Changing Epidemiology of Gonorrhea in Adelaide, South Australia.

BACKGROUND: Gonorrhea is a significant public health concern. The changing epidemiology of gonorrhea in Australia has highlighted the need for detailed examination of surveillance data to determine population groups at greatest risk for infection. METHODS: We analyzed deidentified gonorrhea notification data for the years 2012 to 2017, in Adelaide (N = 3680), calculating age-adjusted notification and antibiotic resistance rates. Age, gender, year, sexual orientation, and socioeconomic status were assessed for associations with gonorrhea notifications using negative binomial, log binomial and spatial autoregressive models. Maps were generated to examine spatial localization of gonorrhea rates in Adelaide. RESULTS: Gonorrhea notification rates in Adelaide increased annually, with a 153% adjusted increase in rates from 2012 to 2017, localized to specific areas and inversely associated with income levels. The increase in rates in 2016 and 2017 was associated with young heterosexuals from low income areas. Azithromycin-resistant notifications increased significantly in 2016 in young heterosexuals. Reinfections were significantly more likely in men who have sex with men than other population groups. CONCLUSIONS: This study demonstrates the changing epidemiology of gonorrhea in Adelaide from a largely men who have sex with men profile toward an increase in young heterosexual gonorrhea. This could be seen as a harbinger for future increases in heterosexually transmitted HIV and other sexually transmitted infections in Australia.

Was an epidemic of gonorrhoea among heterosexuals attending an Adelaide sexual health services associated with variations in sex work policing policy?

BACKGROUND: A review of historical trends in gonococcal diagnoses made at the Adelaide Sexual Health Clinic (ASHC), South Australia, identified a substantial rise in diagnoses among heterosexuals between 2006 and 2010. Sex work is illegal in South Australia, regulated in Victoria and legal in New South Wales. This and other factors that could have influenced the epidemic were explored in this analysis. METHODS: Retrospective analyses of gonorrhoea diagnoses made by sexual health services between 1990 and 2012 in three Australian state capitals, Melbourne (Victoria) and Sydney (New South Wales) were undertaken. RESULTS: At the ASHC the proportion of gonorrhoea diagnoses was higher between 2006 and 2010 among heterosexual men (5.34% vs 0.84%, p<0.001), non-sex worker women (0.64% vs 0.28%, p<0.001) and female sex workers (FSWs) (1.75% vs 0.24%, p<0.001) compared with other years. This relationship was not seen at the Melbourne Sexual Health Clinic and corresponding data from the Sydney Sexual Health Centre showed that FSWs were less likely to have gonorrhoea between 2006 and 2010 than the other groups (p=0.746, p=0.522, p=0.024, respectively). At ASHC FSWs were significantly more likely to be diagnosed between 2006 and 2010 (OR 2.8, 95% CI 1.48 to 5.27, p=0.002). Charges against sex workers peaked in 2007/2008. CONCLUSIONS: A substantial, self-limiting rise in diagnoses of heterosexual gonorrhoea was seen in Adelaide FSWs between 2006 and 2010. Removing barriers to condom use is vital to the prevention of HIV and STI transmission.

Sexually transmissible infections and characteristics of men aged 60 years and over attending a public sexually transmitted diseases (STD) clinic in South Australia.

UNLABELLED: Background With society ageing, sexually transmissible infections (STIs) in the older population are of interest from an economic, health-related and social burden perspective. Few studies on STIs in men older than 60 years of age exist. METHODS: A retrospective study was performed looking at characteristics of, and STIs in, 29106 men (of which 689 were older than 60 years of age), at first presentation, visiting the only South Australian public sexually transmitted diseases (STD) clinic over a 13-year period. RESULTS: Older men [men who have sex with men (MSM) and men who have sex with women (MSW)] were less likely than younger men to have been tested for HIV. CONCLUSION: There is a need for increased HIV testing in older men.

Epidemiology of gonorrhoea notifications in Australia, 2007-12.

UNLABELLED: Background An increase in the notification rate of gonorrhoea was observed in the national surveillance system. In Australia, gonorrhoea is relatively rare, apart from among some populations of Aboriginal people and men who have sex with men. METHODS: Data about gonorrhoea cases reported between 2007 and 2012 from all Australian jurisdictions were extracted from the National Notifiable Diseases Surveillance System. Analyses were undertaken of the time trends in counts and rates, according to jurisdiction, gender, Aboriginal and Torres Strait Islander status, diagnosis method and sexual orientation. RESULTS: The largest increase in notifications between 2007 and 2012 was observed in both men and women in New South Wales (2.9- and 3.7-fold greater in 2012 than 2007, respectively) and Victoria (2.4- and 2.7-fold greater in 2012 than 2007, respectively), men in the Australian Capital Territory and women in Queensland. The highest notification rates remained in Indigenous people in the Northern Territory and Western Australia, and particularly in women, although rates may have decreased over the study period. Changes in age and sex distribution, antimicrobial resistance and patterns of exposure and acquisition were negligible. CONCLUSIONS: There is an ongoing gonorrhoea epidemic affecting Aboriginal and Torres Strait Islander people in Australia, but the increases in notifications have occurred primarily in non-Aboriginal populations in the larger jurisdictions. Interpretation of these surveillance data, especially in relation to changes in population subgroups, would be enhanced by laboratory testing data. Further efforts are needed to decrease infection rates in populations at highest risk.

Consider HIV--testing for HIV and HIV indicator diseases.

BACKGROUND: Since the advent of highly active antiretroviral therapy (HAART), human immunodeficiency virus (HIV) can be considered a treatable condition. In Australia in 2010, 40% of people had their HIV diagnosed late, where late is defined as CD4 <350 cells/mm³ (CD4 normal range = 450-1,500 cells/mm³). This late diagnosis can significantly impact on prognosis. OBJECTIVE: This article provides examples of late HIV diagnosis and an update of how and when to test for HIV in clinical practice. DISCUSSION: While HIV is usually diagnosed in those with identifiable risk factors, awareness of indications to test and potential HIV indicator diseases can provide the general practitioner with a cue to offer testing to a patient. Early diagnosis of HIV offers benefits to the patient and the community.

HIV non-B subtype distribution: emerging trends and risk factors for imported and local infections newly diagnosed in South Australia.

Monitoring HIV subtype distribution is important for understanding transmission dynamics. Subtype B has historically been dominant in Australia, but in recent years new clades have appeared. Since 2000, clade data have been collected as part of HIV surveillance in South Australia. The aim of this study was to evaluate the prevalence of and risk factors for HIV-1 non-B subtypes. The study population was composed of newly diagnosed, genotyped HIV subjects in South Australia between 2000 and 2010. We analyzed time trends and subtype patterns in this cohort; notification data were aggregated into three time periods (2000-2003, 2004-2006, and 2007-2010). Main outcome measures were number of new non-B infections by year, exposure route, and other demographic characteristics. There were 513 new HIV diagnoses; 425 had information on subtype. The majority (262/425) were in men who have sex with men (MSM), predominantly subtype B and acquired in Australia. Infections acquired in Australia decreased from 77% (2000-2003) to 64% (2007-2010) (p=0.007) and correspondingly the proportion of subtype B declined from 85% to 68% (p=0.002). Non-B infections were predominantly (83%) heterosexual contacts, mostly acquired overseas (74%). The majority (68%) of non-B patients were born outside of Australia. There was a nonsignificant increase from 1.6% to 4.2% in the proportion of locally transmitted non-B cases (p=0.3). Three non-B subtypes and two circulating recombinant forms (CRFs) were identified: CRF_AE (n=41), C (n=36), CRF_AG (n=13), A (n=9), and D (n=2). There has been a substantial increase over the past decade in diagnosed non-B infections, primarily through cases acquired overseas.

Patterns of treatment of external genital warts in Australian sexual health clinics.

BACKGROUND: External genital warts are a common sexually transmitted viral disease. We describe the patterns of treatment for initial presentations of external genital warts (EGWs) in Australian sexual health centers. METHODS: This was a retrospective audit of 489 case notes from consecutive individuals who presented with a new diagnosis of EGWs to 1 of 5 major sexual health clinics in Australia. Eligibility criteria were consecutive patients aged 18 to 45 years inclusively, presenting with first ever episode of EGWs from January 1, 2004. Exclusion criteria were patients who were immunocompromised, including HIV infection, or enrollment in a treatment study for EGWs. RESULTS: The median age at presentation of women was 23.2 years and of men 26.8 years. One quarter (n = 127) of patients had another sexually transmitted infection diagnosed at presentation. Nearly half of the patients (n = 224) presented only once for treatment. Most often, patients were treated with a monotherapy (n = 382/489; 78%), usually cryotherapy (257; 53%). Staff applied treatment in 361 (74%) cases. There was wide variation across sites, possibly reflecting local policies and budgets. We found no difference in wart resolution (n = 292; 60%) by initial treatment chosen. CONCLUSIONS: The diagnosis and treatment of genital warts constitute a sizable proportion of clinical visits to the audited sexual health services and require a large input of staff time to manage, including the application of topical treatments. Our results help complete the picture of the burden of EGWs on Australian sexual health centers before the introduction of the HPV vaccine.

Real-time PCRs for detection of Trichomonas vaginalis beta-tubulin and 18S rRNA genes in female genital specimens.

Trichomonas vaginalis is the cause of one of the most common types of vaginitis, trichomoniasis. The incidence of trichomoniasis in developed countries has decreased substantially during the past decade, but high prevalence of this disease can still be found in rural and remote areas of Australia. Clinical manifestations of symptomatic women are generally non-specific, but include vaginal discharge, vaginitis and irritation. T. vaginalis infection has also been linked to the increased risk of human immunodeficiency virus transmission. Current diagnosis of T. vaginalis relies on the visualization of motile organisms in a wet-mount preparation. Culture is used mainly in reference laboratories. The latter two methods require viable organisms and would not be suitable for use where transportation of specimens can be delayed. Two real-time fluorescence resonance energy transfer (FRET) hybridization probe PCR assays were used in this study to test for T. vaginalis DNA, targeting the beta-tubulin and 18S rRNA genes. We tested 500 randomly selected female patients, in an STD setting, for T. vaginalis DNA. The FRET PCRs targeting the beta-tubulin gene and the 18S rRNA gene detected 96 % (85/89) and 100 % (89/89) , respectively, of the positive specimens (first-void urine sample or genital swabs). Wet-mount microscopy was performed on 76 of these PCR-positive specimens and showed a sensitivity of 38 % (29/76). The prevalence, by PCR, of trichomoniasis was 18 % in this study. The two real-time PCRs developed in this study, targeting different genetic regions of the organism, provide a rapid, sensitive and specific diagnosis of T. vaginalis infection.

Recurrent gonorrhoea in South Australia, 1987-2003.

In Australia, it is unclear if individuals are being recurrently infected with gonorrhoea, a proxy for identifying core groups. We reviewed all notified gonococcal (GC) infections in South Australia between 1987 and 2003. A case of repeated GC infection is one in which at least one further episode of GC infection occurred after 30 days and within 365 days of the first infection. There were 253 recurrent infections (7.26%) from 238 individuals. Men who have sex with men (MSM) and Aboriginal and Torres Strait Islanders (ATSI) were significantly more likely to be recurrently infected with gonorrhoea than the rest of the South Australian population. This method of identifying individuals who have recurrent gonococcal infections can be used to target more frequent screening for individuals in a population who are more likely to be a part of the core group.