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Background Surveillance data indicate that Aboriginal and Torres Strait Islander young people are more likely than their non-Indigenous counterparts to experience sexually transmissible infections (STIs) and teenage pregnancy. Despite increasing emphasis on the need for strengths-based approaches to Aboriginal sexual health, limited published data document how young Aboriginal people reduce sexual health risks encountered in their everyday lives. Methods: In-depth interviews with 35 young Aboriginal women and men aged 16–21 years in two remote Australian settings were conducted; inductive thematic analysis examining sexual health risk reduction practices was also conducted. Results: Participants reported individual and collective STI and pregnancy risk reduction strategies. Individual practices included accessing and carrying condoms; having a regular casual sexual partner; being in a long-term trusting relationship; using long-acting reversible contraception; having fewer sexual partners; abstaining from sex; accessing STI testing. More collective strategies included: refusing sex without a condom; accompanied health clinic visits with a trusted individual; encouraging friends to use condoms and go for STI testing; providing friends with condoms. Conclusion: Findings broaden understanding of young Aboriginal people’s sexual health risk reduction strategies in remote Aboriginal communities. Findings signal the need for multisectoral STI prevention and sexual health programs driven by young people’s existing harm minimisation strategies and cultural models of collective support. Specific strategies to enhance young people’s sexual health include: peer condom distribution; accompanied health service visits; peer-led health promotion; continued community-based condom distribution; enhanced access to a fuller range of available contraception in primary care settings; engaging health service-experienced young people as ‘youth health workers’.

Background HIV prevalence among female sex workers in Indonesia remains high and large proportions of female sex workers have never been tested for HIV. International research highlights the importance of community-led strategies to increase HIV testing in this population. Little qualitative research has been conducted to address these issues in Indonesia or other Asia-Pacific countries. This paper documents social influences that enhance HIV testing among female sex workers in urban Indonesia. Methods: This was an interpretive qualitative study in Yogyakarta, Denpasar and Bandung. In total, 57 female sex workers participated in 11 focus group discussions, and four participated in individual semi-structured interviews. Deductive and inductive thematic analysis techniques were used to identify narratives of strengths pertaining to uptake of HIV testing. Results: Participants described supportive relationships with peers, community-based organisations and ‘bosses’. Participants reported trusted networks with peers within which to share information about HIV testing and receive emotional support. Relationships with community outreach workers facilitated HIV testing through reminders, accompanied visits, and emotional/informational support. Community-based organisations worked with health services to facilitate mobile, community-based testing to overcome employment- and family-related constraints that inhibited women’s clinic attendance. ‘Bosses’ employed a variety of practices to encourage HIV testing among their workers. Conclusions: Relationships, practices and action in community- and workplace-based settings outside formal health service spaces enhanced HIV testing among female sex workers. Community- or workplace-based HIV testing with outreach support from health services, peer-led HIV testing within existing social and work-based networks, and working with bosses to implement HIV prevention strategies can address low HIV testing rates in this key population.

Background In this paper, factors associated with HIV and syphilis infection in three cities in Papua New Guinea are explored. Methods: Respondent-driven sampling surveys among FSW in Port Moresby, Lae, and Mt. Hagen (2016–17) were conducted. FSW who were aged ≥12 years, who were born female, who spoke English or Tok Pisin and who had sold or exchanged vaginal sex in the past 6 months were eligible to participate. Participants were interviewed face-to-face and offered rapid HIV and syphilis testing. Survey logistic procedures were used to identify factors associated with HIV and syphilis infection, including modern contraception use, physical violence and having a casual male partner. Weighted data analysis was conducted. Results: Overall, 2901 FSW (Port Moresby, 673; Lae, 709; and Mt. Hagen, 709) were enrolled in the study. HIV prevalence was 15.2% in Port Moresby, 11.9% in Lae and 19.6% in Mt. Hagen. Factors associated with HIV varied by city; for example, use of modern contraception in Port Moresby, experiences of physical violence in Lae and ever having tested for HIV in Mt. Hagen. No one variable was associated with HIV in all cities. Prevalence of syphilis infection was 7.1%, 7.0%, and 3.0% in Port Moresby, Lae, and Mt. Hagen, respectively. Factors associated with syphilis infection also varied by city and were only significant in Lae. Conclusion: The different factors associated with HIV and syphilis infection in each city highlight the complex HIV and syphilis epidemics among FSW and the importance of conducting surveys in multiple locations and developing local interventions.

Background: This study aimed to examine trends in chlamydia and gonorrhoea testing and positivity in Aboriginal and non-Aboriginal women of reproductive age. Methods: A cohort of 318002 women, born between 1974 and 1995, residing in Western Australia (WA) was determined from birth registrations and the 2014 electoral roll. This cohort was then probabilistically linked to all records of chlamydia and gonorrhoea nucleic acid amplification tests conducted by two large WA pathology laboratories between 1 January 2001 and 31 December 2013. Trends in chlamydia and gonorrhoea testing and positivity were investigated over time and stratified by Aboriginality and age group. Results: The proportion of women tested annually for chlamydia increased significantly between 2001 and 2013 from 24.5% to 36.6% in Aboriginal and 4.0% to 8.5% in non-Aboriginal women (both P-values 80%) and so patterns of gonorrhoea testing were similar. Chlamydia and gonorrhoea positivity were substantially higher in Aboriginal compared with non-Aboriginal women; age-, region- and year-adjusted incidence rate ratios were 1.52 (95% confidence interval (CI) 1.50–1.69, P

Background Gonorrhoea occurs at high levels in young Aboriginal and Torres Strait Islander people living in remote communities, but there are limited data on urban and regional settings. An analysis was undertaken of gonorrhoea testing and positivity at four non-remote Aboriginal Community Controlled Health Services participating in a collaborative research network. Methods: This was a retrospective analysis of clinical encounter data derived from electronic medical records at participating services. Data were extracted using the GRHANITE program for all patients aged 15–54 years from 2009 to 2013. Demographic characteristics and testing and positivity for gonorrhoea were calculated for each year. Results: A total of 2971 patients (2571 Aboriginal and/or Torres Strait Islander) were tested for gonorrhoea during the study period. Among Aboriginal and/or Torres Strait Islander patients, 40 (1.6%) tested positive. Gonorrhoea positivity was associated with clinic location (higher in the regional clinic) and having had a positive chlamydia test. By year, the proportion of patients aged 15–29 years tested for gonorrhoea increased in both men (7.4% in 2009 to 15.9% in 2013) and women (14.8% in 2009 to 25.3% in 2013). Concurrent testing for chlamydia was performed on 86.3% of testing occasions, increasing from 75% in 2009 to 92% in 2013. Factors related to concurrent testing were sex and year of test. Conclusions: The prevalence of gonorrhoea among young Aboriginal and/or Torres Strait Islander people in non-remote settings suggests that the current approach of duplex testing for chlamydia and gonorrhoea simultaneously is justified, particularly for women.

Background Patient-delivered partner therapy (PDPT) for chlamydia is an effective and safe additional partner management strategy. Some Australian regulatory changes have been made to support PDPT, but implementation guidance is lacking. This paper describes a pilot implementation program of PDPT in New South Wales (NSW), the Australian Development and Operationalisation of Partner Therapy (ADOPT). Methods: ADOPT involved: (1) clarification of the NSW PDPT legal and policy framework; (2) development and implementation of PDPT service models, resources and data collection tools for select publicly funded sexual health services (PFSHS) and Family Planning (FP) NSW clinics; and (3) evaluation of PDPT uptake. Results: PDPT can be undertaken in NSW if accompanied by adequate provider, patient and partner information. Regulatory amendments enabled medication prescribing. The pilot implementation took place in four PFSHS and five FPNSW clinics from January to December 2016. In PFSHS, 30% of eligible patients were offered PDPT and 89% accepted the offer. In FPNSW clinics, 42% of eligible patients were offered PDPT and 63% accepted the offer. Most partners for whom PDPT was accepted were regular partners. Conclusions: A close collaboration of researchers, policy makers and clinicians allowed successful implementation of a PDPT model for chlamydia in heterosexual patients at select PFSHS and FPNSW clinics, providing guidance on its use as standard of care. However, for the full public health benefits of PDPT to be realised, it must be implemented in general practice, where most chlamydia is diagnosed. Further work is recommended to explore feasibility, develop guidelines and promote the integration of PDPT into general practice.

Background In response to the high prevalence of sexually transmissible infections (STIs) in many central Australian Aboriginal communities, a community-wide screening program was implemented to supplement routine primary health care (PHC) clinic testing. The uptake and outcomes of these two approaches were compared. Methods: Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) community and clinic screening data for Aboriginal people aged 15–34 years, 2006–2009, were used. Regression analyses assessed predictors of the first test occurring in the community screen, positivity and repeat testing. Results: A total of 2792 individuals had 9402 tests (median: four per person) over 4 years. Approximately half of the individuals (54%) were tested in the community and clinic approaches combined, 29% (n = 806) in the community screen only and 18% (n = 490) in the clinic only. Having the first test in a community screen was associated with being male and being aged 15–19 years. There was no difference between community and clinic approaches in CT or NG positivity at first test. More than half (55%) of individuals had a repeat test within 2–15 months and of these, 52% accessed different approaches at each test. The only independent predictor of repeat testing was being 15–19 years. Conclusions: STI screening is an important PHC activity and the findings highlight the need for further support for clinics to reach young people. The community screen approach was shown to be a useful complementary approach; however, cost and sustainability need to be considered.

Background Earlier age at sexual debut is associated with drug and alcohol use, risky sexual behaviours and sexually transmissible infections (STI). Methods: In the present study, 2320 young Indigenous Australians were surveyed. Results: Most study participants had sex for the first time when they were 14 years or younger (79% and 67% for males and females respectively). More than 80% of participants were categorised as being in the high-risk category for the combined sexual risk factors (i.e. not using condoms, drunk or high at last sexual act, or three or more sexual partners in the past year). There was a linear decreasing trend between the proportion of males and females who had less than high school education and age at first sex (Ptrend

Background Infection with herpes simplex virus type 2 (HSV-2) is common worldwide and an important risk factor for HIV infection. Aetiological diagnosis of HSV-2 is typically determined with the use of commercially available type-specific enzyme-linked immunosorbent assays (ELISAs). This study aimed to determine the prevalence of HSV-2 among people attending sexual health clinics in the Highlands of Papua New Guinea. The study also aimed to compare the performance of two type-specific ELISA assays, the Kalon and HerpeSelect glycoprotein G2 assays, in this context. Methods: Participants were recruited as part of a longitudinal sexual health study. Participants attended four appointments over a 12-month period and had blood taken for HSV-2 serology at each time point. Both the Kalon and HerpeSelect assays were performed as per manufacturer’s instructions. Results: A total of 132 participants were tested for HSV-2 using the Kalon and HerpeSelect ELISAs. HSV-2 prevalence was 52% (95% CI, 43–60) and 61% (95% CI, 52–69) with Kalon and HerpeSelect assays respectively. There was high concordance (87%, к = 0.75, P

Background Despite the availability of testing and treatment, bacterial sexually transmissible infections (STIs) continue to occur at endemic levels in many remote Indigenous communities in Australia. New generation molecular point-of-care (POC) tests have high sensitivity, comparable with conventional diagnostic tests, and have the potential to increase the impact of STI screening. Methods: We developed mathematical models of gonorrhoea (Neisseria gonorrhoeae) and chlamydia (Chlamydia trachomatis) transmission in remote Indigenous communities in Australia to evaluate screening and treatment strategies that utilise POC tests. Results: The introduction of POC testing with 95% sensitivity could reduce the prevalence of gonorrhoea and chlamydia from 7.1% and 11.9% to 5.7% and 8.9%, respectively, under baseline screening coverage of 44% per year. If screening coverage is increased to 60% per year, prevalence is predicted to be reduced to 3.6% and 6.7%, respectively, under conventional testing, and further reduced to 1.8% and 3.1% with the introduction of POC testing. Increasing screening coverage to 80% per year will result in a reduction in the prevalence of gonorrhoea and chlamydia to 0.6% and 1.5%, respectively, and the virtual elimination of both STIs if POC testing is introduced. Conclusions: Modelling suggests that molecular POC tests of high sensitivity have great promise as a public health strategy for controlling chlamydia and gonorrhoea. However, evaluation of the cost-effectiveness of POC testing needs to be made before widespread implementation of this technology can be considered.

Background Regular testing of individuals at higher-risk of HIV is central to current prevention strategies. The aim of the present study was to examine the extent to which confidence in one’s perceived ability to undertake various aspects of HIV testing and self-testing (self-efficacy) affected HIV testing outcomes. We assessed factors, including self-efficacy, associated with HIV testing frequency and the likelihood to self-test among gay and bisexual men (GBM). Methods: Participants were HIV-negative GBM at an increased risk of HIV (more than five partners or condomless anal intercourse in the previous 3 months) enrolled in a randomised controlled trial of HIV self-testing. The baseline questionnaire captured data regarding sociodemographic characteristics, HIV and/or sexually transmissible infection testing history, sexual behaviour, beliefs and attitudes towards HIV and eight items capturing confidence in HIV testing ability that were combined as a single broad measure of HIV testing self-efficacy (α = 0.81). Factors associated with three or more HIV tests in the past year and the likelihood of self-testing in the future were determined using logistic regression. Results: Of 354 GBM, 34% reported three or more HIV tests in the past year, and 64% reported being ‘very likely’ to self-test. Factors independently associated with three or more HIV tests in the past year were: higher self-efficacy (adjusted odds ratio (aOR) 1.08 per unit increase; 95% confidence interval (CI) 1.02–1.14; P = 0.004); >10 male partners in the past 6 months (aOR 1.79; 95% CI 1.05–3.04; P = 0.031) and higher optimism regarding the effects of HIV treatments on HIV transmission (aOR 1.14; 95% CI 1.00–1.29; P = 0.044). Only higher self-efficacy was independently associated with reporting a greater likelihood to self-test in the future (aOR 1.10; 95% CI 1.05–1.15; P < 0.001). Conclusions: Improving self-efficacy by enhancing GBM’s knowledge and experience may lead to higher testing frequency. The self-efficacy measure used in the present study could be useful in identifying GBM likely to face difficulties with HIV testing and self-testing.

Background: Rapid point-of-care tests (POCTs) for chlamydia ('Chlamydia trachomatis') and gonorrhoea ('Neisseria gonorrhoeae') have the potential to confer health benefits in certain populations even at moderate sensitivities; however, suitable POCTs for these organisms are currently lacking. Methods: In this study, we investigated the use of direct urine polymerase chain reaction (PCR), with the view of implementing a simplified PCR strategy for high-throughput chlamydia and gonorrhoea screening in remote settings. Briefly, a simple dilution of the urine was performed before adding it directly to a real-time PCR reaction. The method was evaluated using 134 stored urine specimens that had been submitted for chlamydia and gonorrhoea testing and had been tested using a commercial 'C. trachomatis' and 'N. gonorrhoeae' PCR method. These included samples that were PCR-positive for chlamydia (n = 87), gonorrhoea (n = 16) or both (n = 2). Direct urine testing was conducted using previously described in-house real-time PCR methods for 'C. trachomatis' and 'N. gonorrhoeae' as well as for recognised 'N.gonorrhoeae' antimicrobial resistance mechanisms. Results: The overall sensitivities and specificities of the direct urine PCR were 78% and 100% for chlamydia, and 83% and 100% for gonorrhoea. 'N.gonorrhoeae' penicillin and quinolone resistance mechanisms were characterised in 14 of the 18 'N. gonorrhoeae'-positive samples. Conclusions: The results of this study show that the simplified PCR strategy may be a feasible approach for rapid screening and improving chlamydia and gonorrhoea treatment in remote settings.

Background: Although half of the HIV notifications among Aboriginal and Torres Strait Islander people ('Indigenous Australians') are attributed to homosexual transmission, there has been little research examining sexual and drug use risk practices among Indigenous Australian men who have sex with men (MSM). Methods: Respondents were Indigenous Australian (n=1278) and Anglo-Australian men (n=24002) participating in the routine cross-sectional Gay Community Periodic Surveys conducted in Australia from 2007 to 2011. Sociodemographic characteristics, sexual risk practices, drug use, HIV testing and HIV status of Indigenous and Anglo-Australian men were compared and evaluated to discover whether Indigenous status was independently associated with HIV risk practices.Results:Although an equivalent proportion of Indigenous and Anglo-Australian men reported being HIV-positive (9.6%), Indigenous MSM were more likely to report unprotected anal intercourse with casual partners in the previous 6 months (27.9% v. 21.5%; Adjusted odds ratio (AOR)=1.29, 95% confidence interval (CI): 1.11-1.49). Indigenous men were more likely than Anglo-Australian men to report use of several specific drugs and twice as likely to report injecting drug use in the previous 6 months (8.8% v. 4.5%; AOR=1.43, 95% CI: 1.11-1.86).Conclusions:Despite a higher proportion of Indigenous men reporting sexual and drug use practices that increase the risk of HIV transmission, there were no differences in the HIV status of Indigenous and Anglo-Australian men. However, the elevated rates of risk practices suggest that Indigenous MSM should remain a focus for HIV prevention, care and support. Additional keywords: Aboriginal, Gay Community Periodic Survey, men who have sex with men, sexual risk.

Background As genital chlamydia (Chlamydia trachomatis) notifications have increased in Australia, time trends in hospitalisations for ectopic pregnancy and female infertility between 2001 and 2008 in New South Wales (NSW), Australia, and their relationship to trends in chlamydia notifications in women were assessed. Methods: Annual rates of chlamydia notification, and hospitalisations for female infertility or ectopic pregnancy in women aged 15–44 years in NSW were calculated using routinely collected data. Chlamydia notifications and hospital separations occurring within each year belonging to the same woman were linked using probabilistic linkage of identifiers so that multiple notifications and admissions for one woman in each calendar year were only counted once. Results: From 2001 to 2008, the annual rate of chlamydia diagnoses in women increased from 157 to 477 per 100 000 population (Ptrend

Objective To describe the frequency of the 3-month test for re-infection among sexual health service patients in Australia. Methods: We assessed the re-testing rates at 30–120 days after chlamydia infection in men who have sex with men (MSM), heterosexual males and females attending sexual health services across Australia between 2004 and 2008. A χ2-test was used to determine significant differences in re-testing rates according to demographic characteristics and trends over time. Results: In the 5-year period, 10 207 MSM, 28 530 heterosexual males and 31 190 heterosexual females were tested for chlamydia. Of those tested, 9057 (13.0%) were positive. The proportion of patients with chlamydia infection who were re-tested in 30–120 days was 8.6% in MSM, 11.9% in heterosexual males and 17.8% in heterosexual females. Among MSM, chlamydia re-testing rates were lower in men aged

Background Sexually transmissible infections (STI) are common in female sex workers (FSW). Aim: To determine if 3-monthly periodic presumptive treatments (PPT) would reduce the prevalence of STI in FSW. Methods: In a cohort study conducted between November 2003 and September 2004, FSW were enrolled, counselled and interviewed. Informed consent was obtained. Testing by using polymerase chain reaction (PCR) for Chlamydia trachomatis (Ct), Neisseria gonorrhoeae (Ng) and Trichomonas vaginalis (Tv), and serology for HIV were performed at baseline and final follow-up visits. Each FSW received 3-monthly oral amoxicillin, probenecid, a combination of amoxicillin and clavulanic acid, and azithromycin. Tinidazole was administered once. Results: The cohort consisted of 129 FSW at baseline and 71 at final follow-up visit. Of these 71 FSW, there was a significant decline in the proportion with positive PCR results for Ct from 38% to 16% (P = 0.001), Ng from 56% to 23% (P =

Melbourne Sexual Health Centre, School of Population Health, The University of Melbourne, Vic. 3053, Australia. Pacific Adventist University, Private Mail Bag, Boroko 111, Port Moresby, National Capital District, Papua New Guinea. Family Health International PNG, Country Office, PO Box 477, Waigani, National Capital District, Port Moresby, Papua New Guinea. Pacific International Hospital, 4 Mile, PO Box, 6103 Stores Road, Boroko, National Capital District, Port Moresby, Papua New Guinea. Key Centre for Women’s, Health in Society, School of Population Health, The University of Melbourne Vic. 3053, Australia. National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, NSW 2052, Australia. Corresponding author. Email: ebruce@mshc.org.au

This paper describes a possible multifaceted approach to human papillomavirus (HPV) related surveillance in Australia following implementation of a national HPV vaccination program. We describe eight main components: monitoring of vaccine coverage, vaccine safety, type-specific HPV infection surveillance, cervical cytology (Pap screening) coverage and screen detected lesion prevalence, cervical cancer incidence and mortality, genital wart incidence, incidence of recurrent respiratory papillomatosis, and knowledge, attitudes and beliefs about HPV and HPV vaccination. Australia is well placed to monitor the impact of its HPV vaccination program as well as to measure vaccine effectiveness with existing HPV vaccines, cervical screening and cancer registries.

Since 1999 there has been an increase in the number of HIV diagnoses in Australia, predominantly among men who have sex with men (MSM), but the magnitude of increase differs between states: approximately 7% rise in New South Wales, approximately 96% rise in Victoria, and approximately 68% rise in Queensland.Epidemiological, clinical, behavioural and biological data were collated into a mechanistic mathematical model to explore possible reasons for this increase in HIV notifications in MSM. The model was then used to make projections to 2015 under various scenarios.The model suggests that trends in clinical and behavioural parameters, including increases in unprotected anal intercourse, cannot explain the magnitude of the observed rise in HIV notifications, without a substantial increase in a 'transmission-increasing' factor. We suggest that a highly plausible biological factor is an increase in the prevalence of other sexually transmissible infections (STI). It was found that New South Wales required an approximately 2-fold increase in other STI to match the data, Victoria needed an ~11-fold increase, and Queensland required an approximately 9-fold increase. This is consistent with observed trends in Australia for some STI in recent years. Future projections also indicate that the best way to control the current rise in HIV notifications is to reduce the prevalence of other STI and to promote condom use, testing for HIV, and initiation of early treatment in MSM diagnosed during primary infection.Our model can explain the recent rise in HIV notifications with an increase in the prevalence of other STI. This analysis highlights that further investigation into the causes and impact of other STI is warranted in Australia, particularly in Victoria.

Objectives: In Australia, HIV notification rates in homosexual men, previously much higher in New South Wales, have become similar across the eastern states. We examined whether trends in HIV prevalence in community-based samples of homosexual men were consistent with the trends in HIV notifications. Methods: We examined data on self-reported HIV status from annual cross-sectional, self-completed anonymous surveys of homosexual men conducted between 1998 and 2006 in Sydney, Melbourne and Brisbane. Men were recruited at gay community venues, clinics and large gay community events. We calculated age-specific and age-standardised HIV prevalence rates. Comparisons of HIV prevalence between the three cities and across time were carried out using age-specific rates, and using logistic regression, controlling for age. Results: Men recruited from clinics had a much higher prevalence of HIV (P < 0.001) and were excluded from further analyses. Among the 50 239 completed questionnaires obtained at non-clinic sites, there was a marked decline in aged-standardised HIV prevalence in Sydney (from 14.2 to 8.98%, P < 0.001), a small decline in Brisbane (from 8.51 to 6.94%, P = 0.012) and no change in Melbourne (from 8.35 to 8.06%, P = 0.848). There were significant declines in men aged less than 50 years in Sydney, and in men aged less than 30 years in Brisbane. In Melbourne there was no significant trend in HIV at any age. Conclusion: HIV prevalence among young homosexual men has declined in Sydney, and these data suggest that HIV incidence among homosexual men is now similar in the eastern state capitals of Australia.

Objectives: To describe trends in HIV notifications and in other measures of HIV incidence in homosexual men in developed countries. Methods: A literature search was conducted using PubMed. In addition to the peer-reviewed literature, data on HIV surveillance trends were sought by searching websites of surveillance authorities in developed countries. Results: The availability of long-term HIV surveillance data varied considerably. However, in almost all jurisdictions in which such data were available, notifications of new HIV diagnoses among homosexual men have increased, mostly since the late 1990s. The magnitude of this increase varied, but was more than 50% in many countries. There were much fewer data available on trends in direct measures of HIV incidence in homosexual men, and increases in HIV testing rates may have contributed to the increases in HIV diagnoses in many countries. However, since the late 1990s, several clinic- and community-based cohort studies in Europe and North America reported increasing incidence. Conclusion: There were increases in HIV notifications in homosexual men in almost all developed countries, starting in the late 1990s and continuing to 2006. Although increases in HIV testing probably contributed to the increases in some settings, limited cohort data do support the existence of a true increase in HIV incidence in European and North American countries. Improved monitoring of HIV incidence in homosexual men at the population level is required to allow more timely assessment of the drivers underlying such trends.

Background: Social networking and digital media increasingly have an impact on the lives of young people. We undertook a systematic review and meta-analysis of studies that examined the relationship between exposure to sexually explicit websites (SEWs) and ‘sexting’ (i.e. sending semi-nude or nude photos from a mobile phone) and the sexual attitudes and practices of young people. Methods: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta Analyses statement, Medline, EMBASE and PsycINFO were searched for papers that described the statistical association between viewing SEWs or sexting by young people (defined as 10–24 years) and their sexual attitudes and behaviours. Results: Fourteen studies, all cross-sectional in design, met the inclusion criteria. Six studies (10 352 participants) examined young people’s exposure to SEWs and eight (10 429 participants) examined sexting. There was substantial variation across studies in exposure and outcome definitions. Meta-analyses found that SEW exposure was correlated with condomless sexual intercourse (odds ratio (OR) 1.23, 95% confidence interval (CI): 1.08–1.38, two studies); sexting was correlated with ever having had sexual intercourse (OR 5.58, 95% CI: 4.46–6.71, five studies), recent sexual activity (OR 4.79, 95% CI: 3.55–6.04, two studies), alcohol and other drug use before sexual intercourse (OR 2.65, 95% CI: 1.99–3.32, two studies) and multiple recent sexual partners (OR 2.79, 95% CI: 1.95–3.63, two studies). Most studies had limited adjustment for important potential confounders. Conclusions: Cross-sectional studies show a strong association between self-reported exposure to sexual content in new media and sexual behaviours in young people. Longitudinal studies would provide a greater opportunity to adjust for confounding, and better insight into the causal pathways underlying the observed associations.

Objectives: To identify factors associated with the uptake and outcome of testing for infectious causes of genital ulcer disease (GUD) in central Australia. Methods: Prospective investigation of GUD cases in central Australia from February 2002 to August 2003. Data were collected from primary health care clinics in remote indigenous communities of Central Australia. Results: During the study period, 134 cases of GUD were reported and investigated. Of these cases, 71 (53%) were in women (age range 14–75, median 28) and 63 (47%) in men (14–63, median 28). Testing for syphilis was undertaken for 111 (82.8%) cases, 75 (56%) were tested for herpes simplex virus infection, and 82 (61.2%) for donovanosis. Testing for at least one of the three sexually transmissible pathogens of interest was undertaken in 128 (95.5%) cases, while 99 (73.9%) were tested for two pathogens and 41 (30.6%) for all three agents. Of subjects tested, 19.8% had new syphilis infection, 51% had herpes simplex virus infection and 7% had donovanosis. In 19 of 41 (46.3%) subjects fully investigated no cause for genital ulceration was found. Conclusion: This study provides the first quantitative description of GUD diagnosis in central Australia. Logistic constraints limited the systematic application of diagnostic tests. Current treatment protocols may need to be reassessed in light of the higher than expected detection of genital herpes as a cause of GUD.

Objectives: To determine the prevalence and incidence of hepatitis A (HAV) and B (HBV) infection and vaccination in HIV-negative homosexual men in Sydney, and associated risk factors. Methods: An open prospective cohort study was conducted among a community-based sample of HIV-negative homosexual men in Sydney in 2001–02. Participants underwent a face-to-face interview, regarding demographics, sexual behavioural risk factors and sexually transmitted infections, and blood samples were collected. They were followed annually. Results: Nine hundred and three men completed a baseline interview by the end of 2002. Among them, 68% were seropositive to hepatitis A. The seroprevalence of prior hepatitis B infection was 19%, and 53% had serological evidence of HBV vaccination. Younger men were much more likely to be seronegative, with 48% and 46% of

Background: Human herpesvirus 8 (HHV-8) is a common sexually transmitted agent among homosexual men, but there are few Australian data. We aimed to describe the prevalence and risk factors for seropositivity to HHV-8 in Australian homosexual men. Methods: We conducted a prospective cohort study of 179 homosexual men in Sydney Australia in 1992–1998. Detailed data on sexual behaviour was collected annually, and HHV-8 status was determined at the end of the study by an algorithm based on results of an immunofluorescence assay and an enzyme-linked immunoassay to the K8.1 protein of HHV-8. HHV-8 DNA was detected in buffy coats using a nested qualitative PCR. Results: Data on sexual behaviour in at least three interviews and HHV-8 status were available in 174 (97%) of 179 men who agreed to participate. Of these, 31 (18%) were HHV-8 seropositive, and HHV-8 DNA was detected in 5 (16%) of these. The prevalence of HHV-8 infection was much higher in HIV positive (52%) than HIV negative (11%) men (OR 8.60, 95% CI 3.55–20.86). HHV-8 infection was related to more frequent reporting of unprotected receptive anal sex (OR for most frequent versus least frequent category 3.03, 95% CI 1.01–9.03, P trend 0.02), insertive oro–anal sex (OR for most frequent v. least frequent category 3.02, 95% CI 1.15–7.93, P trend 0.02) and receptive oro–anal sex (OR for most frequent v. least frequent category 3.09, 95% CI 1.11–8.60, P trend 0.05) with casual partners. Conclusions: These data are consistent with sexual transmission of HHV-8, but the precise mode of HHV-8 transmission remains unclear. Studies to elucidate the precise mode of sexual transmission of HHV-8 need to focus on potential salivary transmission, and should collect data on the HHV-8 infection and excretion status of the sexual partner.

Background Compared with non-Indigenous Australians, Aboriginal and Torres Strait Islander people have higher rates of sexually transmissible infections (STI). The identification of the sexual risk and healthcare seeking behaviours of young Aboriginal and Torres Strait Islander people in a regional Australian setting was sought. Methods: A cross-sectional survey of 155 young Aboriginal and Torres Strait Islander people (16–24 years) in Townsville was conducted. Results: Most participants (83%) reported ever having had sex, with a median age of 15 years at first sex and a range from 9 to 22 years. While young men reported more sexual partners in the last 12 months than young women, they were also more likely to report condom use at the last casual sex encounter (92% vs 68%, P = 0.006). Young women were significantly more likely than young men to report never carrying condoms (35% vs 16%); however, they were more likely to have had STI testing (53% vs 28%, P = 0.004). Of those reporting previous STI testing, 29% reported ever being diagnosed with an STI. Conclusions: The sample of young Aboriginal and Torres Strait Islander people reported an early age at first sex, variable condom use and low uptake of STI testing. The high prevalence of self-reported STI diagnoses indicate a need for opportunistic sexual health education and efforts designed to promote the uptake of STI screening in this group.

Background Point-of-care (POC) tests could be important public health tools in settings with treatment delays and high rates of sexually transmissible infections (STIs). Use is limited due to suboptimal performance. The performance and ease-of-use of a new molecular-based POC test for simultaneous detection of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) was assessed, alongside two single-organism immunochromatographic tests (ICT). Methods: The evaluation occurred between May 2012 and March 2013 during community STI screens in two remote Aboriginal health services. Urine was tested with the GeneXpert®CT/NG and if sufficient volume, also with Diaquick CT and Gonorrhoea Card. The gold standard comparison was laboratory nucleic acid amplification testing (NAAT). Operational characteristics were also assessed. Results: Among 198 samples, GeneXpert CT sensitivity and specificity was 100% [95% confidence intervals (CI): 75.9–100] and 99.5% (95% CI: 96.5–100), and NG was 100% (95% CI: 96.5–100) and 100% (95% CI: 97.5–100), respectively. Among a sample subset, Diaquick CT (n = 104) sensitivity and specificity was 27.3% (95% CI: 7.3–60.7) and 66.7% (95% CI: 12.5–98.2), and Gonorrhoea Card (n = 29), was 66.7% (95% CI: 12.5–98.2) and 76.9% (95% CI: 56.0–90.2), respectively. GeneXpert required 1 mL of urine, four steps, 1 min specimen preparation and 90 min to result. ICTs required 15 mL of urine, eight steps, 18 min preparation and 10–15 min to result. Conclusion: The accuracy and operational benefits of GeneXpert CT/NG make it very suitable in these settings where delays to treatment are encountered.

Background To inform a sexual health quality improvement program we examined chlamydia and gonorrhoea testing rates among 15–29 year olds attending Aboriginal Community Controlled Health Services (ACCHS) in New South Wales, Australia, and factors associated with chlamydia and gonorrhoea testing. Methods: From 2009 to 2011, consultation and testing data were extracted from four ACCHS. Over the study period, we calculated the median number of consultations per person and interquartile range (IQR), the proportion attending (overall and annually), the proportion tested for chlamydia and gonorrhoea, and those who tested positive. We examined factors associated with chlamydia and gonorrhoea testing using logistic regression. Results: Overall, 2896 15–29-year-olds attended the ACCHSs, 1223 were male and 1673 were female. The median number of consultations was five (IQR 2–12), four (IQR 1–8) for males and seven (IQR 3–14) for females (P 3 consultations (AOR: 16.97, 95% CI: 10.32–27.92). Conclusions: More frequent attendance was strongly associated with being tested for chlamydia and gonorrhoea. To increase testing, ACCHS could develop testing strategies and encourage young people to attend more frequently.

Background Remote Australian Aboriginal communities experience high rates of bacterial sexually transmissible infections (STI). A key strategy to reduce STIs is to increase testing in primary health care centres. The current study aimed to explore barriers to offering and conducting STI testing in this setting. Methods: A qualitative study was undertaken as part of the STI in Remote communities, Improved and Enhanced Primary Health Care (STRIVE) project; a large cluster randomised controlled trial of a sexual health quality improvement program. We conducted 36 in-depth interviews in 22 participating health centres across four regions in northern and central Australia. Results: Participants identified barriers including Aboriginal cultural norms that require the separation of genders and traditional kinship systems that prevent some staff and patients from interacting, both of which were exacerbated by a lack of male staff. Other common barriers were concerns about client confidentiality (lack of private consulting space and living in small communities), staff capacity to offer testing impacted by the competing demands for staff time, and high staff turnover resulting in poor understanding of clinic systems. Many participants also expressed concerns about managing positive test results. To address some of these barriers, participants revealed informal strategies, such as team work, testing outside the clinic and using adult health checks. Conclusions: Results identify cultural, structural and health system issues as barriers to offering STI testing in remote communities, some of which were overcome through the creativity and enthusiasm of individuals rather than formal systems. Many of these barriers can be readily addressed through strengthening existing systems of cultural and clinical orientation and educating staff to view STI in a population health framework. However others, particularly issues in relation to culture, kinship ties and living in small communities, may require testing modalities that do not rely on direct contact with health staff or the clinic environment.

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

Background Papua New Guinea (PNG) has one of the highest prevalences of HIV and sexually transmissible infections (STIs) in the Asia-Pacific region, and one of the highest burdens of maternal syphilis and cervical cancer globally. Despite this disease burden, only limited clinical research in sexual and reproductive health has been conducted in PNG. Methods: A longitudinal clinical cohort study was conducted at two sexual health clinics. Participants completed a behavioural interview, clinical assessment and genital examination at baseline, and at 12, 24 and 50 weeks, including specimen collection for STI diagnostics. Results: In total, 154 people attended a screening visit. Reattendance at 12, 24 and 50-weeks was 87%, 78% and 80% respectively. At baseline, HIV prevalence was 3.3%; chlamydia (Chlamydia trachomatis), 29.2%; gonorrhoea (Neisseria gonorrhoeae), 22.1%; Trichomonas vaginalis 15.6%; herpes simplex type-2 (HSV-2), 46.1%; active syphilis, 11.7%. Multiple infections were common particularly among women. The incidence of chlamydia was 27 per 100 person-years (PY); gonorrhoea, 15 out of 100 PY; T. vaginalis, 29 out of 100 PY; HSV-2, 12 out of 100 PY; syphilis, 8 out of 100 PY. No incident HIV cases were recorded. At baseline, 39% of men in Mt Hagen and 65% in Port Moresby had a penile foreskin cut, with a dorsal slit being the most common. Two men underwent penile cutting during the follow-up period. Conclusions: The prevalence and incidence of STIs, HIV and penile cutting were high among sexual health clinic attendees. High retention figures suggest that this population may be suitable for future interventions research and clinical trials.

Objective To determine young women’s experience of having a chlamydia (Chlamydia trachomatis) test as part of a chlamydia incidence study, and to determine how women who tested positive during the study experienced having a test compared with the experience of women who always tested negative. Methods: Women in an Australian chlamydia incidence study were tested at 3- to 6-monthly intervals during a 12-month period. At the final stage of the study, the women completed a questionnaire about how they felt about testing positive or how they anticipated they might feel about testing positive if they only tested negative. Questions about future sexual behaviour and testing were included. Results: The questionnaire was completed by 872 out of 1116 (78%) women, including 67 women who tested positive. Many women (75%) felt anxious when having a chlamydia test but women who tested positive were less concerned about their future health (61% v. 81%, P

The most recent estimates indicate that in 2011, 34 million people were living with HIV, the majority in sub-Saharan Africa. Even though the estimated number of new infections is decreasing, there remains an urgent need for new prevention technologies, particularly those controlled by women and men who have receptive sex. Microbicides are products designed to be applied vaginally or rectally to prevent acquisition of HIV and other sexually transmissible infections and, as such, provide a great hope for female-controlled HIV prevention. Oral prevention drugs are a more recent development that also has great potential. The field changed radically in 2010–2011 with the first trials demonstrating effectiveness of a microbicide and oral prevention drugs. The seventh biannual Microbicides conference, which took place in Sydney, Australia, in April 2012, was the first conference in this series since these new results and represented a transition from the discovery phase of research to considerations of implementation. Researchers, advocates, community representatives, funders and the media came together over 3 days to talk about the realities of implementation, particularly in regard to challenges in adherence and funding, and also examined early findings for new prevention technologies. This report of the 2012 International Microbicides Conference provides a summary of recent developments and ongoing challenges in the field of microbicides research.

To answer a key question (‘Are Australian sexual health clinics attracting priority populations?’), we used data from 44 Australian sexual health clinics between 2004 and 2011. We assessed the proportion of patients that were from priority populations (deemed to be at risk of sexually transmissible infections) and compared this to their proportions in the general population using data from Australian Bureau of Statistics and the Australian Study of Health and Relationships. A χ2-test was used. A total of 278 154 new patients attended during 2004–2011. The proportions from each priority population were significantly higher (P

[Extract] Point-of-care (POC) diagnostic tests conducted at the time of the patient visit have the potential to improve treatment and management of curable sexually transmissible infections (STI) such as chlamydia, gonorrhoea and trichomoniasis. For Aboriginal and Torres Strait Islander remote communities, STI remain an important and long-standing public health issue. They are associated with serious sequelae including pelvic inflammatory disease, infertility and systemic disease, are are particularly prevalent in remote communities. In 2009, chlamydia and gonorrhoea notification rates for Aboriginal and Torres Strait Islander peoples were very high at 2620 and 2252 per 100 000 population in 2009.

Objective To systematically review evaluations of the impact of sexually transmissible infection (STI) programs delivered by primary health care services in remote Aboriginal communities. Methods: PubMed, Google Scholar, InfoNet, Cochrane Controlled Trials Register, Australian New Zealand Clinical Trial Registry, conference proceedings and bulletins were searched to April 2011 using variations of the terms ‘Aboriginal’, ‘programs’ and ‘STI’. The primary outcome of interest in the review was the change in bacterial STI infection prevalence in the target age group assessed through cross-sectional screening studies over a 5-year period or more. The characteristics of the primary health care service, STI programs and other clinical service outcomes were also described. Results: Twelve reports described four distinct STI programs in remote communities and their impact on STI prevalence. In the Anangu Pitjantjatjara Yankunytjatjara (APY) lands of northern South Australia, there was a reduction in the age-adjusted chlamydia and gonorrhoea prevalence by 58% and 67%, respectively (1996–2003). In the Tiwi Islands of Northern Territory (NT), chlamydia and gonorrhoea positivity decreased by 94% and 34%, respectively (2002–2005). In the Ngaanyatjarra Lands of Western Australia, crude chlamydia and gonorrhoea prevalence decreased by 36% and 48%, respectively (2001–2005), and in the central Australian region of NT, there was no sustained decline in crude prevalence (2001–2005). Conclusion: In three of the four programs, there was some evidence that clinical best practice and well coordinated sexual health programs can reduce STI prevalence in remote Aboriginal communities.

Background: Annual notifications of chlamydia (Chlamydia trachomatis) diagnoses have increased steadily in Australia in the last decade. To guide public health programs, we developed 10 national chlamydia prevention indicators and report on each indicator for New South Wales (NSW). Methods: Using systematic methods, we reviewed the literature to report on the 10 health and behaviour indicators for 15- to 29-year-old heterosexuals in NSW from 2000. We included data with two or more time points.Results:Chlamydia notification rates (Indicator 1) in 15- to 29-year-olds have increased by 299%, from 237 per 100000 population in 2001 to 946 per 100000 population in 2010; and the percent of 15- to 34-year-olds with an annual Medicare-rebated chlamydia test (Indicator 2) increased by 326%, from 1.9% in 2001 to 8.1% in 2010. Since 2004, sentinel surveillance showed a 28% increase in chlamydia prevalence (Indicator 3) in 15- to 29-year- oldfemalestestedattheir firstsexualhealthservicevisit(from8.5%in2004to10.9%in2010)butnosignificantincreasein males. No NSW-specific chlamydia incidence (Indicator 4) was available. Pelvic inflammatory disease hospitalisation separations rate decreased from 0.58 per 1000 in 2001 to 0.44 per 1000 in 2010 in 15- to 29-year-old females (Indicator 5). Secondary school surveys in 2002 and 2008 showed chlamydia knowledge increased in males. The sexual risk-taking behaviour of young people remained unchanged (Indicators 6-10). Conclusions: Although notifications have risen steeply, the modest increase in chlamydia prevalence maybe a more realistic reflection of transmission rates. Strategies are needed to increase testing and to modify sexual risk behaviour. Crucial gaps in epidemiological data were identified. Additional keywords: epidemiology, heterosexuals, surveillance, young people.

In Australia, data for induced abortions (IA) is unreliable, although accurate information is essential for the development of policy and funding for services relating to IA. The rate of induced abortion was an incidental finding from questionnaire data collected for a longitudinal study of chlamydia in young women in Australia. We found a pregnancy rate of 7.2/100 woman years (95% confidence interval (CI): 5.7–9.0) (n = 76) and IA rate of 2.1/100 women years (95% CI: 1.4–3.2) (n = 22). Differences were found between States and Territories, information which might influence the development of services in regions of Australia.

Background: Men who have sex with men (MSM) are disproportionately affected by HIV. The proven efficacy of circumcision in reducing the risk of HIV acquisition among African heterosexual males has raised the question of whether this protective effect may extend to MSM populations. We examined the potential impact of circumcision on an HIV epidemic within a population of MSM. Methods: A mathematical model was developed to simulate HIV transmission in an MSM population. The model incorporated both circumcision and seropositioning, and was used to predict the reduction in HIV prevalence and incidence as a result of the two interventions. Estimates for the time required to achieve these gains were also calculated. Results: We derive simple formulae for the decrease in HIV prevalence with increased circumcision. Our model predicts that if an initially uncircumcised MSM population in a developed country with a baseline HIV prevalence of 10% underwent universal circumcision, HIV incidence would only be reduced to 95% of pre-intervention levels and HIV prevalence to 9.6% after 20 years. In the longer term, our model predicts that prevalence would only decrease from 10% to 6%, but this would take several generations to achieve. The effectiveness of circumcision increases marginally with higher degrees of seropositioning. Conclusions: The results of these calculations suggest that circumcision as a public health intervention will not produce a substantial decrease in HIV prevalence or incidence among MSM in the near future, and only modest reductions are achievable in the long-term.

Background: Sexually transmissible infections (STIs) are common in female sex workers (FSWs), most of which are asymptomatic and therefore under-reported. Our aim was to determine the sensitivity and specificity of reported symptoms obtained via questionnaire augmented with leukocyte esterase (LE) urine dipstick test for the detection of Chlamydia trachomatis (Ct), Neisseria gonorrhea (Ng) and Trichomonas vaginalis (Tv) detected using polymerase chain reaction (PCR). Methods: In November 2003, a cohort of FSWs was screened for STIs and completed a questionnaire. Results: We enrolled 129 FSWs (90% participation rate) of whom 48 (37%), 30 (23%) and 53 (41%) were diagnosed with Ng, Ct and Tv, respectively, by PCR. Of those diagnosed with any of these infections, 78% reported anogenital symptoms and of those without infections, 28% reported symptoms. Anogenital symptoms were present in over 50% FSWs. Genital odour (present in 26%), lower abdominal pain (present in 29%), dysuria (present in 19%) had a sensitivity around (50%), specificity (>80%) and all were significantly associated with positive PCR results for individual organisms; however, the sensitivity of these symptoms to detect the presence of any positive PCR result was low (1 was combined with the presence of three reported symptoms the sensitivity was 86%, specificity of 73% and a positive predictive value of 72%; a better predictor of infections. Conclusions: Our finding suggest an approach that incorporates LE urine dipstick test >1 and multiple symptoms may be a feasible option for screening infections among FSWs in resource constraint settings.

Background: Syphilis has re-emerged and become established in gay communities in most developed countries since the late 1990s. HIV infected men have been disproportionately affected by this endemic, but it is unclear whether this is due to behavioural or biological reasons. We report incidence and risk factors for syphilis in two community-based cohorts of HIV-negative and HIV-positive homosexual men in Sydney, Australia. Methods: Participants were recruited using similar community-based strategies in both cohorts and underwent annual face-to-face interviews. Syphilis screening was offered to all consenting participants at annual visits. Results: In the HIV-negative cohort, 21 men seroconverted to syphilis and one man had a syphilis re-infection during 2001–07, an incidence of 0.49 per 100 person-years (95% CI: 0.31–0.74). In the HIV-positive cohort during 2005–07, eight men seroconverted and one man had a syphilis re-infection, giving an incidence of 3.62 per 100 person-years (95% CI: 1.67–6.48). All nine reported a recent CD4 count of more than 350 cells µL–1. Syphilis incidence was significantly higher in the HIV-positive cohort after adjustment for age (hazard ratio (HR) = 9.20, 95% CI: 3.63–23.31). Unprotected anal intercourse (UAI) with HIV-positive partners was significantly associated with incident syphilis in both cohorts (HR = 4.45, 95% CI: 1.37–14.45 in HIV-negative; HR = 8.67, 95% CI: 1.03–72.76 in HIV-positive). Conclusion: Syphilis incidence was almost 10-fold higher in HIV-positive than in HIV-negative homosexual men, and it was not related to a CD4 count below 350 µL–1. UAI with HIV positive partners was of particular importance in the transmission of syphilis.

Objective: To describe recent trends in the diagnosis of HIV infection in Australia. Methods: National HIV surveillance data from 1993 to 2006 were analysed with a focus on geographic differences by HIV exposure route and late presentation (HIV within 3 months of a first AIDS-defining illness or a CD4 count of less than 200 cells μL–1). Results: In 1993–99, the number of HIV diagnoses declined by 32%, and then increased by 39% from 1999 to 2006. From 2000 onwards, rates increased significantly in Victoria, Queensland, South Australia and Western Australia. The most frequently reported routes of HIV exposure were male to male sex (71%) and heterosexual contact (18%), and the population rate of diagnoses have increased in both categories. Among the cases reported as heterosexually acquired (n = 2199), 33% were in people born in a high-prevalence country and 19% in those with partners from a high-prevalence country. Late presentation was most frequent in heterosexually acquired infections in persons who had a partner from a high-prevalence country: 32% compared with 20% overall. Conclusions: Recent increases in annual numbers of HIV diagnoses in Australia underline the continuing need for HIV-prevention programs, particularly among men having male to male sex. Early diagnosis and access to care and treatment should also be emphasised, as a substantial proportion of people with HIV infection are unaware of their status until late in the course of disease.

Background: To review existing data on sexually transmissible infections (STI) in men who have sex with men in Australia in order to determine the possible contribution of STI to diverging trends in HIV notifications in different states. Methods: We reviewed data from multiple sources, including routine national surveillance data, laboratory surveillance data, self-reported information on STI testing in men who have sex with men and ad hoc reports of STI prevalence. Results: We found increasing rates of gonorrhoea and infectious syphilis notifications in urban men in Australia between 1997 and 2006, and increasing rates of chlamydia notifications in men aged 30–49 years. There was little difference in these trends by state. Differences in the population groups sampled meant we were unable to gain further information on trends in men who have sex with men from these studies. Data on STI testing showed an increase in anal STI testing between 2003 and 2006, which may have increased the number of diagnoses of chlamydia and gonorrhoea for men who have sex with men during this period. Conclusions: Over the past 10 years, there has been a substantial increase in diagnoses of gonorrhoea and infectious syphilis, and probably chlamydia, in men who have sex with men in Australia. However, it is unlikely that changes in the pattern of STI transmission are responsible for the recent divergence in HIV rates between Australian states because there is little evidence that trends in STI also differ by state.

Objectives: Sexually transmitted infections (STIs) are believed to increase the risk of HIV acquisition, but few studies have focused on homosexual men. We examined sexual behaviour and common STIs as independent risk factors for HIV seroconversion in a community-based cohort of homosexual men in Sydney. Methods: Between 2001 and 2004, 1427 initially HIV-negative men were enrolled. They were tested annually for HIV, for gonorrhoea and chlamydia in the urethra and anus (strand displacement amplification, BDProbeTec), and for herpes simplex virus types 1 and 2 (HSV-1 and HSV-2) using type specific ELISA. Participants also reported diagnoses of STIs since their last interview. Detailed information on sexual risk behaviours was collected every 6 months. Results: There were 49 HIV seroconversions through 2006, an incidence of 0.80 per 100PY. A higher number of episodes of insertive and receptive unprotected anal intercourse (UAI) with HIV positive or HIV status unknown partners was each significantly associated with HIV seroconversion. In multivariate analysis of behavioural risk factors, HIV seroconversion was significantly associated with a higher number of episodes of receptive UAI with a partner of unknown HIV status (p trend

Objectives: We examined circumcision as a risk factor for HIV seroconversion in a community-based cohort of homosexual men in Sydney. Methods: Between 2001 and 2004, 1427 initially HIV-negative men were enrolled. Circumcision status was self-reported at baseline, and self-report was validated by clinical examination during study visits in a sub-sample of approximately 300 participants. All participants were tested annually for HIV and offered testing for other sexually transmitted infections (STIs). Detailed information on sexual risk behaviours was collected every 6 months. Results: At baseline, 66% of participants reported being circumcised; mostly as infants. The proportion circumcised ranged from 83% in those aged 45 or more to only 50% in those aged less than 25 (p�

The relevance of circumcision in preventing HIV male-to-male sex transmission is poorly understood, in particular because any potential effect could be obscured by sexual practice as a mediating or confounding factor. Using data from the Health in Men (HIM) cohort of 1426 HIV-negative homosexually active men in Sydney, we compared the sexual practices and sexual experiences of circumcised and uncircumcised men. Overall 66% of men (n�=�939) in the cohort were circumcised. After adjusting for age and ethnicity, we found no difference between circumcised and uncircumcised men in anal sexual practices, difficulty using condoms, or sexual difficulties (e.g. loss of libido). Among the circumcised men, we compared those circumcised at infancy (n�=�854) with those circumcised after infancy (n�=�81). The majority cited phimosis (i.e., an inability to fully retract the foreskin) and parents' decision as the main reasons for circumcision after infancy. After adjusting for age and ethnicity, men circumcised after infancy were more likely to practise receptive anal sex (88% vs 75%, p�

Objectives: To examine circumcision status as an independent risk factor for prevalent and incident sexually transmitted infections (STIs) in the community-based Health in Men (HIM) cohort of homosexual men. Methods: Between 2001 and 2004, 1427 initially HIV-negative men were enrolled. Circumcision status was self-reported at baseline and was validated by clinical examination in a sub-sample of participants. All participants were tested annually for HIV and offered testing for other STIs including nucleic acid amplification tests (NAAT) for urethral gonorrhoea and chlamydia, and serology for syphilis and herpes simplex virus (HSV). Demographic information and past history of STIs was collected at baseline and detailed information on sexual risk behaviours was collected every 6 months. At annual face-to-face visits, participants reported diagnoses of STIs made in the previous 12 months. Results: At baseline, 66% of participants reported being circumcised; mostly as infants. Uptake of STI testing was high with over 90% of participants tested each year. On multivariate analysis, controlling for age and sexual risk behaviour, circumcision was not associated with baseline seropositivity to syphilis (p�=�0.34), HSV1 (p�=�0.33) or HSV2 (p�=�0.92), nor with a history of self-reported genital warts (p�=�0.18). There was also no association with incident bacterial urethral infections (p�=�0.67 & p�=�0.89 for gonorrhoea and chlamydia, respectively), self-reported incident genital warts (p�=�0.35), incident HSV1 (p�=�0.70) or incident HSV2 (p�=�0.36). However, circumcision was associated with a significantly reduced risk of incident syphilis after controlling for age, number of casual partners in the previous 6 months and unprotected anal intercourse according to partners' HIV status (HR�=�0.35, 95% CI 0.14-0.87, p�=�0.024). Conclusion: Circumcised men had a reduced risk of incident syphilis in this cohort. Although most STIs were not associated with circumcision, these data suggest that circumcision may have an effect on syphilis acquisition in homosexual men.

Background: Rates of newly acquired HIV infection are increasing in Australia, and sexual contact between men accounts for 85% of cases. Objective: To investigate behavioural risk factors for HIV seroconversion among gay and bisexual men from Sydney and Melbourne, Australia. Methods: 103 men with newly acquired HIV infection were recruited from clinics in Sydney and Melbourne and behavioural risk factor questionnaires were administered between January 2003 and October 2004. Results were compared with a cross sectional and a cohort study performed by our group that enrolled similar populations of men. Results: The majority of seroconverters (73%) reported more than five sexual partners in the last six months. Ninety-five men (92%) were able to identify a high-risk event (HRE) that they thought had led to their HIV seroconversion. Most (70%) reported receptive unprotected anal intercourse (UAI), insertive UAI, or both at their HRE. Sixteen men (16%) reported no UAI in the preceding six months including the HRE. Men were more likely to report receptive UAI at their HRE when they perceived a partner to be HIV-negative as compared with when they perceived a partner to be HIV-positive (P = 0.05). Injection drug use was reported by 22% of the men in the previous six months, and 62% reported intoxication with alcohol (≥5 drinks) or mood altering recreational drug use at the HRE. Conclusions: Gay and bisexual men who have recently seroconverted are highly sexually active and report high rates of unprotected anal intercourse and recreational drug use at the HRE.

Male circumcision may reduce the risk of HIV acquisition in heterosexual men. In observational studies, confounding by demographic factors could produce spurious associations between circumcision and HIV risk. To assess this possibility, cross-sectional data on self-reported circumcision status and demographic factors were collected at baseline as part of the Health in Men study. Two-thirds of 1426 subjects were circumcised, mostly in the neonatal period. In multivariate analyses, age, ethnicity and country of birth were independently associated with circumcision status. Confounding by these demographic factors must be considered in future epidemiological studies addressing circumcision and HIV acquisition.