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The Australian Paediatric Surveillance Unit (APSU) has been conducting surveillance of rare communicable and non-communicable conditions in children since its inception in 1993. In this report, the results are described of surveillance of ten communicable diseases (and complications) for 2021, including the numbers of cases and incidence estimates; demographics; clinical features; and management and short-term outcomes. The included diseases are: acute flaccid paralysis (AFP); congenital cytomegalovirus (CMV); neonatal herpes simplex virus (HSV) infection; paediatric human immunodeficiency virus (HIV) infection; perinatal exposure to HIV; severe complications from influenza; juvenile-onset respiratory papillomatosis (JoRRP); congenital rubella syndrome; congenital varicella syndrome; and neonatal varicella infection. In 2021, cases of JoRRP were reported to the APSU for the first time since 2017, indicating potential gaps in HPV vaccination. AFP surveillance by APSU again contributed to Australia achieving a minimum target incidence of one AFP case per 100,000 children aged < 15 years. There were no cases of children with severe complications of influenza. No cases of varicella or congenital rubella were reported; however, at-risk populations, especially young migrant and refugee women from countries without universal vaccination programs, need to be screened and prioritised for vaccination prior to pregnancy. Cases of perinatal exposure to HIV continue to increase; however, the rate of mother-to-child-transmission remains at low levels due to the use of effective intervention strategies. Case numbers of congenital CMV and neonatal HSV remain steady in the absence of vaccines, prompting the need for greater awareness and education, with recent calls for target screening of at-risk infants for congenital CMV.

Background Hepatitis B virus (HBV) vaccination in the Northern Territory (NT) was funded for all Aboriginal and Torres Strait Islander newborns in 1988 and for all newborns in 1990. The prevalence of HBV in the Northern Territory was found to be higher in Aboriginal and Torres Strait Islander women than in non-Indigenous women across 2005–2010. We examined more recent data to assess whether the gap remains. Methods We linked data from two routinely collected registries, the NT Perinatal Register and the NT Notifiable Diseases System, to investigate the prevalence of HBV infection, according to eligibility for infant HBV vaccination, in women giving birth during 2005–2015. Results There were 22,781 women recorded as giving birth in public hospitals in the Northern Territory during 2005–2015. Hepatitis B virus prevalence was highest in Aboriginal and Torres Strait Islander (1.8%) and overseas-born women (1.8%). Among Aboriginal and Torres Strait Islander women, estimated hepatitis B virus prevalence was significantly higher in those born before the implementation of the vaccination program than in those born afterwards (2.4% versus 0.3%). Prevalence was highest amongst those living in very remote areas, both overall (2.2%) and within the birth cohort eligible for HBV vaccination. Conclusions Hepatitis B virus prevalence in Northern Territory Aboriginal and Torres Strait Islander women appears to be declining as more individuals vaccinated as part of infant vaccination programs reach adulthood. Prevalence remains highest in remote areas, highlighting the importance of ongoing monitoring and of promoting vaccination in these regions.

IntroductionDetermining the proportion of people living with HIV who are undiagnosed is critical for Australia to accurately assess the country’s progress toward UNAIDS’ 95-95-95 interim targets by 2025 and progress with elimination goals. We aimed to investigate the utility of two additional measures, the Yearly Diagnosed Fraction, and the Case Detection Rate, in elucidating trends over time in the rate of undiagnosed HIV.MethodsUsing routinely collected national HIV surveillance data, we produced estimates for the number living with undiagnosed HIV and the number of new HIV infections using the European Centre for Disease Protection and Control (ECDC) HIV modelling tool to calculate the Total Diagnosed Fraction (TDF), the Yearly Diagnosed Fraction (YDF), and the Case Detection Rate (CDR) from 2008 to 2019 for Australian-born and overseas-born individuals who have reported having male-to-male sexual contact, and heterosexual women and men. We calculated rate ratios using Poisson Regression models to compare trends for each sub-population.ResultsOver 2008-2019, each metric for the Australian-born male-to-male sexual contact group improved consistently over the period with the case detection rate rising above one in 2013. The total diagnosed fraction for the overseas born group fell slightly from 85.0% to 81.9%, the yearly diagnosed fraction fell from 23.1% to 17.8% and the case detection rate stayed below one, falling from 0.74 to 0.63. In the heterosexual group, women and men had consistent increasing trends for the total diagnosed fraction and yearly diagnosed fraction but with women having consistently higher estimates than men, 92.6% vs 80.8% and 26.3% vs 17.4%, respectively in 2019. However, heterosexual men had a declining case detection rate, falling below one in 2019 (0.83), compared to an increase for women.ConclusionThe additional metrics presented provide important information on Australia’s progress toward HIV elimination. The more dynamic changes in the undiagnosed population seen highlight diverging trends for key populations with growing undiagnosed populations not seen in the total diagnosed fraction. Periodic trend analyses will help strengthen the use of the metrics and ease of interpretation for national surveillance reporting.

BACKGROUND Australia has set the goal for the virtual elimination of HIV transmission by the end of 2022, yet accurate information is lacking on the level of HIV transmission occurring among residents. We developed a method for estimating the timing of HIV acquisition among migrants, relative to their arrival in Australia, and applied it to surveillance data from the Australian National HIV Registry. To apply a novel algorithm to ascertain the level of HIV transmission occurring among migrants before and after migration, and to inform appropriate local public health interventions. OBJECTIVE To apply a novel algorithm to ascertain the level of HIV transmission occurring among migrants before and after arrival in Australia, and to inform appropriate local public health interventions.We developed an algorithm incorporating CD4+ T-cell decline back-projection and enhanced variables (clinical presentation, past HIV testing history and clinician estimate of the place of HIV acquisition) and compared it to a standard algorithm which uses CD4+ T-cell back-projection only. We applied both of these algorithms to all new HIV diagnoses among migrants to estimate whether HIV infection occurred before or after arrival in Australia. METHODS We developed an algorithm incorporating CD4+ T-cell decline back-projection and enhanced variables (clinical presentation, past HIV testing history and clinician estimate of the place of HIV acquisition) and compared it to a standard algorithm which uses CD4+ T-cell back-projection only. We applied both of these algorithms to all new HIV diagnoses among migrants to estimate whether HIV infection occurred before or after arrival in Australia. RESULTS Between 1 January 2016 and 31 December 2020, 1,909 migrants were newly diagnosed with HIV in Australia, 85% were men, and the median age was 33 years. Using the enhanced algorithm, 923 (48%) were estimated to have acquired HIV after arrival in Australia, 640 (34%) before arrival (from overseas), 248 (13%) close to arrival, and 98 (5%) were unable to be classified. Using the standard algorithm, 610 (32%) were estimated to have acquired HIV in Australia, 483 (25%) before arrival, 322 (17%) close to arrival, and 494 (26%) were unable to be classified. CONCLUSIONS Using our algorithm, close to half of migrants diagnosed with HIV were estimated to have acquired HIV after arrival in Australia, highlighting the need for tailored culturally appropriate testing and prevention programs to limit HIV transmission and achieve elimination targets. Our method reduced the proportion of HIV cases unable to be classified and can be adopted in other countries with similar HIV surveillance protocols, to inform epidemiology and elimination efforts.

International audience; Human T-lymphotropic virus type 1 (HTLV-1) is estimated to affect 5 to 10 million people globally and can cause severe and potentially fatal disease, including adult T-cell leukemia/lymphoma (ATL) and HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP). The burden of HTLV-1 infection appears to be geographically concentrated, with high prevalence in discrete regions and populations. While most high-income countries have introduced HTLV-1 screening of blood donations, few other public health measures have been implemented to prevent infection or its consequences. Recent advocacy from concerned researchers, clinicians, and community members has emphasized the potential for improved prevention and management of HTLV-1 infection. Despite all that has been learned in the 4 decades following the discovery of HTLV-1, gaps in knowledge across clinical and public health aspects persist, impeding optimal control and prevention, as well as the development of policies and guidelines. Awareness of HTLV-1 among health care providers, communities, and affected individuals remains limited, even in countries of endemicity. This review provides a comprehensive overview on HTLV-1 epidemiology and on clinical and public health and highlights key areas for further research and collaboration to advance the health of people with and at risk of HTLV-1 infection.

The ability to treat gonorrhoea with current first-line drugs is threatened by the global spread of extensively drug resistant (XDR) Neisseria gonorrhoeae (NG) strains. In Australia, urban transmission is high among men who have sex with men (MSM) and importation of an XDR NG strain in this population could result in an epidemic that would be difficult and costly to control. An individual-based, anatomical site-specific mathematical model of NG transmission among Australian MSM was developed and used to evaluate the potential for elimination of an imported NG strain under a range of case-based and population-based test-and-treat strategies. When initiated upon detection of the imported strain, these strategies enhance the probability of elimination and reduce the outbreak size compared with current practice (current testing levels and no contact tracing). The most effective strategies combine testing targeted at regular and casual partners with increased rates of population testing. However, even with the most effective strategies, outbreaks can persist for up to 2 years post-detection. Our simulations suggest that local elimination of imported NG strains can be achieved with high probability using combined case-based and population-based test-and-treat strategies. These strategies may be an effective means of preserving current treatments in the event of wider XDR NG emergence., Author summary In most high-income settings, gonorrhoea is endemic among men who have sex with men (MSM). While gonorrhoea remains readily treatable with antibiotics, there are major concerns about the threat of antimicrobial resistance arising from recent reports of treatment failure with first-line therapy and limited remaining treatment options. Here we investigated the potential for test-and-treat response strategies to eliminate such strains before their prevalence reaches a level requiring a shift to new first line therapies. Rather than directly consider resistance, we explore the mitigating effect of various test-and-treat measures on outbreaks of a generic imported strain which remains treatable. This is done within the framework of a realistic mathematical model of gonorrhoea spread in an MSM community that captures cases, anatomical sites of infection and sexual contacts at an individual level, calibrated to relevant Australian epidemiological data. The results indicate that strategies such as partner testing and treatment in combination with elevated asymptomatic community testing are highly effective in mitigating outbreaks but can take up to 2 years to achieve elimination. As there are currently no clear alternative drugs of proven efficacy and safety to replace ceftriaxone in first-line therapy, these promising results suggest potential for use of these outbreak response strategies to preserve current treatment recommendations.

OBJECTIVES The aim of the study was to describe time trends in cancer incidence in people living with HIV (PLHIV) in Australia between 1982 and 2012. METHODS A population-based prospective study was conducted using data linkage between the national HIV and cancer registries. Invasive cancers identified in PLHIV were grouped into AIDS-defining cancers (ADCs), infection-related non-ADCs (NADCs), and non-infection-related NADCs. Crude and age-standardized incidence rates of cancers were calculated and compared over five time periods: 1982-1995, 1996-1999, 2000-2004, 2005-2008 and 2009-2012, roughly reflecting advances in HIV antiretroviral therapy. Standardized incidence ratios (SIRs) compared with the Australian general population were calculated for each time period. Generalized linear models were developed to assess time trends in crude and age-standardized incidences. RESULTS For ADCs, the crude and age-standardized incidences of Kaposi sarcoma and non-Hodgkin lymphoma substantially declined over time (P-trend

Background Syphilis in pregnancy can have devastating consequences with over half of untreated infections leading to serious complications. In Australia, an outbreak was detected in remote Indigenous communities in 2011, with recent increases in non-Indigenous heterosexuals. To understand the distribution and impact of these increases, we analysed notification trends in women of childbearing age. Methods National infectious syphilis notification data (2011–2018) for women aged 15–44 years were used to calculate notification rates per 100,000 by Indigenous status, age, remoteness and year, and congenital syphilis cases per 100,000 live births by Indigenous status and year. We determined trends in notification rates using Poisson regression. Results Between 2011–2018, there were 1391 and 909 notifications in Indigenous vs non-Indigenous women, with the rate 31 times higher (188 vs 6 per 100,000) in 2018, respectively. For Indigenous women, the highest rate was among women living in remote areas (522 per 100,000 in 2018) with increases in remote (174%), regional (808%) and urban areas (475%), p Conclusion Rates of infectious syphilis are increasing for Indigenous and non-Indigenous women of child-bearing age, with the greatest burden of disease in Indigenous women living in remote areas. Responses need to be delivered with further potency to control syphilis in Australia.

Background In recent years, gonorrhea notifications have increased in women in Australia and other countries. We measured trends over time and risk factors among Australian Aboriginal and Torres Strait Islander ("Aboriginal") and non-Aboriginal women. Methods We conducted a cross-sectional analysis of data from 41 sexual health clinics. Gonorrhea positivity at each patient's first visit (first-test positivity) during the period 2009 to 2016 was calculated. Univariate and multivariate analyses assessed risk factors for first-test positivity in Aboriginal and non-Aboriginal women. Results Gonorrhea positivity decreased among Aboriginal women (7.1% in 2009 to 5.2% in 2016, P < 0.001) and increased among non-Aboriginal women (0.6%-2.9%, P < 0.001). Among Aboriginal women, first-test positivity was independently associated with living in a regional or remote area (adjusted odds ratio [aOR], 4.29; 95% confidence interval [CI], 2.52-7.31; P < 0.01) and chlamydia infection (aOR, 4.20; 95% CI,3.22-5.47; P < 0.01). Among non-Aboriginal women, first-test positivity was independently associated with greater socioeconomic disadvantage (second quartile: aOR, 1.68 [95% CI, 1.31-2.16; P < 0.01]; third quartile: aOR, 1.54 [95% CI, 1.25-1.89; P < 0.01]) compared with least disadvantaged quartile: recent sex work (aOR, 1.69; 95% CI, 1.37-2.08; P < 0.01), recent injecting drug use (aOR, 1.85; 95% CI, 1.34-2.57; P < 0.01), and chlamydia infection (aOR, 2.35; 95% CI, 1.90-2.91; P < 0.01). For non-Aboriginal women, being aged 16 to 19 years (aOR, 0.62; 95% CI, 0.49-0.80; P < 0.01) compared with those ≥30 years was a protective factor. Conclusions These findings highlight 2 different epidemics and risk factors for Aboriginal and non-Aboriginal women, which can inform appropriate health promotion and clinical strategies.

BACKGROUND: Anal cancer incidence increased markedly in people living with HIV (PLWHIV) after the introduction of HAART, but in a few setting settings, recent declines have been reported. We report the incidence and time trends of anal cancer in PLWHIV in Australia. STUDY DESIGN: A data linkage study between the National HIV Registries and the Australian Cancer Database. METHODS: Cases of anal squamous cell carcinoma (ASCC) in Australians aged 16 years and above diagnosed with HIV between 1982 and 2012 were identified. Standardized incidence ratios (SIRs) were calculated to compare incidence with that of the general population. Poisson regression models were developed to describe the time trends of ASCC over time and to compare ASCC risk within subgroups of PLWHIV. RESULTS: Among 28 696 individuals, a total of 129 cases of ASCC were identified. The crude incidence was 36.3 per 100 000 person-years and it increased sharply from 14.8 to 62.1 per 100 000 person-years between 1982–1995 and 2009–2012 (P trend

The ability to treat gonorrhoea with current first-line drugs is threatened by the global spread of extensively drug resistant (XDR) Neisseria gonorrhoeae (NG) strains. In Australia, urban transmission is high among men who have sex with men (MSM) and emergence of an imported XDR NG strain in this population could result in an epidemic that would be difficult and costly to control. An individual-based, anatomical site-specific mathematical model of NG transmission among Australian MSM was developed and used to evaluate the potential for elimination of an emergent XDR NG strain under a range of case-based and population-based test-and-treat strategies. When applied upon detection of the imported strain, these strategies enhanced the probability of elimination and reduced the outbreak size compared with current practice. The most effective strategies combined testing targeted at regular and casual partners with increased rates of population testing. However, even with the most effective strategies, outbreaks could persist for up to 2 years post-detection. Our simulations suggest that local elimination of emergent NG XDR strains can be achieved with high probability using combined case-based and population-based test-and-treat strategies. These strategies may be an effective means of preserving current treatments in the event of wider XDR NG emergence.Author SummaryIn most high-income settings, gonorrhoea transmission is endemic among men who have sex with men (MSM). While gonorrhoea remains readily treatable, there are major concerns about further resistance due to recent reports of treatment failure with first-line therapy and limited remaining treatment options. Here we investigated the potential for trace and treat response strategies to eliminate such strains before their prevalence reaches a level requiring a shift to new first line therapies. Rather than directly consider resistance, we explore the mitigating effect of various test and trace measures on outbreaks of a generic imported strain which remains treatable. This is done within a realistic mathematical model of spread in an MSM community that captures cases, anatomical sites of infection and contacts at an individual level, calibrated to Australian epidemiology. The results indicate that strategies such as partner tracing and treatment in combination with elevated asymptomatic community testing are highly effective in mitigating outbreaks but can take up to 2 years to achieve elimination. As there are currently no clear alternatives of proven efficacy and safety to replace ceftriaxone in first-line therapy, these promising results suggest potential for use of these outbreak response strategies to enable continuation of current treatment recommendations.

For 27 years, national prospective data on selected rare childhood diseases have been collected monthly by the Australian Paediatric Surveillance Unit (APSU) from paediatricians and other clinical specialists who report cases in children aged up to 16 years. We report here the annual results of APSU surveillance in 2020 for ten rare communicable diseases and complications of communicable diseases, namely: acute flaccid paralysis (AFP); congenital cytomegalovirus (CMV) infection; neonatal herpes simplex virus (HSV) infection; perinatal exposure to human immunodeficiency virus (HIV); paediatric HIV infection; severe complications of seasonal influenza; juvenile onset recurrent respiratory papillomatosis (JoRRP); congenital rubella syndrome; congenital varicella syndrome; and neonatal varicella infection. We describe the results for each disease in the context of the total period of study, including demographics, clinical characteristics, treatment and short-term outcomes. Despite challenges presented by the coronavirus disease 2019 (COVID-19) pandemic in 2020, more than 1,400 paediatricians reported regularly to the APSU and an overall monthly reporting rate of > 90% was achieved. The minimum AFP target of 1 case per 100,000 children aged less than 15 years was achieved and there were few cases of vaccine-preventable diseases (JoRRP, rubella, varicella). However, high cases of congenital CMV, neonatal HSV and perinatal exposure to HIV persist. There were no severe complications of seasonal influenza reported for the first time in 13 years. This is consistent with other surveillance data reporting a decline of influenza and other communicable diseases in 2020, and likely reflects the wider effects of public health measures to reduce transmission of SARS-CoV-2 in the Australian community.

The Australian Paediatric Surveillance Unit (APSU) has been prospectively collecting national data on rare childhood conditions since 1993, with monthly reporting of cases by paediatricians. In this report we describe annual results from studies for ten communicable diseases and complications of communicable diseases that were conducted using APSU surveillance in 2019 and place these in an historic context. Results are reported on acute flaccid paralysis, congenital cytomegalovirus infection, neonatal herpes simplex virus infection, perinatal exposure to HIV, paediatric HIV infection, severe complications of seasonal influenza, juvenile onset recurrent respiratory papillomatosis (JoRRP), congenital rubella syndrome, congenital varicella syndrome and neonatal varicella infection. APSU provides rich clinical data to complement data collected from other surveillance systems and to improve understanding and response to rare childhood infections.

Australia has set a national target of ending HIV by 2020, achieving this will require the inclusion of priority populations (eg, Indigenous Australians) in strategies to reach elimination. To assist in evaluating the target of elimination, we analysed HIV notification data for Indigenous and non-Indigenous Australians.Using the National HIV Registry at The Kirby Institute at UNSW, Sydney, NSW, Australia, we collated and analysed annual HIV notification data for 1996-2015. Patients who were not born in Australia were excluded. We calculated the rates of HIV diagnoses with annual trends in notification rates for Indigenous versus non-Indigenous Australians by demographic characteristics, exposure categories, and stage of HIV at diagnosis. For missing data, assumptions were made and verified through sensitivity analyses. Annual rate ratio (RR) and 4 year summary rate ratio (SRR) trends were calculated to determine patterns of HIV diagnosis in the two populations.Between Jan 1, 1996, and Dec 31, 2015, 11 492 people born in Australia were reported with a diagnosis of HIV, of whom 461 (4%) were recorded as Indigenous Australians and we classified the remaining 11 031 (96%) as non-Indigenous Australians. For exposure to HIV, among Indigenous Australians a higher proportion of diagnoses occurred among women, and through injecting drug use and heterosexual sex than among non-Indigenous Australians (p0·0001). Among Indigenous Australians, we found a significantly higher SRR of HIV diagnoses among men in the period 2012-15 than in previous periods (SRR 1·53, 95% CI 1·28-1·83; p0·0001), and significantly higher diagnosis among Indigenous women (4·92, 4·02-6·02; p0·0001) for the entire study period than among non-Indigenous women. Concurrently, a decrease in HIV diagnoses of 1% per annum (RR 0·99, 95% CI 0·98-0·99; p0·0001) across the study period was seen among non-Indigenous people. Indigenous Australians were more likely to be diagnosed at an advanced stage of HIV infection than non-Indigenous Australians (20·8% vs 15·1%; p=0·0088).Greater efforts should be made to include Indigenous people in prevention strategies, particularly newer biomedical interventions, such as scale up of pre-exposure prophylaxis and treatment as prevention initiatives in Australia. More involvement of Indigenous Australians in these approaches is also required to prevent widening of the gap in HIV diagnosis rates between non-Indigenous and Indigenous Australians.None.

Background Young people living in remote Australian Aboriginal communities experience high rates of sexually transmissible infections (STIs). STRIVE (STIs in Remote communities, ImproVed and Enhanced primary care) was a cluster randomised control trial of a sexual health continuous quality improvement (CQI) program. As part of the trial, qualitative research was conducted to explore staff perceptions of the CQI components, their normalisation and integration into routine practice, and the factors which influenced these processes. Methods In-depth semi-structured interviews were conducted with 41 clinical staff at 22 remote community clinics during 2011–2013. Normalisation process theory was used to frame the analysis of interview data and to provide insights into enablers and barriers to the integration and normalisation of the CQI program and its six specific components. Results Of the CQI components, participants reported that the clinical data reports had the highest degree of integration and normalisation. Action plan setting, the Systems Assessment Tool, and the STRIVE coordinator role, were perceived as adding value to the program, but were less readily integrated or normalised. The remaining two components (dedicated funding for health promotion and service incentive payments) were seen as least relevant. Our analysis also highlighted factors which enabled greater integration of the CQI components. These included familiarity with CQI tools, increased accountability of health centre staff and the translation of the CQI program into guideline-driven care. The analysis also identified barriers, including high staff turnover, limited time involved in the program and competing clinical demands and programs. Conclusions Across all of the CQI components, the clinical data reports had the highest degree of integration and normalisation. The action plans, systems assessment tool and the STRIVE coordinator role all complemented the data reports and allowed these components to be translated directly into clinical activity. To ensure their uptake, CQI programs must acknowledge local clinical guidelines, be compatible with translation into clinical activity and have managerial support. Sexual health CQI needs to align with other CQI activities, engage staff and promote accountability through the provision of clinic specific data and regular face-to-face meetings. Trial registration Australian and New Zealand Clinical Trials Registry ACTRN12610000358044. Registered 6/05/2010. Prospectively Registered. Electronic supplementary material The online version of this article (10.1186/s12913-018-3024-y) contains supplementary material, which is available to authorized users.

Background: Substantial declines in genital warts have been observed in countries with quadrivalent/nonavalent human papillomavirus (q/n HPV) vaccination programmes, with Australia showing the most pronounced and long-term reductions. No study has assessed progress towards elimination of genital warts in a nation-wide sample of patients, and migrants’ contribution to population-level control of genital warts. We assessed Australia's progress towards genital warts elimination by examining trends in diagnoses in Australian- and overseas-born patients of sexual health clinics (SHCs) across Australia. Methods: A cross-sectional trend analysis of new genital warts diagnoses among first-time patients of 34 SHCs, between 2004 and 2018, was performed. Rate ratios (RR) were calculated using Poisson regression models, for comparing trends in proportions of new genital warts diagnoses in Australian- and overseas-born patients during the pre-vaccination era (2004-2007) and the vaccination era (2008-2018), and by 2018 relative to 2004-2007. Findings: A total of 439,957 new patients (Australian-born: 230,230; overseas-born: 209,727) were seen at SHCs, 6•4% were diagnosed with genital warts (Australian-born: 7•1%; overseas-born: 5•6%). By 2018, there had been a 64% reduction in the proportion of all SHC patients with a genital warts diagnosis relative to 2004-2007 (RR: 0•36, 95% CI: 0•35-0•38). The decline was more pronounced at 72% (RR: 0•28, 95% CI: 0 •27-0•30) among Australian-born patients, with the greatest reduction in women and men aged

Background and aim Interferon-free direct-acting antiviral regimens for hepatitis C virus (HCV) infection have been recently available in Australia, beginning a new era in clinical and public health management of HCV infection. This study provided updated estimates of the HCV infection care cascade and burden in Australia as a reliable platform for assessing the future impact of interferon-free therapies. Methods A modeling approach was applied to estimate the number of individuals living with chronic HCV infection and with various liver disease stages. Data from national registries of HCV notification and liver transplantation, literature review, and expert consensus informed the model parameters. HCV notification and Pharmaceutical Benefits Scheme data were used to estimate the number of HCV diagnosed individuals and treatment uptake. Results In 2014, an estimated 230 470 individuals (range: 180 490-243 990) were living with HCV, among whom 75% were diagnosed (n = 172 720; range: 156 720-188 770), 20% had ever received treatment (n = 45 000; range: 39 280-50 720), and 11% had been cured (n = 24 750; range: 21 520-27 990). Among individuals with HCV infection, the proportion with hepatic fibrosis stage ≥F3 doubled during the last decade, increasing from 9% (n = 18 580) in 2004 to 19% (n = 44,730) in 2014. Individuals initiating HCV treatment increased from 1100 in 1997 to 3840 in 2007, plateaued until 2010 and decreased to 2790 in 2014. Conclusions The burden of HCV-related liver disease has increased markedly. Although the proportion diagnosed was high, treatment uptake remained low, with no increase over the last 7 years. Reducing the HCV burden in Australia requires scale-up of interferon-free HCV therapies.

Summary Background Remote Australian Aboriginal communities have among the highest diagnosed rates of sexually transmissible infections (STIs) in the world. We did a trial to assess whether continuous improvement strategies related to sexual health could reduce infection rates. Methods In this stepped-wedge, cluster-randomised trial (STIs in remote communities: improved and enhanced primary health care [STRIVE]), we recruited primary health-care centres serving Aboriginal communities in remote areas of Australia. Communities were eligible to participate if they were classified as very remote, had a population predominantly of Aboriginal people, and only had one primary health-care centre serving the population. The health-care centres were grouped into clusters on the basis of geographical proximity to each other, population size, and Aboriginal cultural ties including language connections. Clusters were randomly assigned into three blocks (year 1, year 2, and year 3 clusters) using a computer-generated randomisation algorithm, with minimisation to balance geographical region, population size, and baseline STI testing level. Each year for 3 years, one block of clusters was transitioned into the intervention phase, while those not transitioned continued usual care (control clusters). The intervention phase comprised cycles of reviewing clinical data and modifying systems to support improved STI clinical practice. All investigators and participants were unmasked to the intervention. Primary endpoints were community prevalence and testing coverage in residents aged 16–34 years for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis. We used Poisson regression analyses on the final dataset and compared STI prevalences and testing coverage between control and intervention clusters. All analyses were by intention to treat and models were adjusted for time as an independent covariate in overall analyses. This study was registered with the Australia and New Zealand Clinical Trials Registry, ACTRN12610000358044. Findings Between April, 2010, and April, 2011, we recruited 68 primary care centres and grouped them into 24 clusters, which were randomly assigned into year 1 clusters (estimated population aged 16–34 years, n=11 286), year 2 clusters (n=10 288), or year 3 clusters (n=13 304). One primary health-care centre withdrew from the study due to restricted capacity to participate. We detected no difference in the relative prevalence of STIs between intervention and control clusters (adjusted relative risk [RR] 0·97, 95% CI 0·84–1·12; p=0·66). However, testing coverage was substantially higher in intervention clusters (22%) than in control clusters (16%; RR 1·38; 95% CI 1·15–1·65; p=0·0006). Interpretation Our intervention increased STI testing coverage but did not have an effect on prevalence. Additional interventions that will provide increased access to both testing and treatment are required to reduce persistently high prevalences of STIs in remote communities. Funding Australian National Health and Medical Research Council.

Purpose: The aim of the article was to investigate recent trends in human immunodeficiency virus (HIV) diagnosis rates among men who have sex with men (MSM) in high-income countries in North America, Western Europe, and Australia. Methods: Data on annual rates of HIV diagnoses among MSM aged 15 to 65 years from 2000 to 2014 were collected from 13 high-income countries. Joinpoint regression software was used to empirically determine country-specific trend periods. Trends in HIV diagnosis rates and in the proportion of diagnoses occurring in young MSM aged 15 to 24 years were analyzed using Poisson regression and log-binomial regression, respectively. Results: Six countries experienced an increasing trend from 2000 to 2007-08 followed by either a stable or declining trend through 2014. Five countries had recently increasing trends, and two countries had one stable trend from 2000 to 2014. All 13 countries experienced increases in the proportion of diagnoses occurring in young MSM. Conclusions: Since 2008, half of the 13 high-income countries examined experienced stable or decreasing trends. Still, some countries continue to experience increasing HIV trends, and young MSM are increasingly represented among new diagnoses. Efforts to support early sexual health promotion, reduce barriers to pre-exposure prophylaxis, and improve care engagement for young MSM are critical to addressing current HIV trends. info:eu-repo/semantics/publishedVersion

Objective: To determine the rates of HIV testing among people who had received positive test results for chlamydia, gonorrhoea and trichomoniasis, or who had been tested for syphilis. Design, setting and participants: Pathology data for the period January 2010 e December 2014 from 65 remote Aboriginal communities participating in the STRIVE trial of sexually transmissible infection (STI) control were analysed. Main outcome measures: Rates of HIV testing within 30 and 90 days of an STI test (for chlamydia, gonorrhoea or trichomoniasis), the result of which was positive, and within 30 days of a test for syphilis; factors independently associated with concurrent HIV testing. Results: 31.8% of 15 260 positive STI test results were linked with an HIV test within 30 days of the test (including 5.6% not on the same day), and 34.8% within 90 days; 44.1% were linked with syphilis testing within 30 days. 53.4% of all those tested for syphilis were also tested for HIV within 30 days. Multivariate analysis found that HIV testing was more likely for men, in geographical regions 3 and 4, in association with positive STI test results during 2012, 2013 or 2014 (v 2010), and in association with positive test results for gonorrhoea or chlamydia. Similar associations with these factors were found for syphilis testing. Conclusions: A significant challenge in Aboriginal health is avoiding an increase in the number of HIV infections. One critical intervention in this regard is timely and appropriate testing. Adhering to screening recommendations is clearly an aspect of the delivery of sexual health services to remote communities that can be improved in striving to achieve this aim.

Achieving the Joint United Nations Program on human immunodeficiency virus (HIV)/AIDS Fast-Track targets requires additional strategies for mobile populations. We examined trends and socio-demographics of migrants (overseas-born) and Australian-born individuals presenting with late and advanced HIV diagnoses between 2008 and 2017 to help inform public health approaches for HIV testing coverage and linkage to care and treatment.We conducted a retrospective population-level observational study of individuals diagnosed with HIV in Australia and reported to the National HIV Registry. Annual proportional trends in late (CD4+ T-cell count

ObjectivesKey strategies to control chlamydia include testing, treatment, partner management and re-testing. We developed a diagnosis and care cascade for chlamydia to highlight gaps in control strategies nationally and to inform efforts to optimise control programmes.MethodsThe Australian Chlamydia Cascade was organised into four steps: (1) annual number of new chlamydia infections (including re-infections); (2) annual number of chlamydia diagnoses; (3) annual number of diagnoses treated; (4) annual number of diagnoses followed by a re-test for chlamydia within 42–180 days of diagnosis. For 2016, we estimated the number of infections among young men and women aged 15–29 years in each of these steps using a combination of mathematical modelling, national notification data, sentinel surveillance data and previous research studies.ResultsAmong young people in Australia, there were an estimated 248 580 (range, 240 690–256 470) new chlamydia infections in 2016 (96 470 in women; 152 100 in men) of which 70 164 were diagnosed (28.2% overall: women 43.4%, men 18.6%). Of the chlamydia infections diagnosed, 65 490 (range, 59 640–70 160) were treated (93.3% across all populations), but only 11 330 (range, 7660–16 285) diagnoses were followed by a re-test within 42–180 days (17.3% overall: women 20.6%, men 12.5%) of diagnosis.ConclusionsThe greatest gaps in the Australian Chlamydia Cascade for young people were in the diagnosis and re-testing steps, with 72% of infections undiagnosed and 83% of those diagnosed not re-tested: both were especially low among men. Treatment rates were also lower than recommended by guidelines. Our cascade highlights the need for enhanced strategies to improve treatment and re-testing coverage such as short message service reminders, point-of-care and postal test kits.

Background Cervical cancer occurrence and mortality are strongly correlated with socioeconomic disadvantage, largely due to unequal access to screening and treatment. Universal human papillomavirus (HPV) vaccination provides the opportunity to greatly reduce this global health disparity. Australian Indigenous women have substantially higher rates of cervical cancer than non-Indigenous women, primarily due to under-screening. We investigated HPV infection rates in Indigenous women 7 years after implementation of the national HPV vaccination program. Methods We used a repeat cross-sectional design, with the baseline being provided by an HPV prevalence survey among Indigenous women attending clinics for cervical cytology screening, prior to the start of the vaccination program in 2007. We returned to clinics in four locations during 2014–15, and invited women aged 18–26 years attending for screening to provide a cervical specimen for HPV testing, as well as to complete a short questionnaire and consent to allow access of their records in the National HPV Vaccination Program Register. We used well-established laboratory methods to test specimens for specific HPV genotypes. Results A total of 142 women were recruited at participating sites and compared to 155 who had been recruited at the same locations in the 2007 pre-vaccine survey. The two groups were identical in regard to age, with the more recent group having a higher proportion of hormonal contraception users, and a lower proportion of smokers. The proportion found to have any HPV type fell from 58 to 36% with the decline being entirely due to reductions in vaccine types, which fell by 94% from 24 to 1.4%. Conclusion Australia’s national HPV vaccination program appears to be successfully protecting a very high proportion of Indigenous women against vaccine targeted HPV types, who have in the past been at elevated risk of cervical cancer.

To the Editors:INTRODUCTIONIn Australia, people born in Sub-Saharan Africa, South-East Asia, and North-East Asia have HIV diagnosis rates 2–4 times higher than people born in Australia,1 and are more likely to be diagnosed late with a CD4 count

Objectives To undertake the first comprehensive analysis of the incidence of three curable sexually transmissible infections (STIs) within remote Australian Aboriginal populations and provide a basis for developing new control initiatives. Methods We obtained all results for Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and Trichomonas vaginalis (TV) testing conducted during 2009–2011 in individuals aged ≥16 years attending 65 primary health services across central and northern Australia. Baseline prevalence and incidence of all three infections was calculated by sex and age group. Results A total of 17 849 individuals were tested over 35 months. Baseline prevalence was 11.1%, 9.5% and 17.6% for CT, NG and TV, respectively. During the study period, 7171, 7439 and 4946 initially negative individuals had a repeat test for CT, NG and TV, respectively; these were followed for 6852, 6981 and 6621 person-years and 651 CT, 609 NG and 486 TV incident cases were detected. Incidence of all three STIs was highest in 16-year-olds to 19-year-olds compared with 35+ year olds (incident rate ratio: CT 10.9; NG 11.9; TV 2.5). In the youngest age group there were 23.4 new CT infections per 100 person-years for men and 29.2 for women; and 26.1 and 23.4 new NG infections per 100 person-years in men and women, respectively. TV incidence in this age group for women was also high, at 19.8 per 100 person-years but was much lower in men at 3.6 per 100 person-years. Conclusions This study, the largest ever reported on the age and sex specific incidence of any one of these three curable infections, has identified extremely high rates of new infection in young people. Sexual health is a priority for remote communities, but will clearly need new approaches, at least intensification of existing approaches, if a reduction in rates is to be achieved.

Objectives To determine the co-occurrence and epidemiological relationships of Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and Trichomonas vaginalis (TV) in a high-prevalence setting in Australia. Methods In the context of a cluster randomised trial in 68 remote Aboriginal communities, we obtained laboratory reports on simultaneous testing for CT, NG and TV by nucleic acid amplification tests in individuals aged ≥16 years and examined relationships between age and sex and the coinfection positivity. ORs were used to determine which infections were more likely to co-occur by demographic category. Results Of 13 480 patients (median age: 30 years; men: 37%) tested for all three infections during the study period, 33.3% of women and 21.3% of men had at least one of them, highest in patients aged 16–19 years (48.9% in women, 33.4% in men). The most frequent combination was CT/NG (2.0% of women, 4.1% of men), and 1.8% of women and 0.5% of men had all three. In all co-combinations, coinfection positivity was highest in patients aged 16–19 years. CT and NG were highly predictive of each other9s presence, and TV was associated with each of the other two infections, but much more so with NG than CT, and its associations were much stronger in women than in men. Conclusions In this remote high-prevalence area, nearly half the patients aged 16–19 years had one or more sexually transmitted infections. CT and NG were more common dual infections. TV was more strongly associated with NG coinfections than with CT. These findings confirm the need for increased simultaneous screening for CT, NG and TV, and enhanced control strategies. Trial registration Australian and New Zealand Clinical Trials Registry ACTRN12610000358044.

usc Introduction: We conducted a detailed analysis of trends in new HIV diagnoses in Australia by country of birth, to understand any changes in epidemiology, relationship to migration patterns and implications for public health programs. Methods: Poisson regression analyses were performed, comparing the age-standardised HIV diagnosis rates per 100,000 estimated resident population between 2006–2010 and 2011–2015 by region of birth, with stratification by exposure (male-to-male sex, heterosexual sex–males and females). Correlation between the number of permanent and long-term arrivals was also explored using linear regression models. Results: Between 2006 and 2015, there were 6,741 new HIV diagnoses attributed to male-to-male sex and 2,093 attributed to heterosexual sex, with the proportion of diagnoses attributed to male-to-male sex who were Australian-born decreasing from 72.5% to 66.5%. Compared with 2006–2010, the average annual HIV diagnosis rate per 100,000 in 2011–15 attributed to male-to-male sex was significantly higher in men born in South-East Asia (summary rate ratio (SRR) = 1.37, p = 0.001), North-East Asia (SRR = 2.18, p

Background: In high-incidence Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) settings, annual re-testing is an important public health strategy. Using baseline laboratory data (2009–10) from a cluster randomised trial in 67 remote Aboriginal communities, the extent of re-testing was determined, along with the associated patient, staffing and health centre factors. Methods: Annual testing was defined as re-testing in 9–15 months (guideline recommendation) and a broader time period of 5–15 months following an initial negative CT/NG test. Random effects logistic regression was used to determine factors associated with re-testing. Results: Of 10 559 individuals aged ≥16 years with an initial negative CT/NG test (median age = 25 years), 20.3% had a re-test in 9–15 months (23.6% females vs 15.4% males, P 90%) Aboriginal people. Additional factors independently associated with re-testing for females were: being aged 25–29 years, attending a centre that used electronic medical records, and for males, attending a health centre that employed Aboriginal health workers and more male staff. Conclusions: Approximately 20% of people were re-tested within 9–15 months. Re-testing was more common in younger individuals. Findings highlight the importance of recall systems, Aboriginal health workers and male staff to facilitate annual re-testing. Further initiatives may be needed to increase re-testing.

Interferon-free direct-acting antiviral regimens for hepatitis C virus (HCV) infection have been recently available in Australia, beginning a new era in clinical and public health management of HCV infection. This study provided updated estimates of the HCV infection care cascade and burden in Australia as a reliable platform for assessing the future impact of interferon-free therapies.A modeling approach was applied to estimate the number of individuals living with chronic HCV infection and with various liver disease stages. Data from national registries of HCV notification and liver transplantation, literature review, and expert consensus informed the model parameters. HCV notification and Pharmaceutical Benefits Scheme data were used to estimate the number of HCV diagnosed individuals and treatment uptake.In 2014, an estimated 230 470 individuals (range: 180 490-243 990) were living with HCV, among whom 75% were diagnosed (n = 172 720; range: 156 720-188 770), 20% had ever received treatment (n = 45 000; range: 39 280-50 720), and 11% had been cured (n = 24 750; range: 21 520-27 990). Among individuals with HCV infection, the proportion with hepatic fibrosis stage ≥F3 doubled during the last decade, increasing from 9% (n = 18 580) in 2004 to 19% (n = 44,730) in 2014. Individuals initiating HCV treatment increased from 1100 in 1997 to 3840 in 2007, plateaued until 2010 and decreased to 2790 in 2014.The burden of HCV-related liver disease has increased markedly. Although the proportion diagnosed was high, treatment uptake remained low, with no increase over the last 7 years. Reducing the HCV burden in Australia requires scale-up of interferon-free HCV therapies.

Background Despite two decades of interventions, rates of sexually transmissible infections (STI) in remote Australian Aboriginal communities remain unacceptably high. Routine notifications data from 2011 indicate rates of chlamydia and gonorrhoea among Aboriginal people in remote settings were 8 and 61 times higher respectively than in the non-Indigenous population. Methods/design STRIVE is a stepped-wedge cluster randomised trial designed to compare a sexual health quality improvement program (SHQIP) to usual STI clinical care delivered in remote primary health care services. The SHQIP is a multifaceted intervention comprising annual assessments of sexual health service delivery, implementation of a sexual health action plan, six-monthly clinical service activity data reports, regular feedback meetings with a regional coordinator, training and financial incentive payments. The trial clusters comprise either a single community or several communities grouped together based on geographic proximity and cultural ties. The primary outcomes are: prevalence of chlamydia, gonorrhoea and trichomonas in Aboriginal residents aged 16–34 years, and performance in clinical management of STIs based on best practice indicators. STRIVE will be conducted over five years comprising one and a half years of trial initiation and community consultation, three years of trial conditions, and a half year of data analysis. The trial was initiated in 68 remote Aboriginal health services in the Northern Territory, Queensland and Western Australia. Discussion STRIVE is the first cluster randomised trial in STI care in remote Aboriginal health services. The trial will provide evidence to inform future culturally appropriate STI clinical care and control strategies in communities with high STI rates. Trial registration Australian and New Zealand Clinical Trials Registry ACTRN12610000358044

Background Extremely high rates of diagnosis of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) have been recorded in remote communities across northern and central Australia. Re-testing at 3 months, after treatment administered, of CT or NG is recommended to detect repeat infections and prevent morbidity and ongoing transmission. Methods: Baseline CT and NG laboratory data (2009–2010) from 65 remote health services participating in a cluster randomised trial was used to calculate the proportion of individuals re-tested after an initial CT or NG diagnosis at

Social policy, behavioural change, psychosocial or psychosexual issues related to sexual health. Background Studies from Sydney Sexual Health Centre (SSHC) in 1993 and 2003 found changes in demographics and safe sex practices of culturally and linguistically diverse (CALD) sex workers attending SSHC over time. We aimed to establish if there are further changes in 2014. Methods A cross sectional survey of CALD sex workers attending SSHC and parlours visited on outreach, was conducted from June 2014 to February 2015. The survey included questions from surveys conducted in 1993 and 2003, so trends could be identified. All studies used an anonymous questionnaire translated into Thai and Chinese. Results were analysed by pair-wise comparisons. Results In 2014, 338 participants were included in the analysis, compared to 65 and 91 participants in 2003 and 1993 respectively. Comparing 2014 to 2003, there was a 91% (p Consistent condom use for vaginal sex increased by 49% (p Conclusion From 2003 to 2014, there has been a decrease in the level of education and English proficiency among CALD sex workers, which may impact on the ability to negotiate sex work safely. There is increased consistent condom use in 2014 compared to 1993, but there has been a downward trend in the last 10 years. Education and access to health services remains crucial for CALD sex workers. Disclosure of interest statement No conflict of interest.

Theme Social policy, behavioural change, psychosocial or psychosexual issues related to sexual health. Background Sydney Sexual Health Centre (SSHC) provides dedicated clinics, outreach services and bilingual health education staff to Chinese and Thai sex workers. We aimed to assess characteristics of these sex workers. Methods A cross-sectional survey was conducted between August 2014–March 2015 using a structured questionnaire in Thai and Chinese, offered to female sex workers attending SSHC and within parlours visited by outreach staff. Results 338 participants were recruited: 106(32%) Chinese and 232(68%) Thai. Overall median age was 31 years. More than half (56%) did not attend high school, with Chinese participants less likely to have attended high school than Thai (67% vs 50%; p = 0.003). Compared with those attending the clinic, women seen on outreach were older (42% >35 vs 20% from clinic; p = 0.00) and less likely to have done sex work previously (90% vs 71% from clinic; p = 0.00). Compared to Thai, Chinese participants were more likely to report “poor” English skills in speaking (61% vs 27% Thai), reading (70% vs 31% Thai) and writing (78% vs 39% Thai) (p While the majority of participants were not on a sex work contract (92%), those who were contracted were more likely to be Thai (10% vs 3% Chinese; p = 0.017). Significantly more Thai participants worked in massage (n = 84,36%) compared with Chinese (n = 16,15%) (p Chinese participants were more likely to check clients for signs of STIs (n = 75,70% vs Thai n = 115,50%; p Conclusion There were significant differences in the characteristics and behaviours of Thai and Chinese sex workers surveyed. Essential education within culturally appropriate health promotion programs should include douching, checking clients for STIs and using condoms for oral sex. Disclosure of interest statement No conflict of interest.

Background Remote Aboriginal communities in Australia experience high rates of bacterial sexually transmissible infections (STIs). To control the transmission and decrease the risk of complications, frequent STI testing combined with timely treatment is required, yet significant delays in treatment have been reported. Perceived barriers to timely treatment for asymptomatic patients in remote communities were explored. Methods: A qualitative study was undertaken as part of the STRIVE (STIs in Remote communities, ImproVed and Enhanced primary health care) project; a cluster randomised controlled trial of a sexual health quality improvement program. During 2012, we conducted 36 in-depth interviews with staff in 22 clinics in remote Australia. Results: Participants included registered nurses (72%) and Aboriginal health practitioners (28%). A key barrier to timely treatment was infrequent transportation of specimens to laboratories often hundreds of kilometres away from clinics. Within clinics, there were delays checking and actioning test results, and under-utilisation of systems to recall patients. Participants also described difficulties in physically locating patients due to: (i) high mobility between communities; and (ii) low levels of community knowledge created by high staff turnover. Participants also suggested strategies to overcome some barriers such as dedicated clinical time to follow-up recalls and taking treatment out to patients. Conclusions: Participants identified barriers to timely STI treatment in remote Aboriginal communities, and systems to address some of the barriers. Innovative strategies such as point-of-care testing or increased support for actioning results, coupled with incentives to individual patients to attend for results, may also assist in decreasing the time to treatment.

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 Remote Aboriginal communities in Australia have substantially higher rates of chlamydia (CT), gonorrhoea (NG) and trichomoniasis (TV) diagnosis compared with non-Indigenous people, despite many years of programme and policy aimed at reducing disparity. Methods ‘STRIVE’ is a stepped wedge cluster randomised controlled trial, underway in 68 remote Aboriginal communities. The primary objective is to assess if a sexual health quality improvement programme within primary care clinics improves STI management and in turn reduces STI prevalence. Data is extracted from both patient management systems and from laboratories. To evaluate the impact of the trial, the largest STI prevalence study in Aboriginal people has been undertaken twice. Results In the first year of the trial, testing rates have improved overall by 27% at 21 sites and by 50% or more at 11 sites. In 2011, baseline prevalences for CT and NG (n = 2483) and TV (n = 1848) among 16–34 year olds were 9%, 7% and 13% respectively. Highest prevalences were reported among 16–19 year olds for CT 13% (95% CI; 10.8–16.4), NG, 12% (95% CI; 9.7–15.1) and TV, 17%(95% CI; 13.7–21.1). There were 17,848 STI tests conducted in 2010 and among females aged 16–34; 33.3% had ≥ 1 STI (highest in 16–19 year olds: 48.9%) and 21.3% of males had ≥ 1 STI (highest in 16–19 year olds:33.4%). The most frequent co-infection was CT and NG which was found in 3.4% of females (highest in 16–19 year olds: 8.6%) and 3.9% of males (highest in 16–19 year olds:10.1%). Discussion STRIVE has provided information not previously available in regard to a comprehensive epidemiological picture of STI morbidity and health service responses in remote Aboriginal communities and highlights work required especially among young people. The results of STRIVE may be of relevance to other areas globally with STI endemic rates.

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.

Fruit set and marketability of cantaloups (Cucumis melo L., var. reticulatus Naud.) in Yuma, Arizona, were correlated with visits by honey bees, Apis mellifera L., up to 13–14/flower. The concept that the stigma is receptive for only a few minutes is proposed. One honey bee for each 10 perfect (hermaphroditic) flowers in the field should ensure visitation during the period of receptivity.