Relationship Between Sexual Behaviors with Non-committed Relationship Partners and COVID-19 Restrictions and Notification Rates: Results from a Longitudinal Study of Gay and Bisexual Men in Australia.

Introduction: COVID-19 related lockdowns have impacted the sexual activity of gay and bisexual men (GBM). We investigated trends in sexual behaviors and the COVID-19 context in which they occurred (COVID-notification rates and jurisdictional restrictions) to understand changes in the duration and severity of periods of lockdown on the sexual behavior of Australian GBM. Methods: In an online, prospective observational study of 831 GBM from May 2020 to May 2021, we investigated associations between changes in sexual behavior among Australian GBM, lockdowns, and COVID-19 notification rates through weekly surveys from May 2020 to May 2021. Results: The mean age was 45.71 years (SD: 13.93). Most identified as gay (89.0%) and 10.2% were living with HIV. There was an overall increase in the mean weekly number of non-committed relationship partners (0.53-0.90, p < 0.001). The state of Victoria experienced a significant extended COVID-19 outbreak, accompanied by severe lockdown restrictions. In response, Victorian men's partner numbers shifted three times, while elsewhere there was an overall gradually increasing trend. Conclusions: Less severe outbreaks with shorter lockdown periods, involving fewer and geographically contained, COVID-19 notifications were accompanied by non-significant changes in sex with non-relationship partners than more severe outbreaks over extended periods and larger geographical areas. Supplementary Information: The online version contains supplementary material available at 10.1007/s13178-022-00733-8.

The impacts of COVID-19 measures on drug markets and drug use among a cohort of people who use methamphetamine in Victoria, Australia.

BACKGROUND AND AIMS: Few studies of the impacts of the coronavirus disease 2019 (COVID-19) public health measures on drug markets and drug use patterns have used longitudinal data. We aimed to examine whether COVID-19 measures were associated with increases in methamphetamine price, decreases in methamphetamine use frequency and subsequent changes in secondary outcomes of other drug use frequency in metropolitan Melbourne and regional Victoria. DESIGN: Longitudinal analysis framework was used from a longitudinal cohort of people who use methamphetamine. SETTING: Victoria state, Australia. PARTICIPANTS: One hundred eighty-five VMAX study participants who reported a methamphetamine purchase after the onset of the pandemic were used for the price paid analysis. Methamphetamine or other drug use frequency analysis was performed using 277 participants who used methamphetamine during the pandemic or in the year before the pandemic. MEASUREMENTS: Price paid per gram of methamphetamine derived from the most recent purchase price and most recent purchase quantity. Frequency of methamphetamine and other drug use measured as the average number of days per week used in the last month. FINDINGS: Compared with pre-COVID-19 period, methamphetamine prices increased by AUD351.63 (P value <0.001) and by AUD456.51 (P value <0.001) in Melbourne and regional Victoria, respectively, during the period in which the most intense public health measures were implemented in Victoria. Although prices decreased after harder restrictions were lifted (by AUD232.84, P value <0.001 and AUD263.68, P value <0.001, in Melbourne and regional Victoria, respectively), they remained higher than pre-COVID-19 levels. A complementary 76% decrease was observed in relation to methamphetamine use frequency in regional Victoria (P value = 0.006) that was not offset by any changes in the frequency of use of other drugs such as alcohol, tobacco or other illicit drugs. CONCLUSION: COVID-19 public health measures in Victoria state, Australia, appear to have been associated with major price changes in the methamphetamine market and decreased frequency of use of the drug.

COVID-19 vaccine attitudes and facilitators among people in Australia who inject drugs.

INTRODUCTION: We aimed to describe COVID-19 vaccination attitudes and identify potential facilitators for vaccine uptake among people who inject drugs. METHODS: People who inject drugs were recruited from all eight Australian capital cities (N = 884; 65% male, mean age 44 years) and interviewed face-to-face or via telephone in June-July 2021. COVID-19 and broader vaccination attitudes were used to model latent classes. Correlates of class membership were assessed through multinomial logistic regression. Probability of endorsing potential vaccination facilitators were reported by class. RESULTS: Three classes of participants were identified: 'vaccine acceptant' (39%), 'vaccine hesitant' (34%) and 'vaccine resistant' (27%). Those in the hesitant and resistant groups were younger, more likely to be unstably housed and less likely to have received the current season influenza vaccine than the acceptant group. In addition, hesitant participants were less likely to report a chronic medical condition than acceptant participants. Compared to vaccine acceptant and hesitant participants, vaccine-resistant participants were more likely to predominantly inject methamphetamine and to inject drugs more frequently in the past month. Both vaccine-hesitant and resistant participants endorsed financial incentives for vaccination and hesitant participants also endorsed facilitators related to vaccine trust. DISCUSSION AND CONCLUSION: People who inject drugs who are unstably housed or predominantly inject methamphetamine are subgroups that require targeted interventions to increase COVID-19 vaccination uptake. Vaccine-hesitant people may benefit from interventions that build trust in vaccine safety and utility. Financial incentives may improve vaccine uptake among both hesitant and resistant people.

How to have sex in a pandemic: the development of strategies to prevent COVID-19 transmission in sexual encounters among gay and bisexual men in Australia.

Although many studies reported on decreases in sexual partner numbers among gay and bisexual-identifying men in the early period of the COVID-19 pandemic, few studies have explored COVID-19 risk-reduction strategies. Drawing on free-text responses in an online survey (from April to July 2020), we describe the ways in which men sought to minimise the risk of COVID-19 in sexual encounters. Partner selection was an important strategy, in particular, restricting sex to men they already knew. Accounts also indicate how participants assessed risk from potential sex partners based on symptoms, residential location, recent travel, work role, and number of other sexual contacts. Less common were in situ practices, such as avoiding kissing. Participants' responses provide insight into creative community-based responses in the early months of the pandemic, some of which have resonances with early responses to HIV. Findings are discussed in relation to the concepts of 'lay epidemiology' and 'counterpublic health'. In particular, we examine how risks and health are experienced and valued in relation to local knowledges, meanings, and practices; and how practices emerge in response to dominant public health discourses that produce an idealised public based on (hetero)normative assumptions.

COVID-19 Testing in a Weekly Cohort Study of Gay and Bisexual Men: The Impact of Health-Seeking Behaviors and Social Connection.

Gay, bisexual, and other men who have sex with men (GBM) have developed community norms for regular HIV/STI testing. We investigated factors associated with self-reported COVID-19 testing in response to reported COVID-19 cases and public health restrictions. Participants responded to weekly cohort surveys between 10th May 2021 and 27th September 2021. We used the Andersen-Gill extensions to the Cox proportional hazards model for multivariable survival data to predict factors influencing COVID-19 testing. Mean age of the 942 study participants was 45.6 years (SD: 13.9). In multivariable analysis, GBM were more likely to report testing during periods of high COVID-19 caseload in their state of residence; if they were younger; university educated; close contact of someone with COVID-19; or reported coping with COVID-19 poorly. COVID-19 testing was higher among men who: were more socially engaged with other GBM; had a higher proportion of friends willing to vaccinate against COVID-19; and were willing to contact sexual partners for contact tracing. Social connection with other gay men was associated with COVID-19 testing, similar to what has been observed throughout the HIV epidemic, making community networks a potential focus for the promotion of COVID-19 safe practices.

Uptake of COVID-19 vaccination among people who inject drugs.

BACKGROUND: People who inject drugs (PWID) may be at elevated risk of adverse outcomes from SARS-CoV-2 infection; however, data on COVID-19 vaccine uptake among PWID are scarce. This study aimed to determine COVID-19 vaccine uptake among PWID, identify factors associated with sub-optimal uptake, and compare uptake to the general population. METHODS: The Australian Needle Syringe Program Survey is an annual sentinel surveillance project, comprising a self-completed questionnaire and provision of a dried blood sample for HIV and HCV testing. In 2021, respondents provided information on their COVID-19 vaccination status. Multivariate logistic regression models identified correlates of vaccine uptake. RESULTS: Among 1166 respondents, 49% had been vaccinated and in most states and territories, vaccine uptake was significantly lower than among the general population. Independent predictors of vaccine uptake were longer duration of vaccine eligibility (AOR 3.42, 95% CI 2.65, 4.41); prior SARS-CoV-2 diagnostic testing (AOR 2.90, 95% CI 2.22, 3.79); injection of opioids (AOR 1.91, 95% CI 1.20, 3.05); and current opioid agonist therapy (AOR 1.70, 95% CI 1.23, 2.33). Women (AOR 0.70, 95% CI 0.54, 0.92) and those who reported daily or more frequent injection (AOR 0.75, 95% CI 0.57, 1.00) were significantly less likely to be vaccinated. CONCLUSIONS: In most Australian states and territories, uptake of COVID-19 vaccine among PWID lagged uptake among the general population. Increased efforts are required to ensure PWID have equitable access to vaccination. Vaccination programmes within harm reduction services and via outreach, coupled with increased support for peers to act as vaccine champions, are likely to reduce barriers and improve COVID-19 vaccine uptake in this population.

COVID-19 vaccine acceptability among people in Australia who inject drugs: Update from the 2021 Illicit Drug Reporting System interviews.

People who inject drugs may be at higher risk of COVID-19 transmission and more severe negative health outcomes following COVID-19 infection. Early research on hypothetical COVID-19 vaccines suggests this population may be less likely to accept vaccination. This commentary extends this research by presenting vaccine intention data from Illicit Drug Reporting System interviews conducted in June-July 2021, in the early stages of vaccine rollout, with people in Australia who inject drugs (N = 888). Half the sample (48%, n = 419) reported that they were hesitant to receive the COVID-19 vaccine, with key barriers relating to vaccine safety and side effect concerns. This level of hesitancy is substantially higher than that of the general population at a similar time. While we note that the subsequent Delta variant-driven third wave of cases in Australia and efforts to increase population vaccination coverage may have altered intent in this group, this level of hesitancy warrants a targeted strategy to mitigate vaccine-related concerns and maximise uptake. Ideally, this should comprise an inclusive health response that is peer-led, with peer-based organisations ideally positioned to direct immunisation service delivery and provide vaccine-related messaging.

Increase in Depression and Anxiety Among Australian Gay and Bisexual Men During COVID-19 Restrictions: Findings from a Prospective Online Cohort Study.

We examined depression and anxiety prior to and during COVID-19 restrictions in Australian gay and bisexual men (GBM). In an online cohort, a COVID-19-focused survey was conducted in April 2020. During 2019 and in April 2020, 664 GBM completed the Patient Health Questionnaire (PHQ-9, measuring depression) and Generalized Anxiety Disorder Assessment (GAD-7, measuring anxiety). Increased depression and anxiety were defined as a ≥ 5 point increase on the respective scales. Mean PHQ-9 and GAD-7 scores increased between 2019 and 2020 (PHQ-9: from 5.11 in 2019 to 6.55 in 2020; GAD-7: from 3.80 in 2019 to 4.95 in 2020). The proportion of participants with moderate-severe depression (PHQ-9 ≥ 10) increased from 18.8% (n = 125) to 25.5% (n = 169), while the proportion of participants with moderate-severe anxiety (GAD-7 ≥ 10) increased from 12.7% (n = 84) to 17.3% (n = 115). Almost one-quarter of participants (n = 158, 23.8%) had increased depression; in these men, mean PHQ-9 increased from 2.49 in 2019 to 11.65 in 2020 (p < 0.001). One-in-five (20.6%) participants (n = 137) had increased anxiety; among these men, mean GAD-7 increased from 2.05 in 2019 to 10.22 in 2020 (p < 0.001). Increases were associated with concerns about job security, reduction in social and sexual connections and opportunities, and being personally concerned about COVID-19 itself. COVID-19 appeared to have a sudden and pronounced impact on depression and anxiety in Australian GBM, with a significant minority showing sharp increases. Ongoing monitoring is required to determine longer-term impacts and GBM need access to appropriate and sensitive supports both during and after the COVID-19 pandemic.

COVID-19 vaccine acceptability among people in Australia who inject drugs: Implications for vaccine rollout.

INTRODUCTION: Vaccine acceptability is a key determinant of vaccination uptake. Despite being at risk of adverse outcomes from coronavirus-19 disease (COVID-19), COVID-19 vaccine acceptability among people who inject drugs is unknown. We surveyed people who inject drugs in Melbourne, Australia to assess potential uptake of COVID-19 vaccines prior to distribution. METHODS: Cross-sectional study, comprising interviewer-administered structured telephone interviews completed from 30 November to 22 December 2020 in Melbourne, Australia. Participants were people aged 18 years or older who injected drugs at least monthly in the past 6 months and had resided in Melbourne in the past 12 months recruited via needle-syringe programs and word-of-mouth. MEASUREMENTS: COVID-19 hypothetical vaccine acceptability, participants' demographic, drug use and drug treatment characteristics. RESULTS: Fifty-eight percent (57/99) of the sample reported that they would definitely or probably be vaccinated for COVID-19, with the remainder indicating that they would not (22%) or were undecided (20%). Among those who indicated that they would definitely or probably not be vaccinated or were undecided (n = 42), safety concerns were most often cited as a reason for not wanting to be vaccinated. DISCUSSION AND CONCLUSIONS: Although a majority of sampled people who inject drugs indicated that they would definitely or probably be vaccinated, efforts to reduce hesitancy and allay COVID-19 vaccine safety concerns will be necessary to optimise vaccine uptake among this population.

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

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.

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.

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.

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.

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.

COVID-19, HIV and key populations: cross-cutting issues and the need for population-specific responses.

INTRODUCTION: Key populations at elevated risk to contract or transmit HIV may also be at higher risk of COVID-19 complications and adverse outcomes associated with public health prevention measures. However, the conditions faced by specific populations vary according to social, structural and environmental factors, including stigma and discrimination, criminalization, social and economic safety nets and the local epidemiology of HIV and COVID-19, which determine risk of exposure and vulnerability to adverse health outcomes, as well as the ability to comply with measures such as physical distancing. This commentary identifies common vulnerabilities and cross-cutting themes in terms of the impacts of COVID-19 on key populations before addressing issues and concerns specific to particular populations. DISCUSSION: Cross-cutting themes include direct impacts such as disrupted access to essential medicines, commodities and services such as anti-retroviral treatment, HIV pre-exposure prophylaxis, opioid agonist treatment, viral load monitoring, HIV and sexually transmitted infections testing, condoms and syringes. Indirect impacts include significant collateral damage arising from prevention measures which restrict human rights, increase or impose criminal penalties, and expand police powers to target vulnerable and criminalized populations. Significant heterogeneity in the COVID-19 pandemic, the underlying HIV epidemic and the ability of key populations to protect themselves means that people who inject drugs and sex workers face particular challenges, including indirect impacts as a result of police targeting, loss of income and sometimes both. Geographical variations mean that transgender people and men who have sex with men in regions like Africa and the middle east remain criminalized, as well as stigmatized and discriminated against, increasing their vulnerability to adverse outcomes in relation to COVID-19. CONCLUSIONS: Disruptions to both licit and illicit supply chains, loss of income and livelihoods and changes in behaviour as a result of lockdowns and physical distancing have the potential to exacerbate the impacts of the COVID-19 pandemic on key populations. While these impacts will vary significantly, human-rights approaches to COVID-19 emergency laws and public health prevention measures that are population-specific and sensitive, will be key to reducing adverse health outcomes and ensuring that no one is left behind.

Challenges in maintaining treatment services for people who use drugs during the COVID-19 pandemic.

The impact of COVID-19 across health services, including treatment services for people who use drugs, is emerging but likely to have a high impact. Treatment services for people who use drugs provide essential treatment services including opiate agonist treatment and needle syringe programmes alongside other important treatment programmes across all substance types including withdrawal and counselling services. Drug and alcohol hospital consultation-liaison clinicians support emergency departments and other services provided in hospital settings in efficiently managing patients who use drugs and present with other health problems.COVID-19 will impact on staff availability for work due to illness. Patients may require home isolation and quarantine periods. Ensuring ongoing supply of opiate treatment during these periods will require significant changes to how treatment is provided. The use of monthly depot buprenorphine as well as moving from a framework of supervised dosing will be required for patients on sublingual buprenorphine and methadone. Ensuring ready access to take-home naloxone for patients is crucial to reduce overdose risks. Delivery of methadone and buprenorphine to the homes of people with confirmed COVID-19 infections is likely to need to occur to support home isolation.People who use drugs are likely to be more vulnerable during the COVID-19 epidemic, due to poorer health literacy and stigma and discrimination towards this group. People who use drugs may prioritise drug use above other health concerns. Adequate supply of clean injecting equipment is important to prevent outbreaks of blood-borne viruses. Opiate users may misinterpret SARS-CoV2 symptoms as opiate withdrawal and manage this by using opioids. Ensuring people who use drugs have access to drug treatment as well as access to screening and testing for SARS-CoV2 where this is indicated is important.