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BACKGROUND: To achieve hepatitis C virus (HCV) elimination targets, simplified care engaging people who inject drugs is required. We evaluated whether fingerstick HCV RNA point-of-care testing (PoCT) increased the proportion of clients attending a supervised injecting facility who were tested for hepatitis C. METHODS: Prospective single-arm study with recruitment between 9 November 2020 and 28 January 2021 and follow-up to 31 July 2021. Clients attending the supervised injecting facility were offered HCV RNA testing using the Xpert® HCV Viral Load Fingerstick (Cepheid, Sunnyvale, CA) PoCT. Participants with a positive HCV RNA test were prescribed direct acting antiviral (DAA) therapy. The primary endpoint was the proportion of clients who engaged in HCV RNA PoCT, compared to a historical comparator group when venepuncture-based hepatitis C testing was standard of care. RESULTS: Among 1618 clients who attended the supervised injecting facility during the study period, 228 (14%) engaged in PoCT. This was significantly higher than that observed in the historical comparator group (61/1,775, 3%; p < 0.001). Sixty-five (28%) participants were HCV RNA positive, with 40/65 (62%) receiving their result on the same day as testing. Sixty-one (94%) HCV RNA positive participants were commenced on DAA therapy; 14/61 (23%) started treatment on the same day as diagnosis. There was no difference in the proportion of HCV RNA positive participants commenced on treatment with DAA therapy when compared to the historical comparator group (61/65, 94% vs 22/26, 85%; p = 0.153). However, the median time to treatment initiation was significantly shorter in the PoCT cohort (2 days (IQR 1-20) vs 41 days (IQR 22-76), p < 0.001). Among participants who commenced treatment and had complete follow-up data available, 27/36 (75%) achieved hepatitis C cure. CONCLUSIONS: HCV RNA PoCT led to a significantly higher proportion of clients attending a supervised injecting facility engaging in hepatitis C t

BACKGROUND: Despite proven benefits for child health, coverage of early infant diagnosis of HIV remains suboptimal in many settings. We aimed to assess the effect of a point-of-care early infant diagnosis test on time-to-results communication for infants vertically exposed to HIV. METHODS: This pragmatic, cluster-randomised, stepped-wedge, open-label trial assessed the effect of the Xpert HIV-1 Qual early infant diagnosis test (Cepheid) on time-to-results communication, compared with standard care laboratory-based testing of dried blood spots using PCR. Hospitals were the unit of randomisation for one-way crossover from control to intervention phase. Each site had between 1 month and 10 months of control phase before transitioning to the intervention, with a total of 33 hospital-months in the control phase and 45 hospital-months in the intervention phase. We enrolled infants vertically exposed to HIV at six public hospitals: four in Myanmar and two in Papua New Guinea. Infants had to have mothers with confirmed HIV infection, be younger than 28 days, and required HIV testing to be eligible for enrolment. Health-care facilities providing prevention of vertical transmission services were eligible for participation. The primary outcome was communication of early infant diagnosis results to the infant's caregiver by 3 months of age, assessed by intention to treat. This completed trial was registered with the Australian and New Zealand Clinical Trials Registry, 12616000734460. FINDINGS: In Myanmar, recruitment took place between Oct 1, 2016, and June 30, 2018; in Papua New Guinea, recruitment was between Dec 1, 2016, and Aug 31, 2018. A total of 393 caregiver-infant pairs were enrolled in the study across both countries. Independent of study time, the Xpert test reduced time to early infant diagnosis results communication by 60%, compared with the standard of care (adjusted time ratio 0·40, 95% CI 0·29-0·53, p<0·0001). In the control phase, two (2%) of 102 study particip

OBJECTIVE: We describe COVID-19 risk reduction strategies adopted by Victorian adults during December 2021-January 2022, a period of high COVID-19 infection and limited government mandated public health measures. METHODS: In February 2022, participants of a Victorian-based cohort study (Optimise) completed a cross-sectional survey on risk reduction behaviours during December 2021-January 2022. Regression modelling estimated the association between risk reduction and demographics. RESULTS: A total of 556 participants were included (median age 47 years; 75% women; 82% in metropolitan Melbourne). Two-thirds (61%) adopted at least one risk reduction behaviour, with uptake highest among younger participants (18-34 years; adjusted relative risk (aRR): 1.20, 95% confidence interval [CI]: 1.01, 1.41) and those with a chronic health condition (aRR: 1.17, 95% CI: 1.02, 1.35). CONCLUSIONS: Participants adopted their own COVID-19 risk reduction strategies in a setting of limited government restrictions, with young people more likely to adopt a risk reduction strategy that did not limit social mobility. IMPLICATION FOR PUBLIC HEALTH: A public health response to COVID-19 that focusses on promoting personal risk reduction behaviours, as opposed to mandated restrictions, could be enhanced by disseminating information on and increasing availability of effective risk reduction strategies tailored to segments of the population.

The COVID-19 pandemic triggered widespread socioeconomic hardship, disproportionately impacting disadvantaged populations. People who use illicit drugs are more likely to experience unemployment, homelessness, criminal justice involvement and poorer health outcomes than the general community, yet little is known about the socioeconomic impacts of the pandemic on their lives. To address this gap in the literature, we conducted in-depth interviews with 76 participants from two cohort studies of people who use illicit drugs (people who inject drugs and/or use methamphetamine) in Victoria, Australia. Findings support claims that pandemic-related Social Security supplementary payments and initiatives to reduce homelessness, although not systemically transforming people's lives, produced temporary relief from chronic socioeconomic hardship. Results also indicate how temporary interruptions to drug supply chains inflated illicit drug prices and produced adverse consequences such as financial and emotional stress, which was exacerbated by drug withdrawal symptoms for many participants. Furthermore, increased community demand for emergency food and housing support during the pandemic appeared to reduce participants' access to these services. Our findings about the unintended consequences of pandemic responses on the socioeconomic lives of a group of people who use illicit drugs provide insights into and opportunities for policy reform to redress their entrenched disadvantage.

UNLABELLED: The Pacific Island Countries and Territories (PICTs) have experienced the coronavirus disease (COVID-19) pandemic in different ways and with different timelines, with some experiencing large outbreaks leading to high levels of morbidity and mortality with significant strain on health systems, while others have had no local transmission or delayed transmission until after vaccine rollouts started. Regardless of COVID-19 trends, the pandemic has had a large impact on the social, political, and economic landscape in the Pacific, the effects of which are still being understood. However, the pandemic has also put renewed focus and investment into public health systems and provided an opportunity for the PICTs to build on existing systems and recent capacity strengthening to improve public health in the Region. FUNDING: Leila Bell was supported by an Australian Government Research Training Program (RTP) Scholarship. Other funding sources had no role in paper design, data collection, data analysis, interpretation, or writing of the paper.

Background: The Australian Collaboration for Coordinated Enhanced Sentinel Surveillance (ACCESS) was established to monitor national testing and test outcomes for blood-borne viruses (BBVs) and sexually transmissible infections (STIs) in key populations. ACCESS extracts deidentified data from sentinel health services that include general practice, sexual health, and infectious disease clinics, as well as public and private laboratories that conduct a large volume of BBV/STI testing. An important attribute of ACCESS is the ability to accurately link individual-level records within and between the participating sites, as this enables the system to produce reliable epidemiological measures. Objective: The aim of this study was to evaluate the use of GRHANITE software in ACCESS to extract and link deidentified data from participating clinics and laboratories. GRHANITE generates irreversible hashed linkage keys based on patient-identifying data captured in the patient electronic medical records (EMRs) at the site. The algorithms to produce the data linkage keys use probabilistic linkage principles to account for variability and completeness of the underlying patient identifiers, producing up to four linkage key types per EMR. Errors in the linkage process can arise from imperfect or missing identifiers, impacting the system's integrity. Therefore, it is important to evaluate the quality of the linkages created and evaluate the outcome of the linkage for ongoing public health surveillance. Methods: Although ACCESS data are deidentified, we created two gold-standard datasets where the true match status could be confirmed in order to compare against record linkage results arising from different approaches of the GRHANITE Linkage Tool. We reported sensitivity, specificity, and positive and negative predictive values where possible and estimated specificity by comparing a history of HIV and hepatitis C antibody results for linked EMRs. Results: Sensitivity ranged from 96% to

People who inject drugs (PWID) are disproportionately represented among individuals who experience imprisonment and often have more complex physical and mental health needs than people in prison without injecting histories. The trajectories of PWID after prison release are poorly understood, hampering the development of effective strategies to address their distinct health needs. The Prison and Transition Health (PATH) Cohort Study is characterising the post-release trajectories of incarcerated male PWID in Victoria, Australia. We outline study methodology and baseline characteristics of participants prior to their release. Four hundred participants were recruited from three prisons and completed researcher-administered baseline interviews covering socio-demographics, social supports, physical health, mental health, alcohol and other drug use, and pre-release and transitional service utilisation. The median age among participants was 36 years (IQR 30–42), and they reported a median of five (IQR 3–9) previous adult incarcerations. Almost half (49%) were reliant on government payments prior to incarceration. One quarter (25%) of participants reported removal from their parents’ care as children and 64% reported being a parent or primary caregiver to children. Most participants (81%) reported a previous mental health diagnosis and 44% reported three or more diagnoses. The most common drugs injected prior to incarceration were crystal methamphetamine (80%) and heroin (62%), and most (85%) reported being under the influence of drugs at the time of committing offences for which they were currently incarcerated. Injecting drug use during their current sentence was reported by 40% of participants, and 48% reported engaging with some form of drug treatment during their current sentence. Study participants are characterised by significant mental health and substance use morbidities, social disadvantage and criminogenic histories that present challenges for the provision of po

Introduction and Aims: Mortality studies of people who inject drugs (PWID) are mostly of older people and drug treatment cohorts. We estimate mortality rates, describe causes of death, and years of potential life lost in a community-recruited cohort of young PWID characterised by high incidence of hepatitis C virus (HCV) infection. Design and Methods: Participant identifiers of 215 PWID from the south-western Sydney sub-cohort of the HCV Cohort were linked to National Death Index records from 1999 to 2010 and crude mortality rates and standardised mortality ratios estimated. Australian life tables were used to calculate years of potential of life lost. Results: Fifteen participants died (7.0%) in 2095 person years (PY) of follow-up. Median age at death was 30.6 years (interquartile range 24.9–32.2). The crude mortality rate was 0.72 per 100PY (95% confidence interval 0.29–0.79) with a standardised mortality ratio of 11.09 (95% confidence interval 6.68–18.39). One-third of deaths were due to accidental drug overdose (5/15) and one-fifth were suicides (3/15). All deaths from defined causes (13/15) were potentially avoidable. Decedents lost on average 49.8 years of potential life. Discussion and Conclusions: Mortality and potential life lost further highlight the impact of accidental overdose deaths and suicide among young PWID. Integration of overdose and suicide prevention into youth-orientated outreach, including innovation in online and mobile technology should be evaluated.

INTRODUCTION: Achieving the virtual elimination of HIV requires equitable access to HIV prevention tools for all priority populations. Restricted access to healthcare means migrants face particular barriers to HIV prevention services. In February 2016, a peer-led rapid HIV testing service for gay, bisexual and other men who have sex with men (gay and bisexual men, GBM) in Melbourne, Australia, introduced free sexually transmissible infection (STI) testing funded through Medicare (Australia's universal healthcare system). Medicare ineligible migrant clients were required to pay up to $158AUD for STI tests. We determined the uptake of STI testing and assessed the impact on repeat HIV testing among Medicare eligible and ineligible clients. METHODS: All HIV tests conducted between August 2014 and March 2018 were included. We describe client characteristics, STI testing uptake and HIV/STI positivity among Medicare eligible and ineligible clients. Repeat HIV testing, assessed as the percentage of HIV tests with a return test within six months, was compared pre-integration (August 2014-June 2016) and post-integration(July 2016-March 2018) of STI testing using segmented linear regression of monthly aggregate data for Medicare eligible and ineligible clients. RESULTS: Analyses included 9134 HIV tests among 4753 individuals. Medicare ineligible clients were younger (p < 0.01), and fewer reported previously testing for HIV (p < 0.01) and high HIV risk sexual behaviours. There was no difference in HIV positivity between the two groups (p = 0.09). STI testing uptake was significantly lower among Medicare ineligible clients (7.6%, 85.3%; p < 0.01). Following STI testing introduction there was an immediate increase in six-month return HIV testing (6.4%; p = 0.02) and a significantly increasing rate of return HIV testing between July 2016 and March 2018 (0.5% per month; p < 0.01) among Medicare eligible clients but no immediate change in return testing (-0.9%; p = 0.7) or the rate

INTRODUCTION: Gay and bisexual men (GBM) are at increased risk of hepatitis C/HIV co-infection. In Australia, the availability of subsidized direct-acting antiviral treatment for hepatitis C has rendered eliminating co-infection possible. High reinfection rates in subgroups with continued exposure may compromise elimination efforts. To inform the development of hepatitis C risk reduction support in GBM, we explored reinfection risk perceptions and attitudes among GBM living with HIV recently cured from hepatitis C. METHODS: Between April and August 2017, 15 GBM living with diagnosed HIV were recruited from high caseload HIV primary care services in Melbourne following successful hepatitis C treatment. In-depth interviews were conducted exploring understandings of hepatitis C risks, experiences of co-infection and attitudes towards reinfection. Constructivist grounded theory guided data aggregation. RESULTS: Participants' understandings of their hepatitis C infection and reinfection trajectories were captured in three categories. Hepatitis C and HIV disease dichotomies: Hepatitis C diagnosis was a shock to most participants and contrasted with feelings of inevitability associated with HIV seroconversion. While HIV was normalized, hepatitis C was experienced as highly stigmatizing. Despite injecting drug use, interviewees did not identify with populations typically at risk of hepatitis C. Risk environments and avoiding reinfection: Interviewees identified their social and sexual networks as risk-perpetuating environments where drug use was ubiquitous and higher risk sex was common. Avoiding these risk environments to avoid reinfection resulted in community disengagement, leaving many feeling socially isolated. Hepatitis C care as a catalyst for change: Engagement in hepatitis C care contributed to a better understanding of hepatitis C risks. Interviewees were committed to applying their improved competencies around transmission risk reduction to avoid reinfection. Int

No Abstract Available

Background: Take-home naloxone (THN) programmes are an evidence-based opioid overdose prevention initiative. Elevated opioid overdose risk following prison release means release from custody provides an ideal opportunity for THN initiatives. However, whether Australian prisoners would utilise such programmes is unknown. We examined the acceptability of THN in a cohort of male prisoners with histories of regular injecting drug use (IDU) in Victoria, Australia. Methods: The sample comprised 380 men from the Prison and Transition Health (PATH) Cohort Study; all of whom reported regular IDU in the 6 months prior to incarceration. We asked four questions regarding THN during the pre-release baseline interview, including whether participants would be willing to participate in prison-based THN. We describe responses to these questions along with relationships between before- and during-incarceration factors and willingness to participate in THN training prior to release from prison. Results: Most participants (81%) reported willingness to undertake THN training prior to release. Most were willing to resuscitate a friend using THN if they were trained (94%) and to be revived by a trained peer (91%) using THN. More than 10 years since first injection (adjusted odds ratio [AOR] 2.22, 95%CI 1.03-4.77), having witnessed an opioid overdose in the last 5 years (AOR 2.53, 95%CI 1.32-4.82), having ever received alcohol or other drug treatment in prison (AOR 2.41, 95%CI 1.14-5.07) and injecting drugs during the current prison sentence (AOR 4.45, 95%CI 1.73-11.43) were significantly associated with increased odds of willingness to participate in a prison THN programme. Not specifying whether they had injected during their prison sentence (AOR 0.37, 95%CI 0.18-0.77) was associated with decreased odds of willingness to participate in a prison THN training. Conclusion: Our findings suggest that male prisoners in Victoria with a history of regular IDU are overwhelmingly willing to partic

Background: Gay and bisexual men are disproportionately affected by HIV and other sexually transmissible infections (STIs), yet opportunities for sexual health testing of this population are often missed or incomplete in general practice settings. Strategies are needed for improving the uptake and completeness of sexual health testing in this setting. Objectives: The goal of the research was to evaluate the impact of an intervention centered around integrated decision support software and routine data feedback on the collection of sexual orientation data and sexual health testing among gay and bisexual men attending general practice. Methods: A study using before/after and intervention/comparison methods was undertaken to assess the intervention’s impact in 7 purposively sampled Australian general practice clinics located near the urban centers of Sydney and Melbourne. The software was introduced at staggered points between April and August 2012; it used patient records to prompt clinicians to record sexual orientation and accessed pathology testing history to generate prompts when sexual health testing was overdue or incomplete. The software also had a function for querying patient management system databases in order to generate de-identified data extracts, which were used to report regularly to participating clinicians. We calculated summary rate ratios (SRRs) based on quarterly trends and used Poisson regression analyses to assess differences between the 12-month preintervention and 24-month intervention periods as well as between the intervention sites and 4 similar comparison sites that did not receive the intervention. Results: Among 32,276 male patients attending intervention clinics, sexual orientation recording increased 19% (from 3213/6909 [46.50%] to 5136/9110 [56.38%]) during the intervention period (SRR 1.10, 95% CI 1.04-1.11, P<.001) while comprehensive sexual health testing increased by 89% (305/1159 [26.32%] to 690/1413 [48.83%]; SRR 1.38, 95% CI 1.

HIV-negative and untested gay and bisexual men from Victoria, Australia (n = 771) were surveyed during August–September 2016 about their comfort having condomless sex with casual male partners in scenarios in which pre-exposure prophylaxis (PrEP) or treatment as prevention were used. Men not using PrEP were most comfortable with the idea of condomless sex with HIV-negative partners (31%), followed by partners using PrEP (23%). PrEP users were more comfortable with the idea of condomless sex with these partner types (64 and 72%, respectively). Very few men not taking PrEP were comfortable with condomless sex with HIV-positive partners (3%), even with undetectable viral loads (6%). PrEP users were more comfortable with condomless sex with HIV-positive partners (29%), and those with undetectable viral loads (48%). Being on PrEP, having recent condomless sex with casual partners or a HIV-positive regular partner were independently associated with comfort having condomless sex.

INTRODUCTION: We determined the contribution of undiagnosed HIV to new infections among gay and bisexual men (GBM) over a 12-year period in Australia where there has been increasing focus on improving testing and HIV treatment coverage. METHODS: We generated annual estimates for each step of the HIV cascade and the number of new HIV infections for GBM in Australia over 2004 to 2015 using relevant national data. Using Bayesian melding we then fitted a quantitative model to the cascade and incidence estimates to infer relative transmission coefficients associated with being undiagnosed, diagnosed and not on ART, on ART with unsuppressed virus, or on ART with suppressed virus. RESULTS: Between 2004 and 2015, we estimated the percentage of GBM with HIV in Australia who were unaware of their status to have decreased from 14.5% to 7.5%. During the same period, there was a substantial increase in the number and proportion of GBM living with HIV on treatment and with suppressed virus, with the number of virally suppressed GBM increasing from around 3900 (30.2% of all GBM living with HIV) in 2004 to around 14,000 (73.7% of all GBM living with HIV) in 2015. Despite the increase in viral suppression, the annual number of new infections rose from around 660 to around 760 over this period. Our results have a wide range due to the uncertainty in the cascade estimates and transmission coefficients. Nevertheless, undiagnosed GBM increasingly appear to contribute to new infections. The proportion of new infections attributable to undiagnosed GBM almost doubled from 33% in 2004 to 59% in 2015. Only a small proportion (<7%) originated from GBM with suppressed virus. DISCUSSION: Our study suggests that an increase in HIV treatment coverage in Australia has reduced the overall risk of HIV transmission from people living with HIV. However, the proportion of infections and the rate of transmission from undiagnosed GBM has increased substantially. These findings highlight the importance of

INTRODUCTION: Outbreaks of hepatitis C virus (HCV) infections among HIV-positive men who have sex with men (MSM) have been observed globally. Using a multi-modelling approach we estimate the time and number of direct-acting antiviral treatment courses required to achieve an 80% reduction in HCV prevalence among HIV-positive MSM in the state of Victoria, Australia. METHODS: Three models of HCV transmission, testing and treatment among MSM were compared: a dynamic compartmental model; an agent-based model (ABM) parametrized to local surveillance and behavioural data ("ABM1"); and an ABM with a more heterogeneous population ("ABM2") to determine the influence of extreme variations in sexual risk behaviour. RESULTS: Among approximately 5000 diagnosed HIV-positive MSM in Victoria, 10% are co-infected with HCV. ABM1 estimated that an 80% reduction in HCV prevalence could be achieved in 122 (inter-quartile range (IQR) 112 to 133) weeks with 523 (IQR 479 to 553) treatments if the average time from HCV diagnosis to treatment was six months. This was reduced to 77 (IQR 69 to 81) weeks if the average time between HCV diagnosis and treatment commencement was decreased to 16 weeks. Estimates were consistent across modelling approaches; however ABM2 produced fewer incident HCV cases, suggesting that treatment-as-prevention may be more effective in behaviourally heterogeneous populations. CONCLUSIONS: Major reductions in HCV prevalence can be achieved among HIV-positive MSM within two years through routine HCV monitoring and prompt treatment as a part of HIV care. Compartmental models constructed with limited behavioural data are likely to produce conservative estimates compared to models of the same setting with more complex parametrizations.

BACKGROUND: Dual substance dependence and psychiatric and psychological morbidities are overrepresented in prison populations and associated with reoffending. In the context of an increasing prison population in Australia, investigating the needs of vulnerable people in prison with a dual diagnosis can help inform in-prison screening and treatment and improve prison and community service integration and continuation of care. In this study we quantified psychiatric well-being in a sample of people in prison with a history of injecting drug use in Victoria, Australia, and identified factors associated with this outcome. METHODS AND RESULTS: Data for this paper come from baseline interviews undertaken in the weeks prior to release as part of a prospective cohort study of incarcerated men who reported regular injecting drug use prior to their current sentence. Eligible participants completed a researcher-administered structured questionnaire that canvassed a range of issues. Psychiatric well-being was assessed using the 12-item General Health Questionnaire (GHQ-12) and potential correlates were included based on a review of the literature. Of the 317 men included for analyses, 139 were classified as experiencing current poor psychiatric well-being. In the multivariate model using modified logistic regression, history of suicide attempt (aOR = 1.36, 95%CI 1.03-1.78), two or more medical conditions (aOR = 1.87, 95%CI 1.30-2.67) and use of crystal methamphetamine in the week prior to their current sentence (aOR = 1.52, 95%CI 1.05-2.22) were statistically significantly associated with current poor psychiatric well-being. CONCLUSIONS: Comprehensively addressing the health-related needs for this vulnerable population will require a multidisciplinary approach and enhancing opportunities to screen and triage people in prison for mental health and other potential co-occurring health issues will provide opportunities to better address individual health needs and reoffending risk.

BACKGROUND: Histories of self-harm and suicide attempts are common among people in prison in Australia, and substance dependence is an established risk factor for these lifetime experiences. We describe the prevalence of self-reported history of non-suicidal self-injury (NSSI) and suicide attempts in a cohort of men with recent histories of injecting drug use (IDU) imprisoned in Victoria, Australia. Baseline interviews from the Prison and Transition Health (PATH) prospective cohort study were conducted in the weeks prior to release from prison among 400 incarcerated men who reported regular IDU in the six months prior to incarceration. RESULTS: Participants completed a researcher-administered structured questionnaire that collected information on sociodemographics, substance use patterns, and physical and mental health indicators. More than one third (37%) reported a history of NSSI and almost half of participants (47%) reported a history of suicide attempts. In multivariable Poisson regression models, a history of NSSI was associated with: being aged 30-39 years; moving accommodation three or more times in the year prior to current sentence; self-reporting a history of mental illness diagnosis; current poor psychiatric well-being; and self-reporting three or more previous drug overdoses. History of suicide attempts was significantly associated with: self-reporting a history of mental illness diagnosis; current poor psychiatric well-being; and self-reporting a history of 1-2 and > 3 drug overdoses. CONCLUSION: We observed a disconcertingly high lifetime prevalence of non-suicidal self-injury and suicide attempts among incarcerated males with a history of recent regular injecting drug use. Significant associations with indicators of mental illness and drug related harms support the need to prioritise in-prison screening and early intervention to reduce the risk of future harms for this population.

Background: Take-home naloxone (THN) programmes are an evidence-based opioid overdose prevention initiative. Elevated opioid overdose risk following prison release means release from custody provides an ideal opportunity for THN initiatives. However, whether Australian prisoners would utilise such programmes is unknown. We examined the acceptability of THN in a cohort of male prisoners with histories of regular injecting drug use (IDU) in Victoria, Australia. Methods: The sample comprised 380 men from the Prison and Transition Health (PATH) Cohort Study; all of whom reported regular IDU in the 6 months prior to incarceration. We asked four questions regarding THN during the pre-release baseline interview, including whether participants would be willing to participate in prison-based THN. We describe responses to these questions along with relationships between before- and during-incarceration factors and willingness to participate in THN training prior to release from prison. Results: Most participants (81%) reported willingness to undertake THN training prior to release. Most were willing to resuscitate a friend using THN if they were trained (94%) and to be revived by a trained peer (91%) using THN. More than 10 years since first injection (adjusted odds ratio [AOR] 2.22, 95%CI 1.03-4.77), having witnessed an opioid overdose in the last 5 years (AOR 2.53, 95%CI 1.32-4.82), having ever received alcohol or other drug treatment in prison (AOR 2.41, 95%CI 1.14-5.07) and injecting drugs during the current prison sentence (AOR 4.45, 95%CI 1.73-11.43) were significantly associated with increased odds of willingness to participate in a prison THN programme. Not specifying whether they had injected during their prison sentence (AOR 0.37, 95%CI 0.18-0.77) was associated with decreased odds of willingness to participate in a prison THN training. Conclusion: Our findings suggest that male prisoners in Victoria with a history of regular IDU are overwhelmingly willing to partic

© 2018 CSIRO. Background: Gay and bisexual men (GBM) with recent HIV infection are a key population to inform HIV-prevention. The National HIV Registry (NHR) provides details about all individuals diagnosed with HIV, but it is unclear how. Methods: Basic sociodemographic characteristics of GBM in the NHR who were diagnosed between 2010 and 2014 were compared with three samples of GBM: men with undiagnosed HIV infection from the Community-Based Study of Undiagnosed HIV and Testing (COUNT) study of HIV prevalence and undiagnosed infection that was conducted during 2013-14; men in the Australian Gay Community Periodic Surveys (GCPS) who were diagnosed with HIV between 2010 and 2014; and men in the HIV Seroconversion Study (SCS) who were also diagnosed in those years. Results: The NHR identified 3629 men who reported male-to-male sex as the exposure risk for their diagnosis between 2010 and 2014. COUNT identified 19 (8.9% of all men who tested HIV positive) men as having undiagnosed HIV. In the GCPS sample, 185 (2.5%) reported being diagnosed with HIV in 2010-14. In total, 367 men in the SCS received their diagnosis during 2010-14. The mean age of men in the NHR (36.8 years) was similar to that in GCPS (36.3 years) and SCS (35.1 years), while undiagnosed men in COUNT were younger (32.6 years), with no other significant differences between the samples. Conclusions: The undiagnosed men were somewhat younger than diagnosed men. To achieve earlier diagnosis of new HIV infections, improved HIV testing frequency is needed among younger men.

© 2018, The Author(s) 2018. Utilizing Bacchi’s poststructuralist approach, “What’s the problem represented to be?,” we critically examine how the “problem” of drug use in prison is represented within a key initiative—the Identified Drug User program (IDUP)—of prison drug policy in one Australian jurisdiction. We use two data sources for our analysis: interview transcripts of recently incarcerated young men (aged 19–24) with histories of injecting drug use and selected prison drug policy and program documents. We examine how the “problem” of drug use in prison is problematized within the IDUP and question commonly accepted ways of thinking that underpin the program. We explore the discursive and subjectification effects of problem representations which produce young men as “rational” and “choosing” and, at the same time, as “untrustworthy” and “deserving of punishment.” We highlight how these effects have consequences for young men’s connections to family while incarcerated which can work against the very issues the IDUP is trying to address. We make two claims in particular: that the IDUP produces harmful effects for young men and their families and that the harmful effects produced are, paradoxically, those the IDUP aims to avoid. Our analysis offers insights into how drug use in prison could be thought about differently, including suggestions that might reduce at least some of its adverse effects.

© 2017, The Author(s). Frequent HIV testing among gay, bisexual and other men who have sex with men (GBM) is a strategic priority for HIV prevention in Australia. To overcome barriers to testing in conventional clinical services, Australia recently introduced peer HIV rapid point of care (RPOC) testing services for GBM. This mixed methods evaluation describes client acceptability and HIV prevention benefits of a peer HIV testing model. Most aspects of the service model were overwhelmingly acceptable to clients. Two-thirds of survey participants reported preferring testing with peers rather than doctors or nurses and over half reported learning something new about reducing HIV risk. Focus group findings suggested peer-delivered HIV RPOC testing reduced stigma-related barriers to frequent testing and provided novel opportunities for GBM to openly discuss HIV prevention and sexual practices, enhancing their HIV risk-reduction knowledge. Analysis of survey data suggested knowledge transfer occurred particularly among younger and less gay community-attached GBM.

© 2017 Public Health Association of Australia. Objective: To measure changes in undiagnosed HIV among gay and bisexual men (GBM) in Melbourne. Methods: Undiagnosed HIV was compared between GBM recruited anonymously in 2008 in gay venues only and GBM anonymously or confidentially (results delivery) recruited in 2014 at gay venues and a community festival. Surveys were completed and oral fluid specimens collected for HIV testing; positive tests among GBM reporting being HIV-negative or unknown/untested were classified as undiagnosed. Tests of proportions compared serological prevalence, undiagnosed prevalence and participant characteristics. Results: HIV prevalence was 9.5% and 7.1% among 639 and 993 GBM recruited in 2008 and 2014, respectively; undiagnosed prevalence declined significantly from 31.1% to 7.1% (p < 0.001). Sexual risk and undiagnosed HIV was highest among venue-recruited participants in 2014 (17.6%). Fewer diagnosed GBM participated confidentially in 2014, but this did not meaningfully influence comparative undiagnosed HIV prevalence. Conclusion: We provide the first estimates of changes in undiagnosed HIV in Australia, demonstrating a marked decline in undiagnosed HIV among GBM. Implications for public health: Our findings are consistent with reports of increases in HIV testing among GBM. Given sustained high HIV diagnosis rates, new testing models that encourage high frequency testing are needed to control the local HIV epidemic.

INTRODUCTION: Contemporary responses to HIV embrace biomedical prevention, particularly treatment as prevention (TasP) and pre-exposure prophylaxis (PrEP). However, large-scale implementation of biomedical prevention should be ideally preceded by assessments of their community acceptability. We aimed to understand contemporary attitudes of gay and bisexual men (GBM) in Australia towards biomedical-based HIV prevention and propose a framework for their measurement and ongoing monitoring. METHODS: A cross-sectional, online survey of GBM ≥18 years has been conducted annually in Victoria, Australia, since 2008. In 2016, 35 attitudinal items on biomedical HIV prevention were added. Items were scored on five-point Likert scales. We used principal factor analysis to identify key constructs related to GBM's attitudes to biomedical HIV prevention and use these to characterise levels of support for TasP and PrEP. RESULTS: A total of 462 HIV-negative or HIV-status-unknown men, not using PrEP, provided valid responses for all 35 attitudinal items. We extracted four distinct and interpretable factors we named: 'Confidence in PrEP', 'Judicious approach to PrEP', 'Treatment as prevention optimism' and 'Support for early treatment'. High levels of agreement were seen across PrEP-related items; 77.9% of men agreed that PrEP prevented HIV acquisition and 83.6% of men agreed that users were protecting themselves. However, the agreement levels for HIV TasP items were considerably lower, with <20% of men agreeing treatment (undetectable viral load) reduced HIV transmission risk. CONCLUSIONS: Better understanding of community attitudes is crucial for shaping policy and informing initiatives that aim to improve knowledge, acceptance and uptake of biomedical prevention. Our analyses suggest confidence in, acceptability of and community support for PrEP among GBM. However, strategies to address scepticism towards HIV treatment when used for prevention may be needed to optimise combination b

BACKGROUND: The 2012 regulatory approval of HIV rapid point of care (RPOC) tests in Australia and a national strategic focus on HIV testing provided a catalyst for implementation of non-clinical HIV testing service models. PRONTO! opened in 2013 as a two-year trial delivering peer-led community-based HIV RPOC tests targeting gay, bisexual and other men who have sex with men (GBM), with the aim of increasing HIV testing frequency. Initial data suggested this aim was not achieved and, as part of a broader service evaluation, we sought to explore client acceptability and barriers to testing at PRONTO! to refine the service model. METHODS: We present descriptive and thematic analyses of data from two in-depth evaluation surveys and four focus groups with PRONTO! clients focused on service acceptability, client testing history, intentions to test and barriers to testing for HIV and other sexually transmitted infections (STIs). RESULTS: The three novel aspects of the PRONTO! model, testing environment, rapid-testing, peer-staff, were reported to be highly acceptable among survey and focus group participants. Focus group discussions revealed that the PRONTO! model reduced anxiety associated with HIV testing and created a comfortable environment conducive to discussing sexual risk and health. However, an absence of STI testing at PRONTO!, driven by restrictions on medical subsidies for STI testing and limited funds available at the service level created a barrier to HIV testing. An overwhelming majority of PRONTO! clients reported usually testing for STIs alongside HIV and most reported plans to seek STI testing after testing for HIV at PRONTO!. When deciding where, when and what to test for, clients reported balancing convenience and relative risk and consequences for each infection as guiding their decision-making. CONCLUSIONS: A community-based and peer-led HIV testing model reduced previously reported barriers to HIV testing, while introducing new barriers. The absence

© 2017, The Author(s) 2017. This research focuses on an under-examined aspect of the post-release prison trajectory for a seldom-researched cohort. Narratives of the immediate days/weeks surrounding release were gathered from young men with histories of injecting drug use (IDU). Twenty-eight participants (aged 19-24) released from adult prisons in Victoria, Australia, participated in face-to-face in-depth qualitative interviews after release. Analysis of findings through the lens of a “risk environment” framework reveals how their experiences were compromised by risk factors embedded in the physical spaces and social situations they inhabited, as well as the multi-sectoral policy environments under which they were governed. A complex interplay between these factors, young men’s drug use and broader issues of structural vulnerability, including institutionalization and social disadvantage, combined to limit young men’s chances of “success” 1 on the outside. Narratives provide evidence for interventions that transform risk environments into enabling environments, thereby promoting a more successful transition from prison to community for young men with IDU histories.

© 2017 Scott et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Aims To determine whether the self-reported personal wellbeing of a cohort of people who inject drugs (PWID) changes over time, and to identify longitudinal correlates of change. Methods We us ed Personal Wellbeing Index (PWI) scores reported between April 2008 and February 2015 by 757 PWID (66% male) enrolled in the Melbourne Injecting Drug Use Cohort Study (2,862 interviews; up to seven follow-up waves). A mixed-effects model was used to identify correlations between changes in temporal variables and changes in individual PWI scores while controlling for demographic variables. Results The cohort's mean PWI score did not significantly differ over time (between 54.4/100 and 56.7/100 across the first four interview waves), and was 25-28% lower than general Australian population scores (76.0/100). However, there were large variations in individuals' PWI scores between interviews. Increased psychological distress, moving into unstable accommodation, reporting intentional overdose in the past 12 months and being the victim of assault in the past six months were associated with declines in PWI scores. Conclusions Participants experienced substantially lower levels of personal wellbeing than the general Australian population, influenced by experiences of psychological distress, assault, overdose and harms related to low socioeconomic status. The results of this study suggest a need to ensure referral to appropriate housing and health support services for PWID.

Copyright © Cambridge University Press 2016.Although high hepatitis C virus (HCV) prevalence has been observed in people who inject drugs (PWID) for decades, research suggests incidence is falling. We examined whether PWIDs' use of opioid substitution therapy (OST) and their needle-and-syringe sharing behaviour explained HCV incidence. We assessed HCV incidence in 235 PWID in Melbourne, Australia, and performed discrete-time survival with needle-sharing and OST status as independent variables. HCV infection, reinfection and combined infection/reinfection incidences were 7.6 [95% confidence interval (CI) 4.8-11.9], 12.4 (95% CI 9.1-17.0) and 9.7 (95% CI 7.4-12.6) per 100 person-years, respectively. Needle-sharing was significantly associated with higher incidence of naive HCV infection [hazard ratio (HR) 4.9, 95% CI 1.3-17.7] but not reinfection (HR 1.85, 95% CI 0.79-4.32); however, a cross-model test suggested this difference was sample specific. Past month use of OST had non-significant protective effects against naive HCV infection and reinfection. Our data confirm previous evidence of greatly reduced HCV incidence in PWID, but not the significant protective effect of OST on HCV incidence detected in recent studies. Our findings reinforce the need for greater access to HCV testing and prevention services to accelerate the decline in incidence, and HCV treatment, management and support to limit reinfection.

© 2016 The Author(s).Background: Australia has increased coverage of antiretroviral treatment (ART) over the past decade, reaching 73% uptake in 2014. While ART reduces AIDS-related deaths, accumulating evidence suggests that it could also bolster prevention efforts by reducing the risk of HIV transmission ('treatment as prevention'). While promising, evidence of community-level impact of treatment as prevention on reducing HIV incidence among gay and bisexual men is limited. We describe a study protocol that aims to determine if scale up of testing and treatment for HIV leads to a reduction in community viraemia and, in turn, if this reduction is temporally associated with a reduction in HIV incidence among gay and bisexual men in Australia's two most populous states. Methods: Over the period 2009 to 2017, we will establish two cohorts making use of clinical and laboratory data electronically extracted retrospectively and prospectively from 73 health services and laboratories in the states of New South Wales and Victoria. The 'positive cohort' will consist of approximately 13,000 gay and bisexual men (>90% of all people living with HIV). The 'negative cohort' will consist of at least 40,000 HIV-negative gay and bisexual men (approximately half of the total population). Within the negative cohort we will use standard repeat-testing methods to calculate annual HIV incidence. Community prevalence of viraemia will be defined as the proportion of men with a viral load ≥200RNA copies/mm3, which will combine viral load data from the positive cohort and viraemia estimates among those with an undiagnosed HIV infection. Using regression analyses and adjusting for behavioural and demographic factors associated with infection, we will assess the temporal association between the community prevalence of viraemia and the incidence of HIV infection. Further analyses will make use of these cohorts to assess incidence and predictors of treatment initiation, repeat HIV testing, and v

Objectives: Testing is the first step in treatment and care for blood-borne viruses (BBVs) and sexually transmitted infections (STIs). As new treatments for viral hepatitis emerge, it is important to document effective models for BBV/STI testing. A nurse-led intervention was implemented across three prisons in Victoria to improve BBV/STI testing. We evaluated the impact of the intervention on BBV/STI testing rates and hepatitis B (HBV) vaccination for reception prisoners. Methods: BBV/STI testing and HBV vaccination data were collected from the medical files of 100 consecutive reception prisoners at three prisons (n=300) prior to and after the intervention was implemented. Results: BBV testing increased significantly from 21% of prisoners to 62% post-intervention. Testing for some STIs increased significantly, but remained low: 5% to 17% for chlamydia and 1% to 5% for gonorrhoea. HBV vaccination increased significantly from 2% to 19%. Conclusions: The nurse-led intervention resulted in substantially increased testing and vaccination, demonstrating the benefits of a concerted effort to improve BBV and STI management in correctional settings. Implications: The availability of new treatments for hepatitis C has precipitated expansion of treatment in prisons. Improving the testing rate of prisoners, the first step in the treatment cascade, will maximise the benefits.

BACKGROUND: Previous research into psychological distress among people who inject drugs (PWID) is predominantly cross-sectional; we determined longitudinal predictors of change in psychological distress among a cohort of PWID. METHOD: We examined Kessler Psychological Distress Scale (K10) scores from 564 PWID (66% male) enrolled in the Melbourne Injecting Drug User Cohort Study. Gender-stratified linear models with fixed effects for each participant were used to examine correlates of change in individual K10 scores. Further linear regressions of adjusted K10 scores were used to measure correlations between demographic variables. RESULTS: Participants reported higher K10 scores (higher psychological distress) than the general Australian population (mean K10 scores 23.4 (95%CI 22.6-24.2) and 14.5 (95%CI 14.3-14.7) respectively). The cohort's mean K10 score did not significantly differ over time, but individual variations were common. Women reported higher K10 scores than men (mean baseline K10 scores 25.2 (95%CI 23.9-26.6) and 22.4 (95%CI 21.5-23.3) respectively), however no significant differences remained after controlling for temporal factors. Key predictors of increases in K10 scores were being the victim of an assault in the past six months (P<0.001 for women and men) and intentionally overdosing in the past 12 months (P=.010 for women and P<0.001 for men). CONCLUSIONS: PWID experience higher levels of psychological distress than the general population. Temporal rather than individual factors may account for the higher levels of psychological distress reported among women. Interventions to reduce rates of assault and/or intentional overdose should be explored to reduce high levels of psychological distress among PWID.

INTRODUCTION: Ex-prisoners with a history of injecting drug use (IDU) experience disproportionate drug-related harm. Rapid resumption of substance use following prison release is common and evidenced in high rates of overdose mortality. However, few studies have documented the rate of IDU resumption following prison release or identified risk factors for relapse. METHODS: Structured interviews were conducted with 533 adults with a history of IDU in Queensland, Australia prior to release from prison and approximately 1, 3 and 6 months post-release. Incidence of self-reported IDU resumption was calculated overall and for each follow-up interval. Risk factors associated with time to resumption of IDU were estimated using discrete-time survival analysis. RESULTS: IDU resumption was reported by 41% of participants during a median of 98days of follow-up (IQR=94-121), an overall crude incidence of 1.06 per person-year. The highest rate was observed in the first month (23%; crude incidence 2.24 per person-year). In adjusted discrete-time survival analyses, being unemployed at the previous interview (AHR=1.59; 95%CI:1.10-2.30), shorter incarceration (=90days vs. >365days; AHR=2.20; 95%CI:1.33-3.65), and IDU during the index incarceration (AHR=2.80; 95%CI:1.92-4.09) were significantly associated with time to IDU resumption; parole was protective (AHR=0.66; 95%CI:0.47-0.92). CONCLUSIONS: Evidence-based efforts to prevent IDU in prison and IDU resumption after release are important for both prisoner and public health. Enhancing opportunities for employment and capitalising on the short-term benefits of parole for ex-prisoners may delay resumption of IDU after release from prison. These strategies should complement rather than replace harm reduction efforts for this high-risk population.

INTRODUCTION: Gay and bisexual men (GBM) with undiagnosed HIV are believed to contribute disproportionately to HIV transmission in Australia but national prevalence estimates have been lacking. METHODS: From November 2013 to November 2014, we recruited men at gay venues and events in six Australian states and territories. Of 7291 survey participants, 3071 men also provided an oral fluid sample for testing and decided whether to receive their test results or not. We calculated raw and population-weighted prevalence estimates and identified associations with undiagnosed infection using logistic regression. RESULTS: Of 3071 participants, 213 men tested HIV-positive (6.9%, 95% confidence interval [CI] 6.0 to 7.8%), of whom 19 (8.9%, 95% CI 5.8 to 13.5%) were previously undiagnosed. After weighting for the size of the gay and bisexual male population in each state or territory, national HIV prevalence was estimated to be 7.2% (95% CI 6.3 to 8.1), of which 9.1% (95% CI 6.0 to 13.6%) were estimated to be undiagnosed. Compared with HIV-negative participants, men with undiagnosed HIV were more likely to report meeting partners at sex venues, using antiretroviral drugs as pre-exposure prophylaxis, condomless anal intercourse with casual partners, using party drugs for sex, injecting drugs and using amyl nitrite, crystal methamphetamine or gamma hydroxybutyrate in the six months prior to the survey. DISCUSSION: The results indicate that the prevalence of undiagnosed HIV is relatively low among Australian GBM but is higher among men who report riskier sex and drug practices. CONCLUSIONS: The results underline the importance of targeted HIV prevention and frequent testing for men at increased risk of infection.

Background. Determination of a patient's sexual orientation is important to guide appropriate health care. We assessed how frequently sexual orientation is included in the health records of men attending general practice and factors associated with its recording. Methods. Routine consultation data were extracted from seven Australian general practices in a 2-year period (2011-12) as part of a sexual health testing intervention for gay and bisexual men. We calculated the proportion of male patients with sexual orientation recorded and used logistic regression to determine patient, provider, clinic and community factors associated with recording. Results. There were 12 475 men who attended the clinics in the study period and sexual orientation was recorded for 42%, of whom 67% were identified as homosexual, 3% bisexual and 30% heterosexual. Recording ranged from 3% to 81% between clinics. Patient factors independently associated with recording of sexual orientation were: being HIV-positive [adjusted odds ratio (AOR) = 1.2, 95% CI: 1.1-1.4], previous sexually transmissible infection/HIV testing at the clinic (AOR = 1.8, 95% CI: 1.6-2.0), and ≥6 previous clinic visits (AOR =1 .1, 95% CI: 1.0-1.1). Provider, clinic and community factors independently associated with sexual orientation recording were: regularly attending a female GP (AOR = 1.3, 95% CI: 1.1-1.4), ≥4 previous consults with a particular GP (AOR = 1.4, 95% CI: 1.2-1.7), attending a clinic with a high caseload of gay/bisexual patients (AOR = 8.8, 95% CI: 1.6-48.1), and the patient residing in a community with ≥10% same-sex partner households (AOR = 1.2, 95% CI: 1.0-1.3). Conclusions. Sexual orientation was incomplete for more than half of male patients. Initiatives targeting both the patients and providers need to be considered to improve recording.

Objectives: To develop a mathematical model to project the potential impact of hepatitis C virus (HCV) treatment on HCV infection prevalence among people who inject drugs (PWID). Design and setting: An existing model of HCV transmission among PWID was parameterised using data from Victoria, Australia, including specific parameter estimates of the number of people who are currently active injecting drug users, average duration of injecting, chronic HCV infection prevalence among PWID, annual mortality, and annual HCV treatment rate. We also explored the impact of prevalence uncertainty, program scale-up, and new treatments. Main outcome measure: Prevalence of chronic HCV infection among people who are currently active injecting drug users. Results: With annual treatment rates of 13, 17, or 25 per 1000 PWID, the model predicts relative prevalence reductions of 20%, 30%, and 50%, respectively, within 30 years. If new treatments giving higher sustained viral response rates are available in 5 years, estimated impact is increased by 21%-23% at 15 years, and 17%-38% at 30 years, depending on treatment rates. Conclusions: This model suggests that modest rates of current HCV treatment among PWID in Victoria, Australia could halve HCV infection prevalence among PWID in 30 years. This finding suggests that interventions aimed at increasing access to HCV treatment in community clinics will benefit individual PWID and reduce HCV infection prevalence.

Objective: To estimate the number of deaths among people released from prison in Australia in the 2007-08 financial year, within 4 weeks and 1 year of release. Design, participants and setting: Application of crude mortality rates for ex-prisoners (obtained from two independent, state-based record-linkage studies [New South Wales and Western Australia]) to a national estimate of the number and characteristics of people released from prison in 2007-08. Main outcome measures: Estimated number of deaths among adults released from Australian prisons in 2007-08, within 4 weeks and 1 year of release, classified by age, sex, Indigenous status and cause of death. Results: It was estimated that among people released from prison in 2007-08, between 449 (95% CI, 380-527) and 472 (95% CI, 438-507) died within 1 year of release. Of these, between 68 (95% CI, 56-82) and 138 (95% CI, 101-183) died within 4 weeks of release. Most of these deaths were not drug-related. Conclusion: The estimated annual number of deaths among recently released prisoners in Australia is considerably greater than the annual number of deaths in custody, highlighting the extreme vulnerability of this population on return to the community. There is an urgent need to establish a national system for routine monitoring of ex-prisoner mortality and to continue the duty of care beyond the prison walls. © The Medical Journal of Australia 2011.