could attract more stigma and that this could erode support from GBM networks for men who use crystal. KIs felt that few "mainstream" organisations could provide appropriate services for GBM who use crystal and furthermore, that there was significant work to "undo" misperceptions of the harms of crystal use. At the policy level, mass media anti-drug campaigns were seen to be a significant generator of stigma with irrelevant and patronising messages that lacked useful information. Efforts to reduce stigma about crystal methamphetamine use amongst GBM must address individual, network, organisation and policy issues and be underpinned by understandings of social power in relation to sex, sexuality, drug use, infectious status and sexual minorities.
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http://dx.doi.org/10.1016/j.drugpo.2021.103229DOI Listing
August 2021

Trends in Belief That HIV Treatment Prevents Transmission Among Gay and Bisexual Men in Australia: Results of National Online Surveys 2013-2019.

AIDS Educ Prev 2021 02;33(1):62-72

Department of Interdisciplinary Social Science, Utrecht University, Utrecht, Netherlands.

We have tracked belief in the effectiveness of HIV treatment as prevention (TasP) among Australian gay and bisexual men (GBM) since 2013. National, online cross-sectional surveys of GBM were conducted every 2 years during 2013-2019. Trends and associations were analyzed using multivariate logistic regression. Data from 4,903 survey responses were included. Belief that HIV treatment prevents transmission increased from 2.6% in 2013 to 34.6% in 2019. Belief in the effectiveness of TasP was consistently higher among HIV-positive participants than other participants. In 2019, higher levels of belief in TasP were independently associated with university education, being HIV-positive, using pre-exposure prophylaxis, knowing more HIV-positive people, being recently diagnosed with a sexually transmitted infection (STI) and use of post-exposure prophylaxis. Belief that HIV treatment prevents transmission has increased substantially among Australian GBM, but remains concentrated among HIV-positive GBM, those who know HIV-positive people, and GBM who use antiretroviral-based prevention.
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http://dx.doi.org/10.1521/aeap.2021.33.1.62DOI Listing
February 2021

Priorities and practices of risk reduction among gay and bisexual men in Australia who use crystal methamphetamine for sex.

Int J Drug Policy 2021 07 16;93:103163. Epub 2021 Feb 16.

Centre for Social Research in Health, UNSW Sydney, Sydney, NSW, 2054, Australia.

Crystal methamphetamine (hereafter crystal) is associated with deleterious health outcomes, such as drug dependence and physical and mental health disorders. While some harms from crystal use can affect all users, there may be additional risks for people who combine the use of drug with sex. Compared with the broader population, gay and bisexual men in Australia report a higher prevalence of methamphetamine use, and crystal is the most commonly injected illicit drug among this population. The Crystal, Pleasures and Sex between Men research project was conducted between 2017 and 2019 and examined gay and bisexual men's crystal use in four capital cities in Australia, with the aim of identifying how to best support men who use crystal for sex. In this article, we examine how risk is understood and prioritised by gay and bisexual men who combine crystal use and sex and identify the range of risk reduction practices that they used. We classified these risks as those associated with the transmission of HIV, HCV and STIs, and those associated with dependence on either crystal or the sex it facilitated. Gay and bisexual men overwhelmingly prioritised the risk of dependence over any other risks associated with crystal-enhanced sex, and this prioritization was reflected in the risk reduction practices they employed. While some of the strategies that gay and bisexual men have adopted may contradict anticipated public health principles, they derive from a carefully considered and shared approaches to the generation of pleasure, the maintenance of a controlled form of feeling "out of control", and the negotiated reduction of risk. The consolidation of these strategies effectively constitutes a "counterpublic health" underpinned by forms of "sex-based sociality", which gives primacy to the priorities and practices of gay and bisexual men in Australia who combine crystal and sex.
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http://dx.doi.org/10.1016/j.drugpo.2021.103163DOI Listing
July 2021

Increasing preexposure prophylaxis use and 'net prevention coverage' in behavioural surveillance of Australian gay and bisexual men.

AIDS 2021 04;35(5):835-840

The Kirby Institute, UNSW Sydney.

Objectives: To assess trends in HIV prevention strategies among Australian gay and bisexual men (GBM) since the introduction of preexposure prophylaxis (PrEP), the level of net prevention coverage (the use of safe strategies), and the characteristics of HIV-negative and untested GBM who remain at risk of HIV.

Design: Repeated behavioural surveillance of GBM recruited from venues, events and online in seven Australian states and territories.

Methods: Participants with casual male partners were included. Trends in sexual practices, prevention strategies, net prevention coverage and the characteristics of 'at risk' participants were assessed with binary and multivariate logistic regression.

Results: A total of 32 048 survey responses (2014-2019) were included. The proportion of participants who reported consistent condom use declined (44.6-23.2%). The proportion who reported any condomless anal intercourse with casual partners increased (37.4-62.0%) but net prevention coverage also increased (68.1-74.9%), with higher levels of undetectable viral load among HIV-positive participants and rapidly increasing PrEP use by HIV-negative participants. PrEP became the most commonly reported prevention strategy in 2019 (31.1%). The analysis of 'at risk' participants showed that they became more likely to report frequent condomless anal intercourse with casual partners but had fewer partners and more partners with undetectable viral load or on PrEP. 'At risk' participants became more likely to identify as bisexual and to be born overseas.

Conclusion: There has been a rapid, historic shift in HIV prevention among GBM in Australia. Net prevention coverage has increased among GBM and 'at risk' GBM have become less at risk of HIV, facilitating reductions in HIV transmission.
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http://dx.doi.org/10.1097/QAD.0000000000002797DOI Listing
April 2021

A New Method for Estimating the Incidence of Infectious Diseases.

Am J Epidemiol 2021 07;190(7):1386-1395

Ambitious World Health Organization targets for disease elimination require monitoring of epidemics using routine health data in settings of decreasing and low incidence. We evaluated 2 methods commonly applied to routine testing results to estimate incidence rates that assume a uniform probability of infection between consecutive negative and positive tests based on 1) the midpoint of this interval and 2) a randomly selected point in this interval. We compared these with an approximation of the Poisson binomial distribution, which assigns partial incidence to time periods based on the uniform probability of occurrence in these intervals. We assessed bias, variance, and convergence of estimates using simulations of Weibull-distributed failure times with systematically varied baseline incidence and varying trend. We considered results for quarterly, half-yearly, and yearly incidence estimation frequencies. We applied the methods to assess human immunodeficiency virus (HIV) incidence in HIV-negative patients from the Treatment With Antiretrovirals and Their Impact on Positive and Negative Men (TAIPAN) Study, an Australian study of HIV incidence in men who have sex with men, between 2012 and 2018. The Poisson binomial method had reduced bias and variance at low levels of incidence and for increased estimation frequency, with increased consistency of estimation. Application of methods to real-world assessment of HIV incidence found decreased variance in Poisson binomial model estimates, with observed incidence declining to levels where simulation results had indicated bias in midpoint and random-point methods.
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http://dx.doi.org/10.1093/aje/kwab014DOI Listing
July 2021

Troubling the non-specialist prescription of HIV pre-exposure prophylaxis (PrEP): the views of Australian HIV experts.

Health Sociol Rev 2020 03 23;29(1):62-75. Epub 2019 Dec 23.

Centre for Social Research in Health, UNSW Sydney, Sydney, Australia.

The broadening of access to HIV pre-exposure prophylaxis (PrEP) in Australia has rekindled debates about which types of clinicians are best suited to deliver HIV prevention innovations: specialist HIV services or primary care physicians and general practitioners (GPs). We conducted 21 semi-structured qualitative interviews in 2017 with Australian HIV sector experts working across policy, advocacy, clinical service provision, research, and health promotion. These interviews took place before a national policy commitment to subsidising access to PrEP was achieved. We explored how participants conceptualised PrEP, patients and GPs at this key turning point in the history of HIV prevention. Participants expressed varied views regarding GPs' anticipated ability to successfully navigate the potential complexities associated with PrEP roll-out. While participants were supportive of greater patient access to PrEP, they expressed concerns about non-specialist GPs' cultural competence and expertise regarding sexuality and clinical practice, and the potential for patients to experience discrimination and homophobia from non-expert GPs. This study has broad implications for thinking about experts and expertise, the implementation of previously specialised medicine into mainstream settings, and the anticipated challenges of LGBTIQ+ inclusive healthcare.
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http://dx.doi.org/10.1080/14461242.2019.1703781DOI Listing
March 2020

Understanding nanoscale structural distortions in Pb(ZrTi)O by utilizing X-ray nanodiffraction and clustering algorithm analysis.

J Synchrotron Radiat 2021 Jan 1;28(Pt 1):207-213. Epub 2021 Jan 1.

Department of Materials Science and Engineering, University of California Davis, 1 Shields Avenue, Davis, CA 95616, USA.

Hard X-ray nanodiffraction provides a unique nondestructive technique to quantify local strain and structural inhomogeneities at nanometer length scales. However, sample mosaicity and phase separation can result in a complex diffraction pattern that can make it challenging to quantify nanoscale structural distortions. In this work, a k-means clustering algorithm was utilized to identify local maxima of intensity by partitioning diffraction data in a three-dimensional feature space of detector coordinates and intensity. This technique has been applied to X-ray nanodiffraction measurements of a patterned ferroelectric PbZrTiO sample. The analysis reveals the presence of two phases in the sample with different lattice parameters. A highly heterogeneous distribution of lattice parameters with a variation of 0.02 Å was also observed within one ferroelectric domain. This approach provides a nanoscale survey of subtle structural distortions as well as phase separation in ferroelectric domains in a patterned sample.
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http://dx.doi.org/10.1107/S1600577520013661DOI Listing
January 2021

Nanoscale Imaging and Control of Volatile and Non-Volatile Resistive Switching in VO.

Small 2020 12 23;16(50):e2005439. Epub 2020 Nov 23.

Department of Physics, University of California San Diego, La Jolla, CA, 92093, USA.

Control of the metal-insulator phase transition is vital for emerging neuromorphic and memristive technologies. The ability to alter the electrically driven transition between volatile and non-volatile states is particularly important for quantum-materials-based emulation of neurons and synapses. The major challenge of this implementation is to understand and control the nanoscale mechanisms behind these two fundamental switching modalities. Here, in situ X-ray nanoimaging is used to follow the evolution of the nanostructure and disorder in the archetypal Mott insulator VO during an electrically driven transition. Our findings demonstrate selective and reversible stabilization of either the insulating or metallic phases achieved by manipulating the defect concentration. This mechanism enables us to alter the local switching response between volatile and persistent regimes and demonstrates a new possibility for nanoscale control of the resistive switching in Mott materials.
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http://dx.doi.org/10.1002/smll.202005439DOI Listing
December 2020

Access to Subsidized Health Care Affects HIV Pre-Exposure Prophylaxis (PrEP) Uptake Among Gay and Bisexual Men in Australia: Results of National Surveys 2013-2019.

J Acquir Immune Defic Syndr 2021 04;86(4):430-435

Centre for Social Research in Health, UNSW Sydney, Sydney, Australia.

Background: We assessed willingness to use HIV pre-exposure prophylaxis (PrEP) and current PrEP use among gay and bisexual men (GBM) in Australia.

Methods: National, online cross-sectional surveys of GBM were conducted in 2013, 2015, 2017, and 2019. Willingness to use PrEP was measured on a previously validated scale. Trends and associations with key measures were analyzed using multivariate logistic regression.

Results: During 2013-2019, 4908 surveys were completed. Among HIV-negative and untested men not currently using PrEP, willingness to use PrEP increased from 23.0% in 2013 to 36.5% in 2017 (P < 0.001) but then plateaued at 32% in 2019 (P = 0.13). The proportion of current PrEP users increased significantly from 2.5% in 2015 to 38.5% in 2019 (P < 0.001). In 2019, factors independently associated with being a current PrEP user (compared with non-PrEP users who were willing to use PrEP) included having subsidized health care (Medicare), knowing HIV-positive people, being recently diagnosed with an STI other than HIV, having higher numbers of recent male sexual partners, recent condomless sex with casual and regular partners, and frequent PrEP sorting.

Conclusion: Willingness to use PrEP has plateaued as its use has rapidly increased among GBM in Australia. PrEP use is concentrated among more sexually active men with access to subsidized health care. Free or low cost access schemes may facilitate broader access among GBM who want or need PrEP but lack access to subsidized health care.
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http://dx.doi.org/10.1097/QAI.0000000000002572DOI Listing
April 2021

Sexual risk-taking among homeless young people in Pakistan.

Health Soc Care Community 2021 09 10;29(5):1550-1558. Epub 2020 Nov 10.

Centre for Social Research in Health, The University of New South Wales, Sydney, Australia.

Homeless young people who engage in sex work are at increased risk of HIV and other sexually transmitted infections like chlamydia, gonorrhoea, syphilis and herpes. Semi-structured interviews were conducted with 29 homeless young people between the ages of 16 and 25 years from Rawalpindi, Pakistan, to explore how sexual practices were mediated through social and contextual conditions. Participants engaged in sex for a range of reported reasons, most commonly to generate income, but also to build intimacy and to establish intimate partnerships which could bring physical protection and social and emotional support. Although participants were aware of the sexual health risks attached to condomless sex, they engaged in it due to the social obligations of intimate partnerships, financial considerations and to better manage potentially violent situations. Instead of condoms, participants used alternate methods like withdrawal, oral sex, post-sex douching and specific sexual positions. These were not always useful, and some methods might have inadvertently increased their risk of HIV. The study findings suggest that an integrated health promotion approach that goes beyond the health sector and a singular emphasis on risk awareness may help reduce young people's risk of homelessness and sexual health risks.
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http://dx.doi.org/10.1111/hsc.13220DOI Listing
September 2021

Issues Associated With Prescribing HIV Pre-exposure Prophylaxis for HIV Anxiety: A Qualitative Analysis of Australian Providers' Views.

J Assoc Nurses AIDS Care 2021 Jan-Feb 01;32(1):94-104

Anthony K. J. Smith, GradCertHumanRights, is a Scientia Doctoral Candidate, Centre for Social Research in Health, UNSW Sydney, Sydney, Australia. Martin Holt, PhD, is a Professor, Centre for Social Research in Health, UNSW Sydney, Sydney, Australia. Bridget Haire, PhD, is a Senior Research Fellow, Kirby Institute, UNSW Sydney, Sydney, Australia. Christy E. Newman, PhD, is an Associate Professor, Centre for Social Research in Health, UNSW Sydney, Sydney, Australia.

Abstract: HIV pre-exposure prophylaxis (PrEP) can alleviate anxiety about acquiring HIV, particularly for gay men and other men who have sex with men. However, research with PrEP providers has rarely examined HIV anxiety. We conducted 25 semistructured interviews in 2019-2020 with PrEP providers in New South Wales and Western Australia, and analyzed data thematically. Participants included general practitioners and sexual health nurses and doctors. Our analysis explores providers' views on providing PrEP to reduce HIV anxiety for gay men, serodiscordant couples where the partner with HIV has an undetectable viral load, and for "worried well" individuals who the providers speculated might have undisclosed risk. Although providers viewed PrEP as beneficial for many people's personal lives and relationships, they felt cautious about prescribing PrEP solely for HIV anxiety, while at the same time reporting that they prescribed PrEP if individuals insisted on it and had no medical contraindications.
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http://dx.doi.org/10.1097/JNC.0000000000000219DOI Listing
June 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

HIV stigma by association among Australian gay and bisexual men.

AIDS 2020 09;34 Suppl 1:S53-S61

Centre for Social Research in Health, University of New South Wales, Sydney, New South Wales, Australia.

Objective: The negative effects of HIV stigma may extend beyond those who are HIV-positive, to people who are perceived to be at risk of HIV. This article examines HIV stigma by association among Australian gay and bisexual men (GBM).

Design: Cross-sectional, online survey of 1280 Australian gay and bisexual men. This article focuses on HIV stigma from within a larger study that investigated stigma related to sexual identity.

Methods: Bivariate and multivariable comparisons were made between men who experienced HIV stigma by association and those who did not. A serial mediation model was tested to investigate relationships between GBM community attachment, sexual identity stigma, HIV testing frequency, HIV stigma by association, psychological distress, and rejection of sex partners.

Results: Results found that 5% of participants were HIV-positive, yet over 70% reported that they had been stigmatized by others for their perceived risk of acquiring HIV. Multivariable analysis indicated that HIV stigma by association was associated with more frequent HIV testing, greater GBM community attachment, experiencing stigma related to sexual identity and psychological distress. Our results suggest flow-on effects of HIV stigma by association, such as being more likely to reject other GBM on the basis of their HIV status or not testing for HIV.

Conclusion: Our results underscore the notion that HIV stigma can have broader, negative effects on HIV-affected populations. There is a need to address HIV stigma within GBM communities and society more broadly in order to encourage HIV testing and prevention among GBM.
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http://dx.doi.org/10.1097/QAD.0000000000002565DOI Listing
September 2020

The Preferred Qualities of Human Immunodeficiency Virus Testing and Self-Testing Among Men Who Have Sex With Men: A Discrete Choice Experiment.

Value Health 2020 07 17;23(7):870-879. Epub 2020 Jul 17.

University of New South Wales, Sydney, Australia.

Objectives: Human immunodeficiency virus self-testing (HIVST) is a promising approach to improve HIV testing coverage. We aimed to understand HIV testing preferences of men who have sex with men (MSM) to optimize HIVST implementation.

Methods: Discrete choice experiments (DCEs) were conducted among HIV-negative MSM living in Australia and aged ≥18 years. Men completed 1 of 2 DCEs: DCETest for preferred qualities of HIV testing (price, speed, window period, test type, and collector of specimen) and DCEKits for preferred qualities of HIVST kits (price, location of access, packaging, and usage instructions). Latent class conditional logit regression was used to explore similarities (or "classes") in preference behavior.

Results: Overall, the study recruited 1606 men: 62% born in Australia, who had an average age of 36.0 years (SD 11.7), and a self-reported median of 4 (interquartile range 2-8) sexual partners in the last 6 months. The respondents to DCETest was described by 4 classes: "prefer shorter window period" (36%), "prefer self-testing" (27%), "prefer highly accurate tests" (22%), and "prefer low prices" (15%). Respondents to DCEKits were described by 4 classes: "prefer low prices" (48%), "prefer retail access (from pharmacy or online stores)" (29%), "prefer access at sex venues" (15%), and "prefer to buy from healthcare staff" (12%). Preferences varied by when someone migrated to Australia, age, frequency of testing, and number of sexual partners.

Conclusion: A subset of MSM, particularly infrequent testers, value access to HIVST. Expanding access to HIVST kits through online portals and pharmacies and at sex venues should be considered.
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http://dx.doi.org/10.1016/j.jval.2020.04.1826DOI Listing
July 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

Sustained, Low Prevalence of Undiagnosed HIV Among Gay and Bisexual Men in Sydney, Australia Coincident With Increased Testing and Pre-exposure Prophylaxis Use: Results From Repeated, Bio-Behavioral Studies 2014-2018.

J Acquir Immune Defic Syndr 2020 11;85(3):e41-e47

Centre for Social Research in Health, UNSW Sydney, Sydney, Australia.

Background: Gay and bisexual men with undiagnosed HIV contribute disproportionately to HIV transmission in Australia.

Methods: In 2014 and 2018, we recruited men at gay venues and events in Sydney. Participants self-completed surveys and provided oral fluid samples for HIV testing. We calculated the prevalence of HIV and undiagnosed infection, and assessed changes in behavior, HIV testing, and the use of pre-exposure prophylaxis. We weighted the samples to adjust for differences in where participants were recruited between rounds. Two-sample tests of proportion were used to compare prevalence estimates and χ tests to assess differences between the samples.

Results: In 2014, 944 men were recruited, and 890 men were recruited in 2018. In 2014, the weighted estimate of HIV prevalence was 6.1% [95% confidence intervals (CI): 4.6 to 7.6], of which 13.8% (95% CI: 5.0 to 22.7) was undiagnosed. In 2018, weighted HIV prevalence was 6.4% (95% CI: 4.8 to 8.0), of which 5.3% (95% CI: 0.5 to 11.1) was undiagnosed. Between 2014 and 2018 among all participants, men reporting at least 10 recent casual partners increased from 22.3% to 27.7% (P = 0.008), condomless anal intercourse with casual partners in the previous 6 months increased from 23.9% to 37.3% (P < 0.001), and sexually transmitted infection diagnoses in the previous year increased from 14.4% to 27.5% (P < 0.001). HIV testing and the use of pre-exposure prophylaxis in the previous 6 months increased from 49.6% to 56.3% (P = 0.004) and 2.0%-21.0% (P < 0.001), respectively.

Conclusions: Repeated, bio-behavioral surveillance suggests the prevalence of undiagnosed HIV remains low in Sydney, despite gay and bisexual men reporting more casual sex partners, condomless sex, and sexually transmitted infections.
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http://dx.doi.org/10.1097/QAI.0000000000002451DOI Listing
November 2020

The Potential Impact of a Gel-Based Point-of-Sex Intervention in Reducing Gonorrhea Incidence Among Gay and Bisexual Men: A Modeling Study.

Sex Transm Dis 2020 10;47(10):649-657

Centre for Social Research in Health, University of New South Wales, Sydney.

Background: Increases in sexually transmitted infections among gay and bisexual men (GBM) over the past decade have coincided with declines in condom use and rapid uptake of HIV preexposure prophylaxis (PrEP). We explored the impact of an antimicrobial gel-based point-of-sex intervention (gel-PSI) with a lower efficacy for reducing gonorrhea transmission risk than condoms on population-level gonorrhea incidence among GBM in Victoria, Australia.

Methods: A deterministic compartmental model of HIV and gonorrhea transmission was used to project annual gonorrhea incidence from 2020 to 2025. Individuals were classified as HIV-negative (PrEP or non-PrEP users) or HIV-positive, and further stratified by gonorrhoea risk (high/low). All possible scenarios where between 0% and 100% of GBM using condoms transitioned to gel-PSI (considered a downgrade in protection) and 0% and 100% of GBM not using condoms transitioned to gel-PSI (considered an upgrade in protection), with gel-PSI efficacy ranging from 20% to 50%, were run.

Results: The baseline scenario of no gel-PSI uptake (status quo) projected 94,367 gonorrhea infections between 2020 and 2025, with an exponentially increasing trend in annual infections. For a gel-PSI efficacy of 30%, a net reduction in cumulative gonorrhea incidence was projected, relative to the status quo, for any ratio of proportion of condom users "downgrading" to proportion of noncondom users "upgrading" to gel-PSI use of less than 2.6. Under the supposition of equal proportions of condom users and noncondom users switching to gel-PSI, a relative reduction was projected for any gel-PSI efficacy greater than 16%.

Conclusions: Our model suggests that the introduction of a gel-PSI could have benefits for controlling gonorrhea transmission among GBM, even in scenarios where the gel-PSI is considerably less efficacious than condoms and when gel-PSI uptake leads to consequent reductions in consistent condom use.
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http://dx.doi.org/10.1097/OLQ.0000000000001239DOI Listing
October 2020
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