Increased targeted HIV testing and reduced undiagnosed HIV infections among gay and bisexual men.

OBJECTIVES: To evaluate the impact of government HIV strategies that aimed to increase HIV testing uptake and frequency among gay and bisexual men (GBM) in New South Wales (NSW), Australia. DESIGN: We analysed HIV testing data from existing passive and sentinel surveillance systems between 2010 and 2018. METHODS: Six indicators were measured: (1) state-wide total HIV laboratory tests; (2) number of GBM attending publicly-funded clinics; (3) 12-monthly testing uptake; (4) annual testing frequency; (5) HIV testing with a STI diagnosis; and (6) HIV positivity. Mathematical modelling was used to estimate (7) the proportion of men with undiagnosed HIV. Indicators were stratified by Australian vs. overseas-born. RESULTS: Overall, 43,560 GBM attended participating clinics (22,662 Australian-born, 20,834 overseas-born) from 2010-2018. Attendees increased from 5,186 in 2010 to 16,507 in 2018. There were increasing trends (p<0.001 for all) in testing uptake (83.9% to 95.1%); testing with a STI diagnosis (68.7% to 94.0%); annual HIV testing frequency (1.4 to 2.7); and a decreasing trend (p<0.01) in HIV positivity (1.7% to 0.9%).Increases in testing were similar in Australian-born and overseas-born GBM. However, there were decreasing trends in the estimated undiagnosed HIV proportion overall (9.5% to 7.7%) and in Australian-born GBM (7.1% to 2.8%), but an increasing trend in overseas-born GBM (15.3% to 16.9%) (p<0.001 for all).

Prevalence and associations of larger burden of intra-anal high-grade squamous intraepithelial lesions at baseline in an Australian cohort of gay and bisexual men: The Study of the Prevention of Anal Cancer.

OBJECTIVES: To investigate factors associated with larger burden of intra-anal high-grade squamous intraepithelial lesions (HSIL) in a natural history study of HSIL. METHODS: 617 gay and bisexual men (GBM) attended a baseline visit. High-resolution anoscopy-directed biopsy was performed of suspected HSIL. GBM with biopsy-confirmed HSIL (bHSIL) affecting a single-octant were compared with those who had bHSIL affecting a larger area. RESULTS: Of 196 men with bHSIL at baseline, 73 (37.2 %) had larger bHSIL burden. Larger burden was independently associated with anal HPV16 detection (aOR 2.06, 95 % CI 1.09-3.89, p = 0.026) and infection with a greater number of high-risk HPV types (aOR per type increase 1.25, 95 % CI 1.05-1.49, p-trend = 0.010). CONCLUSION: The observation that men with a larger burden of HSIL also had more risk factors for anal cancer suggests this group may warrant closer observation to ensure earlier detection, and thus improved prognosis, of individuals whose HSIL may progress to anal cancer.

Association of anal symptoms with anal high grade squamous intraepithelial lesions (HSIL) among men who have sex with men: Baseline data from the study of the prevention of anal cancer (SPANC).

BACKGROUND: The association between anal high-grade squamous intraepithelial lesion (HSIL) and anal symptoms has not been systematically investigated. METHODS: The Study of Prevention of Anal Cancer is a prospective cohort study of men who have sex with men (MSM) ≥ 35 years old in Sydney, Australia. Self-reported symptoms were collected. Anal cytology and high-resolution anoscopy were undertaken. Using baseline visit data, men negative for squamous intra-epithelial lesion (SIL) were compared with men diagnosed with composite-HSIL (cytology and/or histology). Logistic regression analyses were performed to assess the association of symptoms with HSIL. RESULTS: Among 414 MSM included (composite-HSIL (n = 231); negative for SIL (n = 183)), 306 (73.9%) reported symptom(s) within the last 6 months. There was no association between any symptom and composite-HSIL. A significant association between anal lump and a larger burden of HSIL (at least 2 intra-anal octants) (anal lump within last month: p = 0.014; anal lump within last 6 months: p = 0.010) became non-significant after adjusting for HIV-status and recent anal warts (anal lump within last month: p = 0.057; anal lump within last 6 months: p = 0.182). CONCLUSIONS: Among MSM age 35 years and older, most anal symptoms are not a useful marker of anal HSIL.

Experience and psychological impact of anal cancer screening in gay, bisexual and other men who have sex with men: a qualitative study.

OBJECTIVE: Human papillomavirus-related anal cancer rates are increasing and are particularly high in gay, bisexual and other men who have sex with men (GBM/MSM), especially HIV-positive individuals. Although screening programs for high-risk populations have been advocated, concerns about possible adverse psychological consequences exist. This study aimed to investigate GBM/MSM's experience, understanding and emotional response to screening techniques for anal cancer to determine how best to minimise psychological distress in future programs. METHODS: In-depth qualitative face-to-face interviews were conducted with 21 GBM/MSM participating in the "Study of the Prevention of Anal Cancer" in Sydney, Australia, between June 2013 and June 2014. Nonrandom, purposive sampling was used to ensure heterogeneity with respect to HIV status and screening test results. Framework analysis method was used to organise the data and identify emerging themes. RESULTS: Knowledge about anal cancer, human papillomavirus and the link between them was limited. Abnormal screening results affected participants' sense of well-being and were associated with anxiety and concern about developing anal cancer. HIV-negative men receiving abnormal results showed higher levels of distress compared to their HIV-positive counterparts. Consultations with general practitioners about abnormal results had an important role in increasing participants' understanding and in moderating their anxiety. CONCLUSION: Anal cancer screening should be accompanied by health education around anal cancer, its aetiology and the meaning of associated test results. Simple and effective communication strategies should be encouraged. Collaboration with general practitioners could assist the process of education and reporting test results.

Hospitalisation rates and associated factors in community-based cohorts of HIV-infected and -uninfected gay and bisexual men.

OBJECTIVES: There is evidence that HIV-positive patients are suffering from a greater burden of morbidity as they age due to nonAIDS-related complications. To date it has been difficult to determine what part of this excess risk is due to the health effects of HIV, its treatment or to lifestyle factors common to gay and bisexual men (GBM). We calculated overall and cause-specific hospitalisation rates and risk factors for hospitalisations in HIV-negative and HIV-positive cohorts of GBM and compare these with rates in the general male population. METHODS: We conducted a record linkage study, linking two cohorts of HIV-negative (n = 1325) and HIV-positive (n = 557) GBM recruited in Sydney, New South Wales (NSW), Australia with the NSW hospital discharge data register. We compared rates of hospitalisation in the two cohorts and risk factors for hospitalisation using random-effects Poisson regression methods. Hospitalisation rates for each cohort were further compared with those in the general male population using indirect standardisation. RESULTS: We observed 2032 hospitalisations in the HIV-negative cohort during 13,016 person-years (PYs) [crude rate: 15.6/100 PYs (95% CI: 14.9-16.3)] and 2130 hospitalisations in the HIV-positive cohort during 5571 PYs [crude rate: 38.2/100 PYs (95% CI: 36.6-39.9)]. HIV-positive individuals had an increased risk of hospitalisation compared with the HIV-negative individuals [adjusted-IRR: 2.34 (95% CI: 1.91-2.86)] and the general population [SHR: 1.45 (95% CI: 1.33-1.59)]. Hospitalisation rates were lower in the HIV-negative cohort compared with the general population [SHR: 0.72 (95% CI: 0.67-0.78)]. The primary causes of hospitalisation differed between groups. CONCLUSIONS: HIV-positive GBM continue to experience excess morbidity compared with HIV-negative GBM men and the general population. HIV-negative GBM had lower morbidity compared with the general male population suggesting that GBM identity does not confer excess risk.

Transmission risk behaviour at enrolment in participants in the INSIGHT Strategic Timing of AntiRetroviral Treatment (START) trial.

OBJECTIVES: A proportion of HIV-positive people have condomless sex. Antiretroviral treatment (ART) reduces infectiousness, but a substantial proportion of HIV-diagnosed people are not yet on ART. We describe baseline self-reported risk behaviours in ART-naïve Strategic Timing of AntiRetroviral Treatment (START) trial participants. METHODS: All START participants completed a risk behaviour questionnaire. Data were collected on sociodemographics, lifestyle factors, health and wellbeing status and clinical status. Recent sexual behaviour and HIV transmission beliefs in the context of ART were also assessed. The primary interest was in condomless sex with serodifferent partners (CLS-D) in the past two months. RESULTS: A total of 4601 of 4685 HIV-positive participants (98%) completed the questionnaire [2559 men who have sex with men (MSM), 803 heterosexual men and 1239 women]. Region of recruitment was Europe/Israel, 33%; South America/Mexico, 25%; Africa, 22%; other, 21%. Median age was 36 years [interquartile range (IQR) 29, 44 years]. Forty-five per cent reported white ethnicity and 31% black ethnicity. Two per cent had HIV viral load < 50 HIV-1 RNA copies/mL. Seventeen per cent (767 of 4601) reported CLS-D; 20% of MSM compared with 10% of heterosexual men and 14% of women. MSM were also more likely to report multiple CLS-D partners. Possible risk limitation measures (reported by more than half of those who had CLS-D) were seropositioning (receptive anal CLS-D only) or withdrawal (insertive anal CLS-D always without ejaculation). CLS-D was more commonly reported by participants from South America/Mexico and North America compared with Europe; among heterosexual men and women CLS-D was also more commonly reported among participants from Africa compared with Europe. Knowledge of ART impact on transmission risk was low. CONCLUSIONS: A substantial minority recruited to the START study reported CLS-D at baseline. CLS-D reporting was higher in MSM than heterosexuals and varied significantly according to region of recruitment. A substantial proportion of MSM reporting CLS-D appear to take transmission risk limitation measures.

Survival after cutaneous melanoma in kidney transplant recipients: a population-based matched cohort study.

Transplant recipients are at elevated risk of melanoma and may have poorer outcomes than nontransplant recipients. We conducted a national, population-based, matched cohort study of Australian kidney transplant recipients and randomly selected members of the general population matched for age, sex, state and year of diagnosis with invasive cutaneous melanoma (1982-2003). Melanoma histopathological characteristics were extracted from cancer registry notifications and death data were obtained from the National Death Index (1982-2011). Histopathology was compared using conditional logistic regression and overall survival analyzed using Cox proportional hazard models. Compared to melanomas in nontransplant recipients (n = 202), melanomas in transplant recipients (n = 75) had a higher Clark's level (p = 0.007) and higher American Joint Committee on Cancer pathologic stage (p = 0.002), but not Breslow thickness (p = 0.11). Posttransplant melanoma conferred higher risk of death (adjusted hazard ratio 4.26, 95% CI 2.71-6.72, p < 0.001) after adjustment for the matching variables, pathologic stage, histological type and anatomic site. This was not explained by transplantation alone. Melanomas in transplant recipients are more invasive than those in nonrecipients. More aggressive tumor behavior is also supported by a markedly poorer outcome. Treatment algorithms developed for the general population with melanoma may not apply to transplant recipients. A review of patient education and skin cancer screening guidelines is warranted.

Anal intraepithelial neoplasia and squamous cell carcinoma in HIV-infected adults.

Anal cancer is one of the most common non-AIDS-defining malignancies in the era of combination antiretroviral therapy. Its precursor lesion, anal intraepithelial neoplasia (AIN), is highly prevalent in HIV-infected populations. More than 90% of anal squamous cell cancers are attributable to human papillomavirus (HPV). While the biology of HPV-related intraepithelial neoplasia is consistent across lower anogenital sites, the natural history of AIN is not well established and cannot be assumed to be identical to that of cervical intraepithelial neoplasia. Screening strategies to prevent anal cancer should be developed based on robust natural history data in HIV-infected and uninfected populations. Likewise, treatments need to be tested in randomized clinical trials, and reserved for those at significant risk of progression to cancer. This review covers the epidemiology, pathogenesis and immunology of HPV infection, AIN and anal cancer, and summarizes the current diagnosis, screening and treatment strategies in HIV-infected adults.

Size of anal squamous cell carcinomas at diagnosis: a retrospective case series.

Anal squamous cell carcinoma is more common in HIV-positive homosexual men than in the general population and prognosis worsens with increasing tumour size. To identify opportunities for earlier diagnosis, we aimed to determine size and visibility of anal squamous cell carcinoma at diagnosis. We conducted a retrospective review of medical records between 1992 and 2010 from one hospital radiotherapy centre, a major centre for HIV care, in Melbourne, Australia. Of 128 cases of anal squamous cell carcinoma, 24 (19%) were in HIV-positive men. At diagnosis, half (52%) of the tumours were externally visible and mean estimated tumour size was 36 mm (29 mm in HIV-positive and 38 mm in HIV-negative patients; p = 0.04) and 114/121 (94%) tumours were 1 cm or larger. The most frequent symptoms were bleeding (43%) and pain (36%) and mean duration of symptoms was 22 weeks. This suggests most anal squamous cell carcinoma were visible or palpable for some time before diagnosis, meaning that screening high-risk groups by anal inspection and palpation is plausible.

Acceptability of digital anal cancer screening examinations in HIV-positive homosexual men.

OBJECTIVES: Anal cancer is more common in HIV-positive homosexual men than in HIV-negative homosexual men and the general population. Earlier diagnosis leads to improved prognosis. We aimed to determine if regular anal inspection and digital examination of asymptomatic homosexual men attending for routine HIV care were acceptable and to record the rate of referral for diagnosis of potentially malignant anal lesions. METHODS: We offered anal examinations to consecutive homosexual men with HIV infection aged ≥ 35 years during their routine HIV clinic visits, aiming to complete three examinations over a 12-month period. Acceptability questionnaires were completed at baseline and after each examination and doctors recorded examination findings and all resulting interventions. Hospital referral outcomes were collected and interventions were costed using the Australian Medical Benefits Schedule. RESULTS: Of 142 men who were offered enrolment in the study, 102 [72%; 95% confidence interval (CI) 64-79%] participated. Following the initial anal examinations, four men were referred to surgeons. Cancer was excluded in three men (3%; 95% CI 1-8%) and one was diagnosed with anal squamous cell carcinoma (SCC). Three men had anoscopy performed at the time and two were referred for colonoscopy. Ninety-eight per cent (95% CI 93-100%) of respondents said that they would probably have the examination next time. The intervention was estimated to cost approximately Australian $16 per examination. CONCLUSIONS: Regular anal digital examinations are an acceptable and inexpensive addition to the routine care of homosexual men with HIV infection.

De novo cancer-related death in Australian liver and cardiothoracic transplant recipients.

Evidence is sparse on the relative mortality risk posed by de novo cancers in liver and cardiothoracic transplant recipients. A retrospective cohort study was conducted in Australia using population-based liver (n = 1926) and cardiothoracic (n = 2718) registries (1984-2006). Standardized mortality ratios (SMRs) were computed by cancer type, transplanted organ, recipient age and sex. During a median 5-year follow-up, de novo cancer-related mortality risk in liver and cardiothoracic recipients was significantly elevated compared to the matched general population (n = 171; SMR = 2.83; 95% confidence interval [95%CI], 2.43-3.27). Excess risk was observed regardless of transplanted organ, recipient age group or sex. Non-Hodgkin lymphoma was the most common cancer-related death (n = 38; SMR = 16.6; 95%CI, 11.87-22.8). The highest relative risk was for nonmelanocytic skin cancer (n = 23; SMR = 49.6, 95%CI, 31.5-74.5), predominantly in males and in recipients of heart and lung transplants. Risk of death from de novo cancer was high in pediatric recipients (n = 5; SMR = 41.3; 95%CI, 13.4-96.5), four of the five deaths were non-Hodgkin lymphoma. De novo cancer was a leading cause of late death, particularly in heart and liver transplantation. These findings support tailored cancer prevention strategies, surveillance to promote early detection, and guidelines for managing immunosuppression once cancer occurs.

Cancer, immunodeficiency and antiretroviral treatment: results from the Australian HIV Observational Database (AHOD).

OBJECTIVES: The objective of the study was to conduct a within-cohort assessment of risk factors for incident AIDS-defining cancers (ADCs) and non-ADCs (NADCs) within the Australian HIV Observational Database (AHOD). METHODS: A total of 2181 AHOD registrants were linked to the National AIDS Registry/National HIV Database (NAR/NHD) and the Australian Cancer Registry to identify those with a notified cancer diagnosis. Included in the current analyses were cancers diagnosed after HIV infection. Risk factors for cancers were also assessed using logistic regression methods. RESULTS: One hundred and thirty-nine cancer cases were diagnosed after HIV infection among 129 patients. More than half the diagnoses (n = 68; 60%) were ADCs, of which 69% were Kaposi's sarcoma and 31% non-Hodgkin's lymphoma. Among the NADCs, the most common cancers were melanoma (n = 10), lung cancer (n = 6), Hodgkin's lymphoma (n = 5) and anal cancer (n = 5). Over a total of 21021 person-years (PY) of follow-up since HIV diagnosis, the overall crude cancer incidence rate for any cancer was 5.09/1000 PY. The overall rate of cancers decreased from 15.9/1000 PY [95% confidence interval (CI) 9.25-25.40/1000 PY] for CD4 counts < 100 cells/µL to 2.4/1000 PY (95% CI 1.62-3.39/1000 PY) for CD4 counts > 350 cells/µL. Lower CD4 cell count and prior AIDS diagnoses were significant predictors for both ADCs and NADCs. CONCLUSIONS: ADCs remain the predominant cancers in this population, although NADC rates have increased in the more recent time period. Immune deficiency is a risk factor for both ADCs and NADCs.

Comparison of de novo cancer incidence in Australian liver, heart and lung transplant recipients.

Population-based evidence on the relative risk of de novo cancer in liver and cardiothoracic transplant recipients is limited. A cohort study was conducted in Australia using population-based liver (n = 1926) and cardiothoracic (n = 2718) registries (1984-2006). Standardized incidence ratios (SIRs) were computed by cancer type, transplanted organ and recipient age. Cox regression models were used to compare cancer incidence by transplanted organ. During a median 5-year follow-up, the risk of any cancer in liver and cardiothoracic recipients was significantly elevated compared to the general population (n = 499; SIR = 2.62, 95%CI 2.40-2.86). An excess risk was observed for 16 cancer types, predominantly cancers with a viral etiology. The pattern of risk by cancer type was broadly similar for heart, lung and liver recipients, except for Merkel cell carcinoma (cardiothoracic only). Seventeen cancers (10 non-Hodgkin lymphomas), were observed in 415 pediatric recipients (SIR = 23.8, 95%CI 13.8-38.0). The adjusted hazard ratio for any cancer in all recipients was higher in heart compared to liver (1.29, 95%CI 1.03-1.63) and lung compared to liver (1.65, 95%CI 1.26-2.16). Understanding the factors responsible for the higher cancer incidence in cardiothoracic compared to liver recipients has the potential to lead to targeted cancer prevention strategies in this high-risk population.

Chlamydia trachomatis serovars in community-based HIV-positive and HIV-negative men who have sex with men in Sydney, Australia.

OBJECTIVES: There are few data on the distribution of specific Chlamydia trachomatis serovars among men who have sex with men (MSM) outside clinical settings. To investigate these patterns, serovar determination was performed on chlamydia-positive samples from two community-based cohort studies of HIV-positive and HIV-negative MSM in Sydney, Australia. METHODS: From January 2005 to June 2007 all positive C trachomatis pharyngeal, urine and anal samples were evaluated. The serovar of each C trachomatis infection was determined by omp1 gene sequencing with confirmatory quantitative PCR screening. Symptom data were routinely reported by study participants at the time of testing. RESULTS: Serovar determination was possible for 54 samples among 52 participants. Seven samples were not able to be typed. Site-specific symptoms were reported by fewer than 10% of participants diagnosed with pharyngeal and anogenital chlamydia. The most commonly identified serovars were serovar D (n=32, 59.3%, 95% CI 45.0 to 72.4), followed by serovar G (n=11, 20.4%, 95% CI 10.6 to 33.5) and serovar J (n=5, 9.3%, 95% CI 3.1 to 20.3). Only one lymphogranuloma venereum serovar was identified (L2b). CONCLUSIONS: This community-based study found a similar distribution of chlamydia serovars to that observed among Australian community-based MSM several years ago, and serovar distribution recently observed among predominantly symptomatic MSM at a Sydney clinic. These findings suggest little change in C trachomatis serovar distribution in Australian MSM over the past decade and a lack of correlation of specific chlamydia serovars with anogenital symptoms among MSM.

Defining high HIV incidence subgroups of Australian homosexual men: implications for conducting HIV prevention trials in low HIV prevalence settings.

OBJECTIVES: The aim of the study was to assess whether subpopulations with sufficiently high HIV incidences for HIV prevention trials can be identified in low HIV incidence settings such as Australia. METHODS: In a community-based cohort study of HIV-negative homosexually active men in Sydney, Australia, potential risk factors associated with an annual HIV incidence of ≥2 per 100 person-years (PY) were identified. A stepwise procedure ranked these factors according to HIV incidence, to create a 'high-incidence' subgroup of participants. Willingness to participate in HIV prevention trials was assessed. RESULTS: Although the incidence in the cohort overall was only 0.78 per 100 PY, nine risk variables were associated with an HIV incidence of 2 per 100 PY or greater. Stepwise inclusion of these variables revealed a 'high-incidence' subgroup of men representing 24% of the total follow-up time with a combined HIV incidence of 2.71 per 100 PY, who reported at least one of three risk factors in the past 6 months. These men were more willing than others to participate in vaccine and antiretroviral therapy HIV prevention trials. CONCLUSIONS: These findings demonstrate that it is possible to identify high HIV incidence subpopulations in low-incidence settings such as Australia, and these men are of above average willingness to participate in HIV prevention trials.

Attitudes towards new HIV biomedical prevention technologies among a cohort of HIV-negative gay men in Sydney, Australia.

OBJECTIVES: The aim of the study was to explore the awareness of rectal microbicides, the use of pre-exposure prophylaxis (PREP) and the willingness to participate in biomedical HIV prevention trials in a cohort of HIV-negative gay men. METHODS: In a community-based cohort study, HIV-negative homosexually active men in Sydney, Australia were questioned about awareness of rectal microbicides, use of PREP, and willingness to participate in trials of such products. Predictors of awareness and willingness to participate were analysed by logistic regression. Use of PREP was examined prospectively. RESULTS: Overall, 14% had heard of rectal microbicides. Older (P=0.05) and university-educated men (P=0.001) were more likely to have knowledge of rectal microbicides. Almost one-quarter (24%) of men reported that they were likely/very likely to participate in rectal microbicide trials. Among those men with definite opinions on participation, awareness of rectal microbicides was significantly associated with unwillingness to participate [odds ratio (OR) 0.78, 95% confidence interval (CI) 0.65-0.93, P=0.007]. Willingness to participate in trials using antiretroviral drugs (ARVs) to prevent HIV infection was reported by 43% of men, and was higher among those who reported unprotected anal intercourse (UAI) with HIV-positive partners (OR 1.88, 95% CI 0.99-3.56). There was no evidence of current PREP use. CONCLUSIONS: This study demonstrates that Australian gay men have had little experience with PREP use and rectal microbicides. About half would be willing to consider participation in trials using ARVs to prevent HIV infection. Extensive community education and consultation would be required before PREP or rectal microbicides could be trialled in populations of gay Australian men.

Anal human papillomavirus genotype diversity and co-infection in a community-based sample of homosexual men.

OBJECTIVES: To determine the prevalence and risk factors for anal human papillomavirus (HPV) infection in community-based cohorts of homosexual men in Sydney, Australia. METHODS: A cross-sectional study in consecutively presenting participants in the positive Health and Health in Men cohorts in 2005. HPV testing was performed on anal PreservCyt specimens collected from 316 homosexual men (193 HIV-negative, 123 HIV-positive) using the Digene Hybrid Capture 2 (HC-2) assay for detection of low-risk (LR) and high-risk (HR) genotypes. HPV genotype testing was also performed on a subset of 133 men (93 HIV-negative, 36 HIV-positive) using Roche Linear Array (LA) assay. RESULTS: HC-2 detected HPV infection in 79% of men (LR 55%, HR 69%). HIV-positive men were more likely than HIV-negative men to have LR-HPV (OR 3.5, 95% CI 2.1 to 5.7) and HR-HPV (OR 5.5, 95% CI 3.0 to 10.2). LA detected HPV infection in 95% of men (LR 85%, HR 77%). HIV-positive men had a mean of 7.1 HPV types compared to 4.2 in HIV-negative men; the difference was significant for both LR-HPV (p<0.001) and HR-HPV (p<0.001). HPV-16 was detected in 36% of HIV-positive and 27% of HIV-negative men. There was no consistent trend in HPV prevalence with increasing age. HR-HPV detection was associated with anal bleeding for HIV-positive men and anal warts for HIV-negative men. CONCLUSIONS: Anal HPV infection was nearly universal in this community-based sample of homosexual men. A wide variety of HPV genotypes were detected, and co-infection with multiple genotypes was common. Anal HPV infection is more prevalent and more diverse in HIV-positive than HIV-negative homosexual men.

Increasing role of herpes simplex virus type 1 in first-episode anogenital herpes in heterosexual women and younger men who have sex with men, 1992-2006.

OBJECTIVES: Herpes simplex virus (HSV) type 1 is causing an increasing proportion of anogenital herpes; however, it is unclear which populations are affected. We describe the contribution of HSV-1 to first-episode anogenital herpes and its associations. METHODS: For all cases of first-episode anogenital herpes diagnosed at the Sydney Sexual Health Centre from 1992 to 2006, medical record review was used to confirm the type and anatomical site. Age, sex, HIV status and sexual behaviour data were extracted from the clinic database. RESULTS: Overall, among 1845 confirmed cases of first-episode anogenital herpes the proportion attributable to HSV-1 increased from 29% to 42% (odds ratio (OR) per 3-year band 1.19; 95% CI 1.11 to 1.27). When stratified by gender of sexual partners the proportion of first-episode anogenital herpes due to HSV-1 increased over time, but only achieved significance in heterosexual women (p<0.01). Among men who have sex with men (MSM), HSV-1 only increased for those less than 28 years of age, 17% in 1992-4 to 76% in 2004-6 (OR per 3-year band 1.58; 95% CI 1.14 to 2.19). The proportion attributable to HSV-1 was higher for anal than genital herpes and MSM were much more likely to have anal disease. CONCLUSIONS: The proportion of first-episode anogenital herpes due to HSV-1 significantly increased among younger MSM and heterosexual women over the 15-year period. In some clinical populations, such as young MSM and women or patients with anal disease, HSV-1 may now account for the majority of first-episode anogenital herpes.

Cost-effectiveness of HIV nonoccupational post-exposure prophylaxis in Australia.

OBJECTIVE: The aim of the study was to determine the cost-effectiveness of HIV nonoccupational post-exposure prophylaxis (NPEP) in Australia. METHODS: A retrospective cost analysis of a population-based observational cohort of 1601 participants eligible for NPEP in Australia between 1998 and 2004 was carried out. We modelled NPEP treatment costs and combined them with effectiveness outcomes to calculate the cost per seroconversion avoided. We estimated the cost-utility of the programme, and sensitivity and threshold analysis was performed on key variables. RESULTS: The average NPEP cost per patient was A$1616, of which A$848 (52%) was for drugs, A$331 (21%) for consultations, A$225 (14%) for pathology and A$212 (13%) for other costs. The cost per seroconversion avoided in the cohort was A$1 647,476 in our base case analysis, and A$512,410 when transmission rates were set at their maximal values. The cost per quality-adjusted life-year (QALY) was between A$40,673 and A$176,772, depending on the risks of HIV transmission assumed. CONCLUSIONS: In our base case, NPEP was not a cost-effective intervention compared with the widely accepted Australian threshold of A$50,000 per QALY. It was only cost-effective after receptive unprotected anal intercourse exposure to an HIV-positive source. Although NPEP was a relatively well-targeted intervention in Australia, its cost-effectiveness could be improved by further targeting high-risk exposures.

Testing for HIV and sexually transmissible infections within a mainly online sample of gay men who engage in group sex.

INTRODUCTION: Group sex among gay men has been associated with other HIV risk behaviours. Gay men who engage in group sex may be at increased risk of infection with HIV and other sexually transmitted infections (STI). METHODS: The Three or More Study (TOMS) of group sex among gay men utilised an anonymous, self-completed survey about participants' most recent occasion of group sex with other men and in-depth interviews with a small number of these survey participants. The 436 men who reported having engaged in group sex within the previous month were included in these analyses. RESULTS: Among 436 men who engaged in group sex within the previous month, 32.5% reported unprotected anal intercourse (UAI) with non-regular, mostly HIV non-seroconcordant partners at this recent group sex encounter (GSE) and the majority reported other sex practices that are risk factors for STI other than HIV. Over one-third reported having been tested for HIV or other STI since their last GSE; those who had engaged in UAI at the GSE were more likely to have been tested (p = 0.008). Men who had a doctor with whom they were able to discuss their group sex activities had received a broader range of STI tests (p = 0.003). CONCLUSION: Sex practices that risk the transmission of STI were common within this high-risk sample, whereas awareness of risk and the need for testing was high but not universal. Frank discussion with doctors of patients' group sex behaviour also enhanced decisions about adequate testing. Gay men in group sex networks are an appropriate priority for sexual health screening.