Sexually transmitted infections: Prevalence and clinical outcomes among pregnant women in Western Sydney.

OBJECTIVE: We report the prevalence, characteristics and clinical outcomes of women with sexually transmitted infections (STIs) in pregnancy in the Western Sydney Local Health District (WSLHD) serving a large culturally and socio-economically diverse community in New South Wales (NSW), Australia, over the last 10 years. METHODS: A retrospective cohort study of all pregnant women booked for antenatal care at three hospitals in WSLHD between September 2012 and August 2022 inclusive. Characteristics and birth outcomes associated with STIs diagnosed in pregnancy (chlamydia, gonorrhea, and syphilis) are reported using multivariable logistic regression adjusting for relevant confounders. RESULTS: During 2012-2022, there were 102 905 births and 451 women (0.44%) with an STI diagnosis during pregnancy. The number of women with a history of chlamydia prior to their current pregnancy has increased over the last 10 years (P < 0.001). STIs in pregnancy were more common in younger women aged <20 years (adjusted odds ratio [aOR] 7.30, 95% confidence interval [CI] 5.04-10.57), 20-24 years (aOR 3.12, 95% CI 2.46-3.96), and >40 years (adj OR 1.67, 95% CI 1.07-2.59), in women with body mass index >30 (aOR 1.73, 95%CI 1.37-2.19), and those who smoked (aOR 2.24, 95% CI 1.71-2.94) and consumed alcohol (aOR 3.14, 95% CI 1.88-5.23) and illicit drugs (aOR 2.10, 95% CI 1.31-3.36). STIs in pregnancy were borderline associated with stillbirth (aOR 2.19 95% CI 0.90-5.36) but did not have a significant impact on preterm birth (aOR 1.21, 95% CI 0.87-1.68), admission to neonatal intensive care unit (NICU) (aOR 1.02, 95% CI 0.77-1.34), or having a small-for-gestational-age (SGA) baby (aOR 0.97, 95% CI 0.74-1.27). CONCLUSIONS: Sociodemographic factors such as age, weight, smoking, and alcohol and drug use, were associated with the STI incidence in pregnancy. While the latter did not have an impact on preterm birth, NICU admission, and SGA in our cohort, there was a borderline association with stillbirth. Future research should identify barriers and facilitators to testing in a multicultural population and understanding the drivers of higher rates of STIs in certain population groups.

Protocol for an open-label, single-arm trial of HIV pre-exposure prophylaxis (PrEP) among people at high risk of HIV infection: the NSW Demonstration Project PRELUDE.

INTRODUCTION: Despite a number of HIV prevention strategies, the number of new HIV infections remains high. In Australia, over three-quarters of new HIV diagnoses are in gay and bisexual men (GBM). Pre-exposure prophylaxis (PrEP) has been shown to be effective at preventing new HIV infections in several randomised trials. The PRELUDE study aims to evaluate the implementation of PrEP in healthcare settings in New South Wales (NSW), Australia, among a sample of high-risk adults. METHODS AND ANALYSIS: PRELUDE is an ongoing open-label, single-arm demonstration project, conducted in public and private clinics across NSW, Australia. Enrolment began in November 2014. The study is designed for 300 high-risk participants-mainly GBM and heterosexual women. Participants receive daily oral PrEP, composed of emtricitabine (FTC) and tenofovir disoproxil fumarate (TDF), for up to 2.5 years. Quarterly study visits include testing for HIV and sexually transmitted infections (STIs), assessment of ongoing eligibility and side effects, and self-reported adherence. Following each study visit, online behavioural surveys are administered to collect information on medication adherence, risk behaviours and attitudes. Blood samples will be collected in a subset of patients 1, 6 and 12 months after PrEP initiation to measure FTC/TDF concentrations. Analyses using longitudinal regression models will focus on feasibility, adherence, safety, tolerability and effects of PrEP on behaviour. This study will inform PrEP policy and guide the implementation of PrEP in Australia in people at high risk of HIV. ETHICS AND DISSEMINATION: The study will be conducted in accordance with the Declaration of Helsinki. All patients will provide written informed consent prior to participation in the study. Publications relating to each of the primary end points will be gradually released after 12 months of follow-up is complete. TRIAL REGISTRATION NUMBER: NCT02206555; Pre-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.

The acceptability of different HIV testing approaches: cross-sectional study among GMSM in Australia.

BACKGROUND: We explored the attitudes of Australian gay and other men who have sex with men (GMSM) about the current standard-of-care (non-rapid tests at healthcare settings) and alternative approaches (rapid tests and testing in non-healthcare settings) to better understand the acceptability of alternative testing approaches. METHODS: The Contemporary Norms in Networks and Communities of GMSM study enrolled GMSM in Sydney, Melbourne and Perth in 2011-2012 using peer referrals. We explored the self-reported preferences for testing: rapid versus non-rapid and in non-healthcare settings (community-based or home-based testing) versus in healthcare settings, and examined factors associated with preferences for these approaches. Analyses of associations used standard univariate and age-adjusted logistic regression models. RESULTS: Among 827 sexually active non-HIV-positive participants, 89% had been tested for HIV. Most preferred by participants was home rapid testing (46%), followed by standard-of-care (23%) and rapid testing in healthcare (20%) or community settings (7%). About 73% of participants preferred rapid over non-rapid testing, and 56% preferred testing in non-healthcare settings rather than in healthcare settings. Preference for rapid testing was associated with being fully employed (adjusted OR (aOR): 1.81; 95% CI 1.16 to 2.82), managerial/professional occupation (aOR: 2.03; 95% CI 1.19 to 3.46) and engaging in unprotected anal intercourse with casual partners (aOR: 1.89; 95% CI 1.29 to 2.78). The same factors were associated with preference for testing in non-healthcare settings. CONCLUSIONS: Australian GMSM prefer alternative testing approaches, possibly due to their convenience. The availability of new testing approaches may provide more options for GMSM at risk for HIV infection, improve access to HIV testing and potentially increase HIV testing rates.

Virulence factor expression patterns in Pseudomonas aeruginosa strains from infants with cystic fibrosis.

Pseudomonas aeruginosa is the leading cause of morbidity and mortality in cystic fibrosis (CF). This study examines the role of organism-specific factors in the pathogenesis of very early P. aeruginosa infection in the CF airway. A total of 168 longitudinally collected P. aeruginosa isolates from children diagnosed with CF following newborn screening were genotyped by pulsed-field gel electrophoresis (PFGE) and phenotyped for 13 virulence factors. Ninety-two strains were identified. Associations between virulence factors and gender, exacerbation, persistence, timing of infection and infection site were assessed using multivariate regression analysis. Persistent strains showed significantly lower pyoverdine, rhamnolipid, haemolysin, total protease, and swimming and twitching motility than strains eradicated by aggressive antibiotic treatments. Initial strains had higher levels of virulence factors, and significantly higher phospholipase C, than subsequent genotypically different strains at initial isolation. Strains from males had significantly lower pyoverdine and swimming motility than females. Colony size was significantly smaller in strains isolated during exacerbation than those isolated during non-exacerbation periods. All virulence factors were higher and swimming motility significantly higher in strains from bronchoalveolar lavage (BAL) and oropharyngeal sites than BAL alone. Using unadjusted regression modelling, age at initial infection and age at isolation of a strain showed U-shaped profiles for most virulence factors. Among subsequent strains, longer time since initial infection meant lower levels of most virulence factors. This study provides new insight into virulence factors underpinning impaired airway clearance seen in CF infants, despite aggressive antibiotic therapy. This information will be important in the development of new strategies to reduce the impact of P. aeruginosa in CF.

Type 3 secretion system effector genotype and secretion phenotype of longitudinally collected Pseudomonas aeruginosa isolates from young children diagnosed with cystic fibrosis following newborn screening.

Studies of the type 3 secretion system (T3SS) in Pseudomonas aeruginosa isolates from chronically infected older children and adults with cystic fibrosis (CF) show a predominantly exoS+/exoU- (exoS+) genotype and loss of T3SS effector secretion over time. Relatively little is known about the role of the T3SS in the pathogenesis of early P. aeruginosa infection in the CF airway. In this longitudinal study, 168 P. aeruginosa isolates from 58 children diagnosed with CF following newborn screening and 47 isolates from homes of families with or without children with CF were genotyped by pulsed-field gel electrophoresis (PFGE) and T3SS genotype and phenotype determined using multiplex PCR and western blotting. Associations were sought between T3SS data and clinical variables and comparisons made between T3SS data of clinical and environmental PFGE genotypes. Seventy-seven of the 92 clinical strains were exoS+ (71% secretors (ExoS+)) and 15 were exoU+ (93% secretors (ExoU+)). Initial exoS+ strains were five times more likely to secrete ExoS than subsequent exoS+ strains at first isolation. The proportion of ExoS+ strains declined with increasing age at acquisition. No associations were found between T3SS characteristics and gender, site of isolation, exacerbation, a persistent strain or pulmonary outcomes. Fourteen of the 23 environmental strains were exoS+ (79% ExoS+) and nine were exoU+ (33% ExoU+). The exoU+ environmental strains were significantly less likely to secrete ExoU than clinical strains. This study provides new insight into the T3SS characteristics of P. aeruginosa isolated from the CF airway early in life.

Gay men who are not getting tested for HIV.

Using data from Australian Gay Community Periodic Surveys 1998-2010, we assessed the prevalence, trends and characteristics of gay men not tested for HIV. In 2010, one in eight Australian gay socially-engaged men were never tested for HIV, most of them sexually active and 56.5 % reporting unprotected anal intercourse. The proportion of not tested men was significantly higher in men younger than 30, of non-European origin and living outside of gay metropolitan areas. Although frequency of testing was associated with sexual practices, significant proportions of men with multiple sex partners and reporting unprotected anal intercourse were not tested as recommended. There were issues with using gay-friendly testing services in gay metropolitan areas. Despite Australia's success in HIV testing, improvement is needed for early detection of HIV infections. Interventions should encourage regular testing, engage with young gay men, improve access and convenience of testing, train service providers and expand testing options.

Current issues in care and support for HIV-positive gay men in Sydney.

We explored current access to care among HIV-positive people in Australia. In 2006, 270 HIV-positive gay men from a community-based Positive Health cohort in Sydney were asked about their health (including medical and social) service needs and, subsequently, about difficulty in accessing services. We report the prevalence of specific needs, barriers and associated factors. Participants most commonly used general practitioners (64%) for HIV management and needed at least one HIV-related medical service (usually several: doctors experienced in HIV management, dentists and hospital pharmacies). Most participants were able to access them. Barriers in accessing services were related to their convenience rather than lack or quality. Cost emerged as a substantial barrier to dental care and psychological counselling (91% and 48% respectively of those in need). Need for an HIV-related social service was reported by 46% of respondents. Difficulties in accessing these related to poor services and staff attitudes. Income was associated with limited access to multiple services. In Australia, HIV-related medical service needs outweigh those for social services. Complex health services remain essential to HIV-positive people, but some services are currently not meeting their needs. To remain adequate, services need to understand and constantly adapt to the changing needs of HIV-positive people.

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.

No increase in HIV or sexually transmissible infection testing following a social marketing campaign among men who have sex with men.

BACKGROUND: A social marketing campaign ran in 2004 in the Victoria to increase rates of HIV/sexually transmissible infection (STI) testing among men having sex with men (MSM). METHODS: To evaluate the initiative data from HIV sentinel surveillance, laboratory data on testing for HIV/STIs and STI/HIV testing uptake reported in annual surveys were analysed. RESULTS: The sentinel surveillance network showed no increase in the overall extent of HIV testing and no difference in the proportion of MSM reporting regular annual HIV testing during the campaign (43%) and post campaign (41%). The annual behavioural surveys showed that between 2004 and 2006 there was no significant increase in this overall proportion of MSM reporting having an HIV test in the last 12 months (p = 0.96). The behavioural surveys also showed an increasing trend in the proportion reporting specific STI tests over time: anal swab (26% to 39%, p

Improvements in sexual health testing among gay men in Sydney, Australia, 2003-2007.

In order to be effective, sexually transmitted infection (STI) testing should be comprehensive based on the clients' sexuality and risk practices. Using data from the Sydney Gay Community Periodic Survey, we explored trends in and factors associated with STI testing among gay men during 2003-2007. Among men who were not HIV-positive, 68% were tested for HIV in 2007. HIV testing was more common than STI testing and remained stable during 2003-2007. Use of swabs and urine samples increased significantly (P-trend<0.001 for each). However, until 2007, 33% of men were not tested. Sexual behaviours (higher number of partners, having casual partners and engaging in unprotected anal intercourse with them) were associated with STI testing. HIV-negative men were tested for STI less often than HIV-positive men (prevalence ratio=0.56; 95% CI: 0.47-0.68). STI testing among HIV-negative men has improved significantly but remains inadequate for STI control and HIV prevention. It should not be assumed that appropriate and comprehensive STI screening is always provided to clients.