Ending HIV Transmission in Australia: Expanding PrEP to Cisgender Women: A Scoping Review.

Pre-exposure prophylaxis (PrEP) availability through the Pharmaceutical Benefits Scheme provides real potential for the elimination of HIV transmission in Australia, as evidenced by a rapid decline in HIV incidence among gay and bisexual men (GBM). However, HIV elimination will not be possible without also extending PrEP to other populations, including cisgender women. We conducted a scoping review to examine the extent to which PrEP access for cisgender women has been considered in Australia. A comprehensive search across five databases, grey literature, and hand search of references was conducted. A single reviewer conducted title and abstract screening and two reviewers completed full-text screening and data extraction. Nineteen documents were included in the final review and included both peer-reviewed journal articles and guidelines and strategies. Focused discussion of cisgender women's use of PrEP was largely missing from the literature and, although their use of PrEP is supported in some relevant guidelines, little has been done to actively develop strategies to inform cisgender women about PrEP as a precursor to prescribing for HIV prevention. Healthcare providers' narrow view of PrEP as being the domain of GBM further limits cisgender women's potential access. If HIV elimination in Australia is to be a reality, we need to develop mechanisms to specifically engage with cisgender women about PrEP.

Provider views of pre-exposure prophylaxis (PrEP) for cisgender women - where do women fit in HIV elimination in Australia?

BACKGROUND: HIV pre-exposure prophylaxis (PrEP) in Australia has largely been targeted at gay, bisexual and other men who have sex with men. In the context of HIV elimination, the aim of this qualitative study was to explore PrEP prescribing for Australian cisgender women from the provider's perspective. METHODS: Semi-structured interviews were held with Australian prescribers in 2022. Participants were recruited through relevant clinical services, newsletter distribution and snowball sampling. Interviews were audio-recorded, transcribed and analysed thematically. RESULTS: Seventeen prescribers participated, of whom 9 were sexual health physicians and 10 worked in New South Wales. All reported limited clinical experience prescribing PrEP for women. Potential enablers to PrEP prescribing to women included education for women and clinicians, easily identifiable risk factors, individualised risk assessment and expansion of existing services. Barriers were limited PrEP awareness among women and prescribers, difficulties with risk assessment and consult and service limitations. The type of service recommended for PrEP provision varied among participants. CONCLUSIONS: Clinician experience of PrEP prescribing to Australian cisgender women is limited, with substantial barriers to access perceived by prescribers. Targeted education to PrEP prescribers, updated national PrEP guidelines to include women as a distinct group and further research regarding women's preferred model of PrEP access are required. Clarity of clinical ownership over PrEP implementation for women and, more broadly, women's sexual health, is essential in order to achieve HIV elimination in Australia.

"Made Me Feel Connected": A Qualitative Comparative Analysis of Intimate Partner Violence Routine Screening Pathways to Impact.

Intimate partner violence (IPV) routine screening is widely implemented, yet the evidence for pathways to impact remains unclear. Of the 32 abused women interviewed 16 weeks after antenatal IPV screening, 24 reported positive impact, six reported nil positive impact, and two reported negative impact. Using qualitative comparative analysis (QCA), key conditions for positive impact were care in asking, and support and validation from the midwife. Lack of these and lack of continuity of care were relevant to nil positive impact. Benefits included naming the abuse, connection, unburdening, taking steps to safety, and enabling informed care. Disclosure was not required for positive impact.

Increases in pharyngeal Neisseria gonorrhoeae positivity in men who have sex with men, 2011-2015: observational study.

OBJECTIVES: Pharyngeal gonorrhoea disproportionately affects men who have sex with men (MSM). We explored temporal trends in pharyngeal gonorrhoea positivity among MSM compared with anorectal and urogenital positivity. METHODS: Data (2011-2015) were extracted from 41 publicly funded sexual health clinics participating in a national surveillance network. Positivity was defined as the proportion of first-visit testing occasions where gonorrhoea was detected. Logistic regression explored trends in positivity and correlates of positive pharyngeal tests. RESULTS: From 2011 to 2015, 24 792 MSM tested (16 710 pharyngeal, 19 810 urogenital and 15 974 anorectal first-visit tests). Pharyngeal positivity increased by 183% from 139/3509 (4.0%) in 2011 to 397/3509 (11.3%) in 2015, p-trend <0.001; urogenital positivity by 39% from 257/4615 (5.6%) to 295/3783 (7.8%), p-trend=0.006; and anorectal positivity by 87% from 160/3469 (4.6%) to 286/3334 (8.6%), p-trend <0.001. The annual temporal increase in positivity was greater in the pharynx (OR 1.33; 95% CI 1.27 to 1.38) than at urogenital (OR 1.06; 95% CI 1.02 to 1.10) and anorectal (OR 1.16; 95% CI 1.11 to 1.21) sites. Factors independently associated with pharyngeal gonorrhoea were: younger age (p<0.001), higher numbers of recent sexual partners (p-trend=0.004), contact with a person with a diagnosed STI (p<0.001), injecting drug use (p<0.001), anogenital symptoms (p<0.001) and HIV-positive status (p=0.050). CONCLUSION: Temporal increases in gonorrhoea positivity occurred at all anatomical sites, with the greatest increase in the pharynx. Risk factors could be used to help to develop testing and prevention strategies among MSM at highest risk. Strengthening sexual health service delivery, testing and surveillance remain priorities for pharyngeal gonorrhoea control.

The efficacy of Plantago lanceolata for mitigating nitrous oxide emissions from cattle urine patches.

Urine deposited by grazing animals is the main source of nitrous oxide (N2O) emissions in New Zealand. Recent studies have suggested that certain pasture plants, for example plantain (Plantago lanceolata), can curb N2O emissions from livestock systems. This study aimed to i) evaluate the potential of plantain for reducing N2O emissions from cattle urine patches; ii) determine the effect of including plantain in animal diets on urine-N loading and its influence on N2O emissions; and, iii) evaluate whether any effects on N2O emissions reduction could be attributed to a 'urine' or a 'plant' effect. A static chamber method was used to measure N2O fluxes from urine collected from cows fed a 0, 15, 30 or 45% plantain mixed with "standard" ryegrass/clover (Lolium perenne/Trifolium repens) diet and applied to plots with the corresponding percentage of plantain in the sward. In addition, we measured N2O emissions from different proportions of plantain in the sward (0, 30, 60 and 100%) that received urine collected from cows fed on ryegrass/clover. The urine N loading rates of animals fed plantain, significantly reduced with increasing proportions of plantain in the diet (r2 = 0.987, P < 0.01). There was a trend of lower N2O emissions with an increasing proportion of plantain in the diet (r2 = 0.830, P < 0.08). However, there was no significantly difference in the N2O emission factors (P > 0.10). Following applications of standard urine, total N2O emissions and emission factor reduced linearly as the proportion of plantain in the sward increased (r2 = 0.969, P < 0.05 and 0.974, P < 0.05, respectively). The results suggest that the efficacy of plantain as a N2O mitigation option is due to both a reduction in urinary N excretion and a plant effect. The latter could be due to biological nitrification inhibition (BNI) caused by the release of root exudates and/or changes in the soil microclimate.

'Yarn about it': Aboriginal Australian women's perceptions of the impact of routine enquiry for intimate partner violence.

Aboriginal women globally are disproportionately affected by intimate partner violence (IPV) and face additional barriers to help-seeking. It is crucial that interventions for IPV are made safe for Indigenous women, given inflated rates of statutory intervention and widespread institutional racism. As part of a larger study of antenatal IPV screening, we interviewed 12 Aboriginal Australian women about the perceived impact of an antenatal IPV routine enquiry intervention. Seven women reported positive impact, and five women reported the absence of positive impact. Qualitative comparative analysis was used to map pathways to perceived impact. Cultural safety - the practice of countering tendencies in health care that undermine safety - was a key condition for positive impact. Others included: (i) continuity of care; (ii) asking about abuse without judgement and with care; and (iii) support and validation. Absence of these factors also typified pathways for nil positive impact. Naming the abuse, a sense of connection, unburdening, taking steps to safety and enabling informed care were all reported benefits. Two women reported explicitly negative impacts: one noted a sense of intrusion, and the other, disengagement from the health service. Interventions for IPV have the potential to benefit Indigenous women where cultural safety is prioritised.

Australian women's attitudes towards and understandings of the subdermal contraceptive implant: a qualitative study of never-users.

OBJECTIVE: Few studies have explored Australian women's understandings of contraception. This study examined the attitudes towards, and understandings of, the subdermal contraceptive implant expressed by women living in New South Wales (NSW), Australia. STUDY DESIGN: As part of a larger qualitative study using in-depth, open-ended interviews in 2012-2013 with women aged 16-49 years who had ever used contraception (n=94), 65 interviews from women who discussed or mentioned the subdermal implant, but had not previously used the device, were examined and analysed using thematic analysis. RESULTS: The emergent themes were: satisfaction with current method; weak personal opinions and ambivalence; uncertainty due to specific concerns; and strong negative reactions - fear and dislike. Although there were a few positive perceptions expressed by women who had never used the subdermal implant, for the majority of women the perception was predominantly negative. DISCUSSION AND CONCLUSION: Women tended to form negative impressions from the stories of other women about the subdermal implant. Interventions to enhance evidence-informed awareness of the relative advantages and disadvantages of the implant - for example, improved access to supportive contraceptive counselling - need investigation in the Australian context. Avenues to improve women's perceived control over the device could also be usefully investigated.

Doctors' experience of the contraceptive consultation: a qualitative study in Australia.

BACKGROUND: Contraception is a field in which good doctor-patient communication is crucial and core to shared decision making. Despite the centrality of contraception to primary health care in Australia, little is known about how doctors manage the contraceptive consultation. In particular, little is known about how doctors discuss sexual issues related to contraception. METHODS: Fifteen contraceptive providers participated in qualitative interviews averaging 45 min. Interviews were audio recorded, transcribed verbatim, and analysed using an inductive thematic approach. RESULTS: We found doctors were aware that they had to modify their illness-based 'scripts' in consultations about contraception, and said it was challenging always to adhere to a shared model of decision making. Prescribing behaviour reflected personal preferences in relation to some forms of contraception, and doctors were enthusiastic about the levonorgestrel-releasing intrauterine system. Doctors identified gaps in training in relation to sexuality and reported feeling tentative in raising sexual issues, even within contraceptive consultations. CONCLUSIONS: A range of factors-including tendencies to use illness scripts, personal preferences, and discomfort with communications about sexuality-appear to influence doctors' approaches to contraceptive management. Medical training that enables doctors to move out of an illness-treating framework and to improve their understanding of and comfort in discussing sexuality issues will improve their management of healthy women seeking contraception.

Performing (heterosexual) femininity: female agency and role in sexual life and contraceptive use - a qualitative study in Australia.

Women's liberation and the sexual revolution have changed the social landscape for heterosexual women in the West over the past 50 years, but exploration of women's lived experiences of contraceptive use in the context of their sexual lives is comparatively recent. We conducted 94 in-depth open-ended interviews with women of reproductive age (16-49 years) living in New South Wales, Australia. Interviews were audio-recorded, transcribed verbatim and analysed using an inductive thematic approach. Four major themes are explored here: (1) what women do and do not do: unspoken gendered assumptions; (2) focus on partner's pleasure; (3) juggling responsibilities: sex as a chore; and (4) women's sexual motivations. Findings suggest sexual double standards and gender expectations continue to pervade women's sexual and contraceptive practices. We found that women performed their femininity by focusing on enabling their male partner's pleasure, while simultaneously ignoring their own sexual desires, wishes or interests. Accompanying new-found freedoms are new-found responsibilities, as women now add managing modern contraceptives and a good sex life to their list of tasks alongside paid employment, domestic labour and childrearing. Our research findings suggest that women may derive different pleasures from sex, including what we term 'connection pleasure'.

Contraceptive choices and sexual health of Japanese women living in Australia: A brief report from a qualitative study.

BACKGROUND: There is a lack of research focused specifically on the contraceptive and sexual health practices of Japanese women living in Australia. OBJECTIVE: This paper reports findings from a cohort of migrant Japanese women who participated in a study of Australian women's understanding and experience of contraceptives. METHODS: In-depth, open-ended interviews were conducted between August 2012 and June 2013 in New South Wales. Audio-recorded interviews of seven Japanese women were transcribed verbatim and analysed thematically. RESULTS: The four prominent themes were the condom and withdrawal methods, varying attitudes to contraceptive practices, discussing contraception and sexual issues with general practitioners (GPs), and the unspoken topic of sexually transmissible infections (STIs). DISCUSSION: Japanese migrants tend to choose the condom and withdrawal methods, which they perceive to be 'standard practice' in Japan. A greater understanding by Australian GPs of Japanese women's attitudes to contraception and sexual health issues could enhance the sexual health of Japanese women.

'They aren't really black fellas but they are easy to talk to': Factors which influence Australian Aboriginal women's decision to disclose intimate partner violence during pregnancy.

OBJECTIVES: intimate partner violence is a significant global health problem but remains largely hidden. Understanding decisions about whether or not to disclose violence in response to routine enquiry in health settings can inform safe and responsive systems. Elevated rates of violence and systematic disadvantage found among Indigenous women globally, can impact on their decisions to disclose violence. This study aimed to test, among Indigenous women, a model for decisions on whether to disclose intimate partner violence in the context of antenatal routine screening. DESIGN: we employed Qualitative Configurative Analysis, a method developed for the social sciences to study complex phenomena with intermediate sample sizes. Data were drawn from single semi- structured interviews with Indigenous women 28+ weeks pregnant attending antenatal care. Interviews addressed decisions to disclose recent intimate partner violence in the context of routine enquiry during the antenatal care. Interview transcripts were binary coded for conditions identified a priori from the model being tested and also from themes identified within the current study and analysed using Qualitative Configurative Analysis to determine causal conditions for the outcome of disclosure or non-disclosure of violence experienced. SETTINGS: five Aboriginal and Maternal Infant Health Services (two urban and three regional), and one mainstream hospital, in New South Wales, Australia. PARTICIPANTS: indigenous women who had experienced partner violence in the previous year and who had been asked about this as part of an antenatal booking-in visit. Of the 12 participants six had elected to disclose their experience of violence to the midwife, and six had chosen not to do so. FINDINGS: pathways to disclosure and non-disclosure were mapped using Qualitative Configurative Analysis. Conditions relevant to decisions to disclose were similar to the conditions for non-Aboriginal women found in our earlier study. Unique to Aboriginal women's decisions to disclose abuse was cultural safety. Cultural safety included elements we titled: Borrowed trust, Build the relationship first, Come at it slowly and People like me are here. The absence of cultural safety Its absence was also a factor in decisions not to disclose experiences of violence by this group of women. KEY CONCLUSIONS: cultural safety was central to Indigenous women's decision to disclose violence and processes for creating safety are identified. Other forms of safety which influenced disclosure included: safety from detection by the abuser; safety from shame; and safety from institutional control. Disclosure was promoted by direct asking by the midwife and a perception of care. Non-disclosure was associated with a lack of care and a lack of all four types of safety. Experiences of institutional racism were associated with Indigenous women's perceived risk of control by others, particularly child protection services. IMPLICATIONS FOR PRACTICE: policies to ask abuse questions at first visits and models where continuity of care is not maintained, are problematic for Aboriginal women, among whom relationship building is important as is ample warning about questions to be asked. Strategies are needed to build cultural safety to counter widespread racism and promote safe opportunities for Indigenous women to disclose intimate partner violence and receive support. Elements of cultural safety are necessary for vulnerable or marginalised populations to fully utilise available health services.

Deciding to tell: Qualitative configurational analysis of decisions to disclose experience of intimate partner violence in antenatal care.

RATIONALE: Intimate partner violence (IPV) is a significant global public health risk causing premature death and morbidity that largely remains hidden. Understanding decisions about whether or not to disclose abuse when asked about it in health settings is important to ensuring that those experiencing violence are provided with access to services to support their safety and wellbeing. OBJECTIVE: This study tested a model for women's decisions to disclose IPV in response to routine inquiry as part of antenatal assessment. METHODS: Qualitative configurational analysis, suited to the study of causal pathways in complex social phenomena, was used to analyse interviews with 32 women who had experienced IPV in the past 12 months and who elected, when asked, to either disclose this to the midwife (n = 24) or not to do so (n = 8). FINDINGS: Multiple pathways to disclosure were identified. While no single factor was necessary or sufficient for a decision to disclose, direct asking and care, defined as showing interest and a non-judgemental attitude, were found to be key conditions. The absence of care was also central to decisions not to disclose, as were perceptions of relevance of the abuse at the time of assessment. CONCLUSION: Confirming key elements of the original model, these findings highlight the importance of being asked about abuse in women's decisions to disclose, as well as the relational nature of this process. Trauma-informed practices for identifying and responding to intimate partner violence are needed.

Blood dioxin biomonitoring to assess local residents' exposure from a large urban remediation project.

BACKGROUND: A total of 265000 m(3) of dioxin contaminated soil and sediments from past industrial activity was treated on site in an urban setting in Sydney, Australia. To respond to local community concerns about potential dioxin exposure from fugitive emissions a human biomonitoring study was undertaken. OBJECTIVE: To determine whether local residents were exposed to significant amounts of dioxin from the remediation process. METHODS: Blood samples were collected from local residents around the site and a representative metropolitan control group. They were pooled within age and sex strata and the change in dioxin concentrations over the remediation period and a summary of the mid point and post remediation dioxin concentrations were compared between groups. Information on dietary intake was collected to look for possible confounding. RESULTS: The mean dioxin Toxic Equivalent concentrations (TeQ) decreased among both the local resident and control groups over the remediation period by 1.9 and 2.1 pg gm(-1) lipid respectively. Modelled blood concentrations adjusting for age and sex did not detect a significant difference between groups for changes in either TeQ or 2,3,7,8-tetrachlorodibenzo-p-dioxin (2,3,7,8 TCDD). The summary measure approach did however demonstrate that the 2,3,7,8 TCDD concentrations among the local resident group was approximately 0.7 pg g(-1) lipid higher compared to the control group post remediation. There were no significant changes in dietary intake sources of dioxin. CONCLUSION: Biomonitoring demonstrated that local residents were not exposed to significant quantities of dioxin. Large scale remediation of dioxin contaminated land can be safely undertaken in an urban setting.

Violence: a priority for public health? (part 2).

Violence continues to grow as a priority for public health practitioners, particularly as its causes and consequences become better understood and the potential roles for public health are better articulated. This article provides the context to "Violence: a glossary (part 1)" published in the last issue of this journal, and updates some of the data, concepts and population approaches presented in the 2002 World report on violence and health. The paper addresses the following questions: What is the magnitude and global burden of injury from violence? What causes violence? Is resilience important? What is the role for public health? What are the key challenges and opportunities? We aim to engage the general reader and to increase understanding of violence as a potentially preventable issue.

Violence: a glossary.

Violence has been explicitly identified as a significant public health problem. This glossary clarifies widely used definitions and concepts of violence within the public health field, building on those promoted through the 2002 World Report on Violence and Health. We provide definitions and concepts that can be usefully applied to identify points for public health intervention to prevent the social and health impacts of violence.

Preventing violence in New South Wales: data sources and their adequacy.

OBJECTIVES: To describe data sources that are relevant to violence in NSW and recommend strategies for improving data collection and dissemination. METHODS: Literature review, interviews with stakeholders and a survey of data custodians within NSW Health. RESULTS: Data sources were mapped using a conceptual framework developed by the Australian Bureau of Statistics. We found that current data sources are only partially effective at characterising the burden of violence in NSW and there are inadequate mechanisms for data review and dissemination. CONCLUSIONS: Improving data collection and dissemination is the first step in the public health contribution towards reducing the burden of violence on society.

Factors associated with low immunity to rubella infection on antenatal screening.

BACKGROUND: Rubella infection during the first trimester results in congenital rubella syndrome. There has been little recent published evidence identifying those at-risk of infection in the first trimester of pregnancy. This study examined the level of rubella immunity in pregnant women in a part of Sydney and risk factors for non-immunity. METHODS: We looked at data on all confinements at two maternity hospitals in Sydney in the 2-year period between July 1999 and June 2001. Variables included in our data set included mother's country of birth, mother's date of birth, hospital status (public or private patient), parity, rubella status and postpartum rubella vaccination. RESULTS: Of the 8096 confinements, the mother was documented as being non-immune to rubella in 567 cases (7%) of cases. Of the 567 confinements where rubella status was documented as non-immune, Asian-born women comprised of 65% (366) of non-immune women while 13% (73) were Australian-born. Country of birth remained a strong predictor of immunity, even after controlling for age, parity and hospital status. Maternal age > 35 years and nulliparity were also significant risk factors for non-immunity. CONCLUSION: Programs targeting underimmunised populations for rubella vaccination should focus on overseas-born women, particularly those born in Asia, nulliparous women and also women > 35 years of age.

A survey of workplace bullying in a health sector organisation.

The purpose of this study was to explore the frequency, nature and extent of workplace bullying in a health care organisation in New South Wales. The survey methodology achieved a 79% response rate (n = 311). Overall, 155 respondents (50%) reported that they had experienced one or more forms of bullying behaviour in the past 12 months. The largest reported source of workplace bullying was peers or fellow workers (49%), followed by clients (42%) and managers or supervisors (38%). Only 36% of respondents who had been bullied had formally reported the episode. The level of bullying reported was unexpectedly high and will require development of strategies to address the issue.