Gonorrhoea: tackling the global epidemic in the era of rising antimicrobial resistance.

This Special Issue of Sexual Health aims to collate the latest evidence base focussed on understanding the current epidemic and transmission of gonorrhoea, choice of treatment, molecular epidemiology application, concerns about antimicrobial resistance and alternative prevention and control for gonorrhoea

Incident HIV infection has fallen rapidly in men who have sex with men in Melbourne, Australia (2013-2017) but not in the newly-arrived Asian-born.

BACKGROUND: We examined differences in incident HIV infection between newly-arrived Asian-born and other men who have sex with men (MSM) after the introduction of universal HIV treatment guidelines in 2015 and pre-exposure prophylaxis in 2016. METHODS: Clinical, demographic, laboratory and behavioural data on MSM presenting for HIV testing at the Melbourne Sexual Health Centre from July 2013 to June 2017 were extracted. We compared the proportion of newly-arrived (four years or less in Australia), Asian-born and other MSM tested each year who were diagnosed with incident HIV infection (negative test within one year or diagnosis with indeterminate or negative Western Blot). RESULTS: We analysed 35,743 testing episodes in 12,180 MSM, including 2781 testing episodes in 1047 newly-arrived Asian-born MSM. The proportion of other MSM tested each year who were diagnosed with incident HIV infection fell from 0.83% in 2014 to 0.38% in 2017 (p = .001), but did not fall in newly-arrived Asian-born MSM (from 1.18% in 2014 to 1.56% in 2017, p = .76). In the multivariate logistic regression, in 2016/2017 but not in 2014/2015, being newly-arrived Asian-born was associated with an increased odds of diagnosis of incident HIV infection (aOR 3.29, 95%CI 1.82-5.94, p < .001). CONCLUSIONS: The epidemiology of HIV in Melbourne Australia has changed dramatically. While there has been an overall reduction amongst MSM, the incidence of HIV in newly-arrived Asian-born MSM remains high. Failing to address these new inequalities leaves individuals at risk and may offset the population benefit of biomedical HIV prevention

Sustained high prevalence of viral hepatitis and sexually transmissible infections among female sex workers in China: a systematic review and meta-analysis.

BACKGROUND: The 1980's economic boom has been associated with a rapid expansion of China's sex industry over the past three decades. Consequently, the spread of sexually transmitted infections (STIs) and hepatitis infections among female sex workers (FSW) has become an important public health issue in China. This study identifies prevalence and risks of hepatitis and STIs in Chinese FSWs. METHOD: Four electronic databases were searched for Chinese and English language peer-reviewed studies conducted between 01/2000-12/2011 that reported prevalence of hepatitis and STIs (excluding HIV) among Chinese FSW. Following the PRISMA guidelines, meta-analysis was used to estimate pooled prevalence and 95% confidence intervals for each infection. RESULT: Three hundred and thirty nine articles (34 in English and 305 in Chinese) investigating 603,647 FSWs in 29 Chinese provinces were included in this review. Over the period 2000-2011, the seroprevalence of active hepatitis B and hepatitis C among FSW were 10.7% (7.3-15.5%) and 1.0% (0.7-1.3%), respectively. The most prevalent STI was human papillomavirus (HPV, 27.0% [10.1-55.1%]), followed by herpes simplex virus-2 (HSV-2, 15.8% [11.7-20.9%]), chlamydia (13.7% [12.1-15.4%]), gonorrhoea (6.1% [5.3-7.0%]), syphilis (5.2% [4.8-5.7%]), genital warts (3.3% [2.5-4.2%]) and Trichomonas vaginitis (2.1% [1.5-24.2%]). Disease burden of both hepatitis and STI among FSW were concentrated in South Central and Southwest China. In particular, chlamydia and syphilis demonstrated a significant declining trend during the studied period (P < 0.05). Compared with the general Chinese population, FSW had significantly higher prevalence of all STIs except Trichomonas vaginitis. Further, compared to the general FSW population, HIV-positive FSW had significantly higher prevalence of syphilis, chlamydia, HSV-2 and Trichomonas vaginitis. CONCLUSION: Prevalence of hepatitis and STIs remained high and mostly stable among Chinese FSW over the period of 2000-2011. Targeted STI and hepatitis surveillance and interventions should be strengthened among Chinese FSWs, especially those who are HIV-positive

A systematic review and meta-analysis of the prevalence, trends, and geographical distribution of HIV among Chinese female sex workers (2000-2011): implications for preventing sexually transmitted HIV.

OBJECTIVE: The aim of this meta-analysis was to investigate temporal and geographical trends in the HIV epidemic among female sex workers (FSWs) recruited from various venues in China. METHODS: Chinese and English peer-reviewed articles published between January 2000 and February 2013 were systematically searched. Standard meta-analysis methods were used to calculate the pooled HIV prevalence, in accordance with the PRISMA guidelines. RESULTS: The national HIV prevalence among FSWs declined from 0.74% (95% confidence interval (CI) 0.37-1.49%) in 2000-2002 to 0.40% (95% CI 0.31-0.53%) in 2009-2011. All Chinese regions demonstrated significant declines in HIV prevalence, apart from the East and South Central regions, in which the epidemics stabilized at low/moderate levels. Despite a significant decline from 1.92% (95% CI 0.86-4.24%) to 0.87% (95% CI 0.65-1.18%) during 2000-2011, Southwest China still bore the greatest HIV disease burden. Nationwide, FSWs recruited from detention centres had the highest HIV prevalence (0.92%, 95% CI 0.46-1.88%), followed by voluntary counselling and testing sites (0.80%, 95% CI 0.46-1.67%) and entertainment venues (0.61%, 95% CI 0.47-0.79%). The prevalences among FSWs in high-, middle-, and low-tier entertainment venues were 0.59% (95% CI 0.32-1.45%), 0.92% (95% CI 0.50-1.77%), and 1.10% (95% CI 0.71-2.16%), respectively. High- and middle-tier FSWs had a significantly lower risk of HIV infection than lower-tier FSWs (high/low: odds ratio (OR) 0.48, 95% CI 0.40-0.59; middle/low: OR 0.49, 95% CI 0.37-0.66). CONCLUSIONS: The HIV epidemic has shown a gradual declining or stabilizing trend among Chinese FSWs. Intervention efforts should be diverted to high-risk subgroups of FSWs, such as drug-using and low-tier FSWs

HIV prevalence ratio of international migrants compared to their native-born counterparts: A systematic review and meta-analysis.

BACKGROUND: People on the move, including international migrants, may face health inequities that expose them to a higher risk for HIV than native-born populations. We conducted a systematic review to calculate the HIV prevalence ratio of international migrants compared with native-born populations. METHODS: We searched five databases between January 2010 and March 2022. Using random-effects meta-analysis, we calculated the pooled HIV prevalence ratios (PR) by comparing the HIV prevalence of migrants with native-born populations. Our research protocol is registered in the International prospective register of systematic reviews (PROSPERO, CRD42021250867). FINDINGS: In total, 5,121 studies were screened, and 38 were included in the final analysis: 7,121,699 migrants and more than 270 million natives were included in the analysis. The pooled PR for any foreign-born migrants was 1·70 (95% CI 1·11 – 2·61, I2=99·67%, n = 33 studies), refugees was 2·37 (95% CI 0·33–16·99, I2=99·5%, n = 5), undocumented people was 3·98 (95% CI 0·11–143·01, I2=94·6%, n = 3), whilst asylum seekers was 54·79 (95% CI 17·23–174·23, I2=90·2%, n = 2). Meta-regression revealed that population type (adjusted R-squared 11.5%), region of origin (11.3%) and migrant type (10.8%) accounted for heterogeneity more than country-income (2.4%) and study setting (2.3%). INTERPRETATION: Although it was not possible to assess if HIV infection occurred in the country of origin or destination, the HIV prevalence ratio was higher among migrants than in native-born populations. Inclusive health policies and strategies for delivering HIV testing, prevention and treatment services for migrant populations tailored to their needs are urgently needed. FUNDING: J.J.O. and E.P.F.C. are supported by the Australian National Health and Medical Research Council (NHMRC) Emerging Leader Fellowship (GNT1193955 and GNT1172873, respectively)

The Diagnostic Accuracy of Syndromic Management for Genital Ulcer Disease: A Systematic Review and Meta-Analysis.

Objectives: Genital Ulcer Disease (GUD) carries a significant disease burden globally. With limited access to diagnostics, the 2001 World Health Organization (WHO) sexually transmitted illnesses (STI) guidelines proposed a syndromic management algorithm that required a clinical decision to determine the management of GUD. We assessed the diagnostic accuracy of this algorithm. Methods: We conducted a systematic review (Prospero: CRD42020153294) using eight databases for publications between 1995 and January 2021 that reported primary data on the diagnostic accuracy of clinical diagnosis to identify aetiological agents of GUD. Titles and abstracts were independently assessed for eligibility, and data were extracted from full texts for sensitivity/specificity. A hierarchical logistic regression model was used to derive pooled sensitivity and specificity. We used GRADE to evaluate the certainty of evidence. Results: Of 24,857 articles, 151 full texts were examined and 29 included in the analysis. The majority were from middle-income countries [(14/29 (48%) lower middle, 10/29 (34%) upper middle)]. We pooled studies where molecular testing was using to confirm the aetiology of GUD: 9 studies (12 estimates) for herpes, 4 studies (7 estimates) for syphilis, and 7 studies (10 estimates) for chancroid. The pooled sensitivity and specificity of GUD for the detection of herpes was 43.5% [95% confidence interval (CI): 26.2-62.4], and 88.0% (95% CI: 67.0-96.3), respectively (high certainty evidence); and for syphilis were 52.8% (95% CI: 23.0-80.7), and 72.1% (95% CI: 28.0-94.5) (moderate certainty evidence); and for chancroid were 71.9% (95% CI: 45.9-88.5) and 53.1% (95% CI: 36.6-68.9) (moderate certainty evidence), respectively. Conclusion: Algorithms requiring a clinical diagnosis to determine and treat the aetiology of GUD have poor sensitivities for syphilis and herpes simplex virus, resulting in significant numbers of missed cases. There is an urgent need to improve access to affordable and efficient diagnostics (e.g., point-of-care tests) to be incorporated into GUD algorithms to better guide appropriate management. Systematic Review Registration: PROSPERO, identifier: CRD42020153294

Clinical Characteristics of Anorectal Mycoplasma genitalium Infection and Microbial Cure in Men Who Have Sex With Men.

BACKGROUND: We report clinical characteristics of proctitis caused solely by Mycoplasma genitalium (MG) compared with chlamydia and gonococcus. We determined the proportions cured with first-line (azithromycin) and second-line antimicrobials (moxifloxacin, pristinamycin). METHODS: A total of 166 patients attending Melbourne Sexual Health Centre from 2012 to 2016 with symptoms of proctitis were tested for MG, Chlamydia trachomatis, and Neisseria gonorrhoeae. Demographic characteristics, sexual behaviors, clinical symptoms, and signs were recorded. Multinomial multivariable logistic regression was used to test for significant differences in symptoms and signs for the pathogens detected. RESULTS: Seventeen percent of men had MG (95% confidence interval, 12-24), 21% had chlamydia (15-27), and 40% had gonococcal monoinfection (32-48), whereas 22% had MG coinfection (16-29). Relative to men with MG monoinfection, those with chlamydial monoinfection reported more anal pain (adjusted prevalence odds ratio (aPOR), 4.68 [1.41-14.19]), whereas men with gonococcal monoinfection reported more anal pain (aPOR, 6.75 [2.21-20.55]) and tenesmus (aPOR, 15.44 [1.62-146.90]), but less anal itch (aPOR, 0.32 [0.11-0.93]). The microbiological cure for MG using azithromycin was low at 35% (22-50), whereas moxifloxacin subsequently cured 92% (64-100) and pristinamycin cured 79% (54-94) of infections. CONCLUSIONS: M. genitalium was almost as common as chlamydia in men presenting to a sexual health center with symptoms of proctitis. Men with anorectal MG monoinfection were less likely to have symptoms and signs compared with those with chlamydia or gonococcus monoinfection. Cure for men with symptomatic anorectal MG by azithromycin was low. We suggest routine testing for MG in cases of proctitis, with test of cure after treatment being essential

The acceptability and usability of two HIV self‐test kits among men who have sex with men: a randomised crossover trial

Objectives: To compare the usability and acceptability of oral fluid- and blood-based HIV self-test kits among men who have sex with men in Australia. Design: Randomised crossover trial. Setting, participants: Gay, bisexual, and other men aged 18 years or older who have sex with men, who attended two metropolitan sexual health clinics in Sydney and Melbourne, 7 January – 10 December 2019. Main outcome measures: Ease of use of HIV self-test kits; preferred HIV self-test type; difficulties encountered during HIV self-testing. Results: 170 men were recruited (median age, 34 years; interquartile range, 29–43 years); 144 identified as gay (85%), 96 were born outside Australia (57%). Participants were more likely to report the oral fluid HIV self-test was easy to use than the blood-based self-test (oral fluid, 99%; blood, 86%; odds ratio [OR], 3.0; 95% confidence interval [CI], 1.4–6.6). The oral fluid test was preferred by 98 participants (58%; 95% CI, 50–65%), the blood-based test by 69 (41%; 95% CI, 33–48%). Difficulties with the oral fluid test kit identified by observing nurses included problems placing the buffer solution into the stand (40 of 170 participants, 24%) and not swabbing both gums (23 of 169, 14%); difficulties with the blood-based test kit included problems filling the device test channel (69 of 170, 41%) and squeezing the finger firmly enough to generate a blood drop (42 of 170, 25%). No participant received an invalid result with the oral fluid self-test; two of 162 participants (1%) received invalid results with the blood self-test. After adjusting for age, education level, and ethnic background, characteristics associated with higher odds of using HIV self-testing in the future were overseas birth (adjusted OR, 3.07; 95% CI, 1.42–6.64), and self-evaluated ease of use and confidence in using the kits. Conclusion: It is important to provide options for obtaining both oral fluid- and blood-based HIV self-tests. The usability and acceptability of both kits were high, but the ease of use and perceived accuracy influenced test kit preference

Co-circulation of Multidrug-resistant Shigella Among Men Who Have Sex With Men in Australia.

BACKGROUND: In urban Australia, the burden of shigellosis is either in returning travelers from shigellosis-endemic regions or in men who have sex with men (MSM). Here, we combine genomic data with comprehensive epidemiological data on sexual exposure and travel to describe the spread of multidrug-resistant Shigella lineages. METHODS: A population-level study of all cultured Shigella isolates in the state of Victoria, Australia, was undertaken from 1 January 2016 through 31 March 2018. Antimicrobial susceptibility testing, whole-genome sequencing, and bioinformatic analyses of 545 Shigella isolates were performed at the Microbiological Diagnostic Unit Public Health Laboratory. Risk factor data on travel and sexual exposure were collected through enhanced surveillance forms or by interviews. RESULTS: Rates of antimicrobial resistance were high, with 17.6% (95/541) and 50.6% (274/541) resistance to ciprofloxacin and azithromycin, respectively. There were strong associations between antimicrobial resistance, phylogeny, and epidemiology. Specifically, 2 major MSM-associated lineages were identified: a Shigellasonnei lineage (n = 159) and a Shigella flexneri 2a lineage (n = 105). Of concern, 147/159 (92.4%) of isolates within the S. sonnei MSM-associated lineage harbored mutations associated with reduced susceptibility to recommended oral antimicrobials: namely, azithromycin, trimethoprim-sulfamethoxazole, and ciprofloxacin. Long-read sequencing demonstrated global dissemination of multidrug-resistant plasmids across Shigella species and lineages, but predominantly associated with MSM isolates. CONCLUSIONS: Our contemporary data highlight the ongoing public health threat posed by resistant Shigella, both in Australia and globally. Urgent multidisciplinary public health measures are required to interrupt transmission and prevent infection

Preferences for HIV prevention strategies among newly arrived Asian-born men who have sex with men living in Australia: A discrete choice experiment.

The HIV epidemic in Australia is changing with higher risk for HIV among newly-arrived Asian-born men who have sex with men (MSM) compared to Australian-born MSM. We evaluated the preferences for HIV prevention strategies among 286 Asian-born MSM living in Australia for <5 years. A latent class analysis uncovered three classes of respondents who were defined by their preferences: "PrEP" (52%), "Consistent condoms" (31%), and "No strategy" (17%). Compared to the "No strategy" class, men in the "PrEP" class were less likely to be a student or ask their partner for their HIV status. Men in the "Consistent condoms" class were more likely to get information about HIV from online, and less likely to ask their partner for their HIV status. Overall, PrEP was the preferred HIV prevention strategy for newly arrived migrants. Removing structural barriers to access PrEP can accelerate progress toward ending HIV transmission