BACKGROUND:People prescribed opioid agonist therapy (OAT) are a key population for hepatitis C virus (HCV) elimination. Health service engagement associated with OAT provision may facilitate hepatitis C testing and treatment. We aimed to quantify the HCV care cascade among people receiving OAT in Australia. METHODS:We extracted linked data from individuals attending any of 58 clinics participating in the ACCESS national sentinel surveillance network of primary care and sexual health clinics from 1 January 2016 to 31 December 2023. Outcomes included evidence of any HCV test (antibody or RNA) or direct-acting antiviral (DAA) prescription at an ACCESS clinic after their first OAT prescription. RNA positive individuals were inferred antibody positive; individuals with a DAA prescription were inferred RNA and antibody positive. We determined the number of individuals at each stage of the following cascade by the end of the study period: (1) positive antibody, (2) positive RNA, and (3) DAA prescription. RESULTS:Among 15 382 individuals prescribed OAT, 44% (6817) had an HCV antibody or RNA test after their first OAT prescription. Of these, 64% (4368/6817) were antibody positive by the end of the study period. Of these, 67% (2911/4368) were RNA positive, and of those, 69% (2007/2911) were prescribed DAAs. CONCLUSIONS:A high proportion of people prescribed OAT were not engaged in care by their OAT provider or across ACCESS network clinics, but when diagnosed, rates of treatment were high. Given high HCV antibody and RNA prevalence, integrating HCV care into regular OAT care should be a priority for HCV elimination in Australia.

BACKGROUND:No vaccines are currently licensed for the prevention of Neisseria gonorrhoeae infection. Observational studies suggest that the four-component meningococcal serogroup B vaccine (4CMenB) may reduce the risk of gonorrhea. METHODS:In this multicenter, double-blind, randomized, placebo-controlled trial, we assigned, in a 1:1 ratio, men who have sex with men (MSM) to receive two doses of 4CMenB or placebo. All the participants had recently received a diagnosis of N. gonorrhoeae infection or infectious syphilis and either tested negative for human immunodeficiency virus (HIV) and were receiving HIV preexposure prophylaxis or were living with HIV. Screening for sexually transmitted infections, including N. gonorrhoeae nucleic acid amplification testing of samples obtained from urogenital, anorectal, and oropharyngeal sites, was performed quarterly for 2 years. The primary outcome was a first N. gonorrhoeae infection after the receipt of vaccine or placebo in the per-protocol population (participants who received both 4CMenB or placebo doses, attended at least two scheduled follow-up visits after the second dose, and did not meet any exclusion criterion pertinent to the assessment of efficacy). RESULTS:From July 2021 through May 2023, a total of 654 participants underwent randomization, of whom 587 were included in the primary analysis. The incidence of N. gonorrhoeae infection was 48.1 events per 100 person-years (160 events among 296 participants) in the 4CMenB group and 47.8 events per 100 person-years (155 events among 291 participants) in the placebo group (incidence rate ratio, 1.01; 95% confidence interval [CI], 0.80 to 1.26; P = 0.97), for a vaccine efficacy of -0.5% (95% CI, -26.2 to 19.9). Vaccine efficacy was 5.5% (95% CI, -56.0 to 42.8) for symptomatic infection, -6.4% (95% CI, -47.5 to 23.2) for asymptomatic infection, and -20.0% (95% CI, -90.2 to 23.9), -1.2% (95% CI, -33.0 to 23.0), and 2.6% (95% CI, -27.7 to 25.7) for urogenital, anorectal, and oropharyngeal infection, respectively. Serious adverse events occurred in 4.7% of the participants in the 4CMenB group and in 2.8% of those in the placebo group. CONCLUSIONS:4CMenB did not result in a lower incidence of N. gonorrhoeae infection than placebo among MSM who were at high risk for gonorrhea. (Funded by the Australian National Health and Medical Research Council and GSK; GoGoVax ClinicalTrials.gov number, NCT04415424.).

BACKGROUND:In Australia, transgender people have largely been excluded from public health surveillance for HIV and other sexually transmissible infections (STIs). We aimed to provide a comprehensive overview of HIV and STIs among transgender people in Australia, including to investigate trends over time and risk factors. METHODS:A retrospective clinical cohort study was conducted using 10 years of health record data (between Jan 1, 2014, and Dec 31, 2023) from 87 health services across Australia. A primary transgender cohort and two comparative cisgender cohorts (gay and bisexual men, and heterosexual people) were established. Incidence was estimated using repeat testing, with the year fitted as an independent variable in Poisson regression while controlling for sociodemographic and behavioural characteristics. FINDINGS:The primary cohort comprised 7284 transgender people (4672 transgender women, 2213 transgender men, and 399 non-binary people); the comparative cisgender cohorts comprised 152 144 gay and bisexual men and 394 332 heterosexual people. Among transgender people, HIV incidence decreased by 93·9%, from 1·19 per 100 person-years to 0·07 per 100 person-years (incidence rate ratio [IRR] per year 0·72 [95% CI 0·66-0·79]). For transgender people, HIV incidence was highest among women (0·37 per 100 person-years) and lowest among men (0·20 per 100 person-years; IRR 0·54 [95% CI 0·29-0·99]). Transgender people overall had an HIV incidence comparable with cisgender gay and bisexual men (0·33 per 100 person-years and 0·29 per 100 person-years, respectively; adjusted IRR 0·87 [95% CI 0·70-1·08]), whereas HIV incidence was lower among cisgender heterosexual people (0·003 per 100 person-years; 0·01 [0·01-0·01]). Incidences of other STIs were generally stable among transgender people over time (33·73 per 100 person-years for chlamydia, 30·18 per 100 person-years for gonorrhoea, and 2·67 per 100 person-years for syphilis), with some distinctions by anatomical site. Among transgender people, HIV pre-exposure prophylaxis was negatively associated with incident HIV (adjusted IRR 0·40 [95% CI 0·19-0·88]) but positively associated with other STIs (1·38 [1·31-1·46]). INTERPRETATION:HIV incidence declined among transgender people in Australia, whereas other STIs were stable. To build on this success, HIV and STI policies, guidelines, interventions, and funding in Australia should more actively support transgender populations. FUNDING:Australian Department of Health & Aged Care and UNSW Health Systems Research.

OBJECTIVE:In remote Australia, where there is a substantial burden of sexually transmitted infections (STIs) among First Nations peoples, testing and timely treatment are key to reducing prevalence. We evaluated the impact of introducing molecular point-of-care (POC) testing for chlamydia/gonorrhoea and later trichomonas on STI testing (including syphilis) and positive tests. METHODS:We conducted a retrospective interrupted time-series analysis of routinely collected data from First Nations peoples aged 15-54 years attending 20 remote/regional clinics participating in the Test, Treat and GO programme (2016-2019). We used segmented regression models to estimate the immediate level change (first month of POC) and after-period trends in monthly tests, positive tests and proportion of concurrent syphilis tests to assess sustainability. Before and after comparisons were estimated using linear regression models. RESULTS:There were 17 437 chlamydia/gonorrhoea and 14 173 trichomonas tests performed, mostly among women (69% and 64%) and individuals aged 15-34 years (72% and 68%). Following the introduction of molecular POC testing, there were immediate level increases in monthly tests: chlamydia/gonorrhoea by 26% (+154, p<0.001) and trichomonas by 21% (+116, p=0.004) and level increases of positive tests: gonorrhoea by 30% (+13, p=0.017) and trichomonas by 29% (+14, p=0.034); chlamydia was unchanged. The proportion of chlamydia/gonorrhoea tests with concurrent syphilis tests remained unchanged (-1.7%; -0.9%; p=0.531), while the proportion increased among positive chlamydia/gonorrhoea tests by 25% (+13%; p=0.013). Increased levels of testing were sustained for gonorrhoea/chlamydia (+2.7, p=0.118) and trichomonas (-3.5, p=0.400) and syphilis among those with positive chlamydia/gonorrhoea tests (-0.2%, p=0.593). CONCLUSION:Molecular POC testing led to immediate and sustained increases in STI testing and an immediate increase in positive tests in remote primary care. The use of POC testing is likely to result in earlier diagnosis and treatment and reduced onward transmission and sequelae, supporting a broader integration of POC testing in high-burden settings.

OBJECTIVES:In remote Australian First Nations communities, the burden of curable sexually transmitted infections (STIs) is highest for young women and men aged 16-29 years and for women is associated with two-fold higher rates of hospitalisations for pelvic inflammatory disease (PID) than for non-First Nations women. Following a randomised trial, decentralised community-led molecular point-of-care (POC) testing for STIs has operated in remote primary care across Australia for more than 7 years, improving uptake and timeliness of treatment for chlamydia, gonorrhoea and trichomonas infections. However, cost-effectiveness remains unknown. METHODS:A decision analytic model was devised to compare costs and outcomes associated with a POC testing programme for chlamydia, gonorrhoea and trichomonas infections in women and men aged 16-29 years seeking care, compared with standard care (laboratory-based testing). The analysis used a government payer perspective and 10-year time horizon. The primary outcome was the cost ($A) per quality-adjusted life year (QALY) gained. Sensitivity analyses examined uncertainty around the results. RESULTS:Based on a combined testing positivity rate of 36% and 29% for chlamydia, gonorrhoea and trichomonas for women and men, respectively, the POC testing programme, compared with laboratory testing, produced an estimated incremental cost per QALY ratio (ICER) of $A19 714 (95% CIs $A19 608 to $A19 821) over 10 years. Among those with an STI, the POC testing programme was predicted to reduce diagnosed PID by 30% and preterm/low birth weight babies by 17%. Sensitivity analyses indicated that the ICER was most sensitive to the probability of infection and receiving treatment within 2 days, based on a willingness-to-pay threshold of $A50 000. CONCLUSION:This health economic evaluation indicates that a scaled molecular POC testing programme for the management of STIs in remote primary care settings is cost-effective compared with standard care. Sustained POC testing in this setting is likely to improve reproductive health outcomes.

Evidence indicates high levels of unmet contraceptive need among justice-involved women, linked to intersecting vulnerabilities such as housing instability, substance use, violence and poor mental health. In Australia, limited research has explored how women in prison navigate access to family planning services. This study aimed to examine the experiences of incarcerated women in New South Wales (NSW) in accessing contraception and making fertility-related decisions. The study formed part of the Second Sexual Health and Attitudes of Australian Prisoners (SHAAP-2) study. Seventeen women aged 19–45 were recruited from two NSW correctional centres. Semi-structured qualitative interviews were conducted face-to-face or via video call, recorded, transcribed, and analysed thematically in NVivo14. Coding drew on the Behavioural Model for Vulnerable Populations, supplemented by inductive thematic analysis to capture cross-cutting themes. Content analysis was also applied to describe contraceptive needs. Three overarching findings were identified. First, women’s access to contraception was less shaped by mistrust of providers than by system unreliability. While some reported supportive care, many described unanswered requests, long delays, and unsafe practices such as attempting implant removals. Second, incarceration prompted reflection and deliberate fertility planning. Women re-evaluated what it meant to be “ready” for motherhood, some seeking to delay pregnancy until achieving stability, others eager to conceive quickly after release, due to a sense of lost time. Third, women’s choices were constrained by side-effects and limited method options. Repeated failures with pills, injections, or devices sometimes led women to sterilisation as the “only certain” option, though some later regretted this decision. Prisons represent a critical but underutilised setting for meeting reproductive health needs. Despite policy commitments to equivalence of care, contraceptive services in custody remain neglected. Findings highlight the need for stronger structural supports including timely service pathways and effective pre-release planning, to ensure women can access safe, flexible, and non-coercive contraception. Addressing these gaps is essential to upholding reproductive rights and reducing health inequities for incarcerated women. This study looked at how women in prison in New South Wales, Australia, access contraception and make decisions about their reproductive health. With many incarcerated women of childbearing age, research indicates that they often experience challenges such as unstable housing, substance use, violence, which can limit access to contraception in the community. Consequently, many women may enter prison with unmet family planning needs. Researchers interviewed 17 women aged 19–45 years. Most did not want to become pregnant after release, and many wanted advice on contraception, help with side-effects, or removal of implants or Intrauterine Devices (IUDs). The study highlighted three main findings. First, women’s ability to access contraception was shaped less by mistrust of providers and more by an unreliable system. Some women received supportive care, but many described delays, unanswered requests, and unsafe practices such as trying to remove expired implants themselves. Second, prison provided time for reflection and intentional fertility planning. Women described rethinking what it meant to be “ready” for motherhood. Some wanted to delay pregnancy until life felt more stable, while others wished to conceive quickly after release, seeing incarceration as lost time. Third, women’s choices were strongly influenced by contraception side-effects and limited options. Repeated failures had led some women to view sterilisation as the only certain choice, though some later reconsidered. Overall, the study shows that prisons are a critical setting for reproductive health, including contraceptive care. However, this is often neglected suggesting that stronger structures, including timely services, choice, and clear pathways, are needed to ensure women receive appropriate care.

INTRODUCTION:Women with a history of incarceration report higher rates of pregnancy and abortion, lower contraception use and poorer birth outcomes compared to other women in the community. This suggests family-planning and reproductive-health needs that are not well served by current models of care. Despite this, little is known about how contraception is provided within Australian carceral settings, or the structural barriers experienced by professional staff working in these environments. We report findings from a qualitative study conducted in New South Wales (NSW), Australia, describing professional staff's views of factors that support or impede women's contraceptive care needs both during and immediately after incarceration. METHODS:We conducted semi-structured interviews with n = 12 professionals working in NSW, who either provide healthcare services or individual case management to women during incarceration or in the immediate post-release period. Data was analysed thematically, initially guided by the Vulnerable Populations Behaviour Model and adjusted iteratively as analysis developed. RESULTS:Participants described contraceptive needs and preferences as shaped by 1) a state of interrupted fertility caused by incarceration, and 2) post-release instability and intersecting demands, which impeded access to community family planning. Areas of high need were characterised by 1) accessible, reversible and non-invasive contraception options, and 2) thoughtful counselling. Structural factors impeding contraception service access during incarceration included: 1) service priorities 2) poor overall health service integration, and 3) inequitable funding models. CONCLUSION:Structural constraints during incarceration, staff attitudes and women's complex post-release circumstances, limit equitable contraception care, underscoring the need to address barriers at system, clinician and patient levels.

INTRODUCTION:In Australia, cross-sectional estimates suggest that over 95% of people with HIV are virally suppressed; however, these measures reflect only the most recent viral load. Sustained viral suppression (SVS) is essential for optimizing health and preventing transmission. This study describes SVS among people with HIV who are engaged in care in Australia and factors associated with SVS. METHODS:We analyzed national data from the ACCESS sentinel surveillance system. Eligible participants attended an ACCESS clinic in 2023, received continuous antiretroviral therapy (ART; ≥1 prescription per calendar year), and had at least two viral load tests in the preceding three years (median:6; IQR: 5-7). SVS was defined as all viral load results less than 200 copies/ml. Multivariable logistic regression identified factors associated with SVS. RESULTS:Of 6036 eligible participants (95% men; median age 54 years), 5751 (95.3%) achieved SVS, while 99.1% were suppressed based on their last test. Older age (adjusted odds ratio [aOR]: 1.01; 95% confidence interval (95% CI): 1.002-1.03), residence in more socioeconomically advantaged areas (aOR: 1.06; 1.01-1.12), and higher mean CD4 + cell count (aOR: 1.00; 1.001-1.002) were associated with higher odds of SVS. Receiving care at publicly funded sexual health/hospital-based clinics (aOR:0.64; 0.48-0.86), more diagnoses of gonorrhea (aOR: 0.81; 0.67-0.96) or infectious syphilis in the last three years (aOR: 0.85; 0.73-0.98), and co-infection with hepatitis C in the last 3 years (aOR: 0.56; 0.36-0.87) were associated with lower SVS. CONCLUSIONS:More than 95% of people with HIV receiving ART and engaged in ongoing care achieved SVS. Strengthened, person-centered support for groups with lower SVS may enhance clinical outcomes and sustain Australia's progress toward HIV elimination goals.

Background Syphilis is caused by the bacteria Treponema pallidum. Primary syphilis might present with multiple, painful lesions that are clinically indistinguishable from herpes. In this prospective cohort study, we aimed to evaluate whether the implementation of routine multiplex PCR testing for T pallidum and herpes simplex virus (HSV) in general practice improves the detection of primary syphilis. Methods From Sept 1, 2022, the PlexPCR VHS (SpeeDx, Eveleigh, NSW, Australia) test, which simultaneously detects T pallidum and HSV-1 and HSV-2 was implemented by Melbourne Pathology (Victoria, Australia). Multiplex testing was done on all samples from patients aged 18 years or older if: (1) the clinician ordered HSV PCR testing only from an anogenital site, or an oral or unspecified site that was also accompanied by a test for another sexually transmitted infection (eg, Chlamydia trachomatis, Neisseria gonorrhoeae, or Mycoplasma genitalium); or (2) the clinician specifically requested T pallidum PCR. All positive T pallidum PCR results were reported to prompt treatment. The number and proportion of T pallidum PCR tests done and T pallidum PCR-positive cases detected were compared between requested T pallidum PCR and T pallidum PCR added to HSV PCR-only requests due to multiplex testing. Syphilis serology was examined among T pallidum PCR-positive cases in which T pallidum PCR had not been requested, to establish the proportion that might have been missed without multiplex testing. Findings Between Sept 1, 2022, and March 27, 2024, 8873 multiplex tests were done in 5847 (65·9%) female patients and 3026 (34·1%) male patients. In 6667 (75·1%) of 8873 T pallidum PCR tests, and 27 (25·2%) of 107 cases detected, T pallidum PCR was added to HSV-only requests through multiplex testing. Compared with cases in which T pallidum PCR was requested, a higher proportion of the 27 cases identified through added T pallidum PCR testing were from female patients (seven [25·9%] of 27 vs eight [10·0%] of 80; p=0·039), syphilis reinfections (eight [29·6%] of 27 vs nine [11·3%] of 80; p=0·024), clinically atypical presentations (12 [44·4%] of 27 vs 16 [20·0%] of 80; p=0·013), or those co-infected with HSV (three [11·1%] of 27 vs one [1·3%] of 80; p=0·049). In 17 (63·0%) of 27 added cases, serology for syphilis was not done or did not indicate reinfection. Interpretation Multiplex PCR testing for syphilis and herpes among patients for whom HSV PCR alone was ordered improved detection of primary syphilis in primary care. More widespread implementation would reduce misdiagnosis of primary syphilis in primary care, potentially reducing transmission and complications. Funding Australian National Health and Medical Research Council.

BACKGROUND:Bacterial sexually transmitted infections (STIs) cause a substantial disease burden worldwide and disproportionately impact young people. In Australia, Aboriginal and Torres Strait Islander people are a priority population in STI testing guidelines. METHODS:The More Options for STI Testing trial evaluated whether providing an incentive impacted STI testing rates in select Central Australian communities. Aboriginal and Torres Strait Islander people aged 16 to 29 years were eligible for a A$30 phone voucher if they had an STI test at a participating Aboriginal community-controlled primary health care clinic. An interrupted time series analysis examined monthly STI test counts for chlamydia, gonorrhea, or syphilis from 2015 to 2020, to determine whether testing increased during the incentives phase (2018-2020). RESULTS:There were a total of 10,457 visits to the clinic in which an STI test was conducted, 5110 of which were during the incentives period. A total of 1526 incentives were provided to eligible clients. The baseline and incentives periods were each divided into 2 phases to account for new clinic openings and the COVID-19 pandemic. Among men, average monthly visits for an STI test were 32.6 (baseline phase 1), 44.1 (baseline phase 2), 50.8 (incentives phase), and 35.4 (incentives/COVID-19 phase). Women had 93.5, 111.3, 118.8, and 113.4 visits, respectively. No significant change in STI testing was observed during the incentives phase. The proportion of visits for an STI test where an incentive was paid (coverage) varied by month, from 36% to 76% of consultations. CONCLUSIONS:The limited impact of incentives could be explained by low coverage or that the incentive was not motivating enough to overcome STI testing barriers. Future studies should investigate alternative methods of increasing STI testing in remote Central Australia, including through primary care clinics.

OBJECTIVE:This survey aimed to examine the impact of decriminalisation on rates of sex worker's condom use with clients, and sexually transmissible infection/blood-borne virus (STI/BBV) testing. METHODS:An anonymous, mixed-methods, online survey among sex workers in Victoria, Australia (December 2022-April 2023). This survey asked about changes in condom use and STI/BBV testing following decriminalisation. RESULTS:101 participants were included in the study. Median age of participants was 29 years (IQR: 25-33), the majority of participants spoke English (97; 96.0%) and had worked in sex work for at least a year (87; 87.0%). Following decriminalisation, the majority of participants reported no change to condom use for giving oral sex (81/92; 88.0%), receiving oral sex (79/87; 90.8%), receptive vaginal sex (73/80; 91.3%), insertive vaginal sex (37/41; 90.2%), receptive anal sex (45/50; 90.0%) or insertive anal sex (37/42; 88.1%). Most participants did not change their testing frequency for STI/BBV (60/99; 60.6%). Free text responses included positive, neutral and fearful aspects of decriminalisation. CONCLUSION:The majority of sex workers maintained high rates of condom use and regular sexual health testing following the decriminalisation of sex work in Victoria. IMPLICATIONS FOR PUBLIC HEALTH:These findings suggest that decriminalisation may not negatively affect sex practices or STI testing, supporting policy changes to reduce stigma and enhance health access for sex workers.

Hepatitis B virus vaccination is currently recommended in Australia for adults at an increased risk of acquiring infection or at high risk of complications from infection. This retrospective cohort study used data from an Australian sentinel surveillance system to assess the proportion of individuals who had a recorded test that indicated being susceptible to hepatitis B infection in six priority populations, as well as the proportion who were then subsequently vaccinated within six months of being identified as susceptible. Priority populations included in this analysis were people born overseas in a hepatitis B endemic country, people living with HIV, people with a recent hepatitis C infection, gay, bisexual and other men who have sex with men, people who have ever injected drugs, and sex workers. Results of the study found that in the overall cohort of 43,335 individuals, 14,140 (33%) were identified as susceptible to hepatitis B, and 5,255 (37%) were subsequently vaccinated. Between 26% and 33% of individuals from priority populations were identified as susceptible to hepatitis B infection, and the proportion of these subsequently vaccinated within six months was between 28% and 42% across the groups. These findings suggest further efforts are needed to increase the identification and subsequent vaccination of susceptible individuals among priority populations recommended for hepatitis B vaccination, including among people who are already engaged in hepatitis B care.

Objective: To evaluate the implementation and impact of the Management of Chlamydia Cases in Australia (MoCCA) intervention for strengthening chlamydia management in Australian general practice. Design: Non randomised implementation and feasibility trial Setting: General practices in the Australian states of New South Wales, Queensland and Victoria. Participants: 14 general practices participated and implemented the MoCCA intervention. General practitioners (GPs) and nurses from participating clinics were interviewed about implementation and use of MoCCA. Deidentified patient attendance and clinical data for patients aged 16 to 44 years were collected for each clinic. Intervention: Multifaceted intervention (website (www.mocca.org.au/), patient factsheets, shortcuts for documenting a chlamydia consultation, mailed specimen kits for chlamydia re-testing, guidance articles, continuing professional development activities) to facilitate chlamydia management in general practice. Clinicians (GPs and nurses) were asked to use the MoCCA intervention to guide their chlamydia and pelvic inflammatory disease (PID) diagnosis and management over a 12-month intervention period. Main outcome measures: The primary outcomes focussed on intervention implementation (acceptability, adoption, appropriateness, feasibility, fidelity, penetration, sustainability). Secondary outcomes focused on chlamydia retesting and reinfection among patients who had a chlamydia infection and PID rates among female patients, comparing the intervention period with a 12-month preintervention period. Results: Clinicians (doctors=26, nurses=7) largely viewed MoCCA as compatible (appropriateness) with the general practice setting and an acceptable approach to streamlining chlamydia management. Some MoCCA components (e.g. website, shortcuts, factsheets, patient delivered partner therapy [PDPT] resources) were preferred for their ease of use and support for decision making over other components (e.g. postal retesting kits). Intention to use MoCCA (adoption) and its uptake (penetration) varied between clinicians and MoCCA components. Some clinicians intended to use MoCCA but did not due to lack of opportunity, forgetting, or other preferred practices. MoCCA was not used uniformly (fidelity), but its flexible design let clinicians use MoCCA components to suit their needs. Clinicians liked that MoCCA facilitated best practice chlamydia management (feasibility) as outlined in Australian STI management guidelines. Reported improvements in care included better quality, continuity and time-efficiency (e.g. website simplified chlamydia management) and patient communication (e.g. shortcuts/factsheets remind to discuss retesting). Many wanted access to MoCCA resources post-study (sustainability). Chlamydia tests were conducted in 17.2% patients preintervention (n=7670/44607, with 4.6% positive) and 18.0% (n=9703/54008, with 5.0% positive) during the intervention. Proportions retested were 18.1% (95% confidence interval (CI) 13.4, 23.7) preintervention and 23.1% (95%CI 18.7, 28.1) in the intervention period (difference=5.0%, 95%CI -2.1, 12.1). Adjusting for gender and clinic location (metropolitan vs non-metropolitan), retesting for 16 to 25 year olds increased between the preintervention and intervention period (adjusted relative risk (aRR) 2.12, 95%CI 1.43, 3.15) and for individuals aged 26 to 44 years results were inconclusive (aRR 1.01, 95%CI 0.66, 1.55). PID diagnosis per 1000 consultations among females were 16.9 preintervention and 19.1 intervention period (absolute difference = 2.18%, 95% CI 0.13, 4.23). Conclusions: MoCCA aligned with the general practice setting and supported improved chlamydia management. ### Competing Interest Statement The authors have declared no competing interest. ### Clinical Protocols ### Funding Statement This study was supported by a National Health and Medical Research Council (NHMRC) Partnership Grant (APP1150014). ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The University of Melbourne Human Research Ethics Committee (ID: 22665) gave ethical approval for this work. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The data that support the findings are not publicly available due to ethical approval for the patient attendance and clinical data pertaining to its collection specifically for the purposes of this study. All relevant data for the present work are contained in the manuscript.

Introduction Women with a history of incarceration report higher rates of pregnancy, pregnancy terminations, and the use of Long-Acting Reversible Contraception (LARC) methods, alongside poorer birth outcomes compared to non-justice involved women, suggesting distinctive family planning needs. Despite this, little is known on how this is provided within carceral settings, or the structural barriers experiences by both staff and other service providers.  In this article, we report findings from a qualitative study conducted with a sample of professionals working in New South Wales (NSW), Australia, who either provide healthcare services to women either during incarceration or in the immediate post-release period. Specifically, we describe structural factors that may impede or support access to the provision, insertion or removal of contraception devices.   Methods We conducted semi-structured interviews with n=12 professionals, working in NSW, who either provide reproductive healthcare services to women during incarceration or in the immediate post-release period. Data was analysed thematically against the Vulnerable Populations Behaviour Model.     Results Seven themes were identified relating to contraception service provision in prison. Participants observed specific patient characteristics which they believed were driving contraception needs including 1) a state of interrupted fertility caused by incarceration, and 2) post-release chaos which impeded access to appropriate family planning in the community. Areas of high need were characterised by 1) accessible, reversible and non-invasive contraception options, and 2) thoughtful counselling. Structural factors impeding contraception service access during incarceration included: 1) service priorities and staff biases negatively impacting access, 2) poor overall health service integration, and 3) inequitable funding models during incarceration. Consequently, incarcerated women do not have comparable access to contraception compared to women in the community.   Conclusion The lack of focus on contraception services in prison represents a missed opportunity to support highly marginalised women who may also face challenges accessing such services upon release. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement The author(s) received no specific funding for this work. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Not Applicable The details of the IRB/oversight body that provided approval or exemption for the research described are given below: HREAP G:Health, Medical, Community and Social Studies ethical review board from the University of New South Wales, Sydney, Australia (#HC210826) approved the study on the 14th October 2021. Aboriginal Health & Medical Research Council of NSW (#1947/22) approved the study on the 20th July 2022. Justice Health & Forensic Mental Health Network ethics committee (#2021/ETH12211) approved the study on the 4th August 2022. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Not Applicable I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Not Applicable I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Not Applicable We are unable to make the data available publicly for a number for reasons related to the ethical restrictions placed by our ethics research committee when providing consent for this study. i. The data set contains highly sensitive information about participants’ views of their employers in regards to highly contentious issues relating to access to sexual and reproductive health rights of incarcerated women. Furthermore, the number of staff who work in this area are small - making the likelihood of identification high. Given these concerns, we do not believe the risk of disclosure to be acceptable by making such a dataset publicly available. ii. As part of the consent process, participants were assured that their data would remain private and only be made available with the express permission of the investigator team where we could ensure the ongoing privacy of the data. We therefore believe that making this data (even if de-identified) publicly available would be a breach of our agreement with participants. We are, however, able to provide the data set for review by individuals at PLOS ONE upon request. The contact details for the ethics committee are listed below: NSW Human Research Ethics Committee HREC Ref: # HC210826 humanethics{at}unsw.edu.au 02 9348 1943

BACKGROUND:Bacterial vaginosis affects one third of reproductive-aged women, and recurrence is common. Evidence of sexual exchange of bacterial vaginosis-associated organisms between partners suggests that male-partner treatment may increase the likelihood of cure. METHODS:This open-label, randomized, controlled trial involved couples in which a woman had bacterial vaginosis and was in a monogamous relationship with a male partner. In the partner-treatment group, the woman received first-line recommended antimicrobial agents and the male partner received oral and topical antimicrobial treatment (metronidazole 400-mg tablets and 2% clindamycin cream applied to penile skin, both twice daily for 7 days). In the control group, the woman received first-line treatment and the male partner received no treatment (standard care). The primary outcome was recurrence of bacterial vaginosis within 12 weeks. RESULTS:A total of 81 couples were assigned to the partner-treatment group, and 83 couples were assigned to the control group. The trial was stopped by the data and safety monitoring board after 150 couples had completed the 12-week follow-up period because treatment of the woman only was inferior to treatment of both the woman and her male partner. In the modified intention-to-treat population, recurrence occurred in 24 of 69 women (35%) in the partner-treatment group (recurrence rate, 1.6 per person-year; 95% confidence interval [CI], 1.1 to 2.4) and in 43 of 68 women (63%) in the control group (recurrence rate, 4.2 per person-year; 95% CI, 3.2 to 5.7), which corresponded to an absolute risk difference of -2.6 recurrences per person-year (95% CI, -4.0 to -1.2; P<0.001). Adverse events in treated men included nausea, headache, and metallic taste. CONCLUSIONS:The addition of combined oral and topical antimicrobial therapy for male partners to treatment of women for bacterial vaginosis resulted in a lower rate of recurrence of bacterial vaginosis within 12 weeks than standard care. (Funded by the National Health and Medical Research Council of Australia; StepUp Australian New Zealand Clinical Trials Registry number, ACTRN12619000196145.).

BACKGROUND:Rising syphilis incidence among Australian gay, bisexual, and other men who have sex with men (GBMSM) requires new early detection strategies. Regular self-digital anorectal examination (self-DARE) may facilitate syphilis identification, potentially reducing transmission. We evaluated its population-level impact and cost-effectiveness in controlling syphilis among Australian GBMSM. METHODS:We developed an integrated transmission-dynamic and health-economic model, calibrated with 2012-2022 Australian GBMSM data. Over a 10-year period (2025-2034), we compared the base case with two scenarios: recommending self-DARE to men with higher sexual activity ("only high group") or to all individuals ("both groups"). We assessed changes in incidence, incremental cost-effectiveness ratios (ICERs), and benefit-cost ratios. RESULTS:The base case projected 110 501 new infections over 10 years. The "only high group" strategy averted 57 115 infections (51.7%) and was cost saving (negative ICER), with a benefit-cost ratio of 2.5. The "both groups" strategy averted more infections (58 216; 52.7%) but was less economically efficient (benefit-cost ratio: 1.6), though also cost-saving. Sensitivity analyses indicated that improving self-DARE sensitivity enhanced its performance. CONCLUSIONS:Self-DARE could effectively and cost-effectively reduce syphilis among GBMSM, particularly when focused on men with higher sexual activity. Further empirical research is needed to confirm its feasibility and effectiveness.

Introduction Despite a decline in unintended teenage pregnancy in Australia, rates remain higher amongst justice-involved adolescent girls, who are more likely to be from disadvantaged socio-economic backgrounds, have histories of abuse, substance use and/or mental health issues. Furthermore, exposure to the criminal justice system may alter access to education and employment and opportunities, potentially resulting in distinct risk-factor profiles. We examine factors associated with unintended pregnancy, non-contraceptive use and Long-Acting Reversible Contraception (LARC) in a sample of sexually active, justice-involved adolescent girls from Western Australia and Queensland. Methods Data from the Mental Health, Sexual Health and Reproductive Health of Young People in Contact with the Criminal Justice System (MeH-JOSH) Study was analysed on 118 sexually active adolescent girls. Participants were aged between 14 and 17 years, purposefully sampled based on justice-system involvement and completed an anonymous telephone survey. We constructed two multivariate models taking reproductive outcomes as the dependent variables. Results Over one quarter (26%, 30/118) reported a past unintended pregnancy, 54 did not use any contraception at their last sexual encounter, and 17 reported LARC use. Following adjustments in the multivariate analysis, lifetime ecstasy use was associated with both unintended pregnancy (aOR 3.795, p = 0.022) and non-contraception use (aOR 4.562, p = 0.004). A history of physical abuse was also associated with both any contraception (aOR 3.024, p = 0.041) and LARC use (aOR 4.892, p = 0.050). Identifying as Aboriginal & Torres Strait Islander, education/employment status and geographic location appeared to have no association. Conclusion Our findings suggest that justice-involved adolescent girls have distinct risk factors associated with unplanned pregnancy and contraception use compared to the general population, but more research is required to understand the mechanisms and contexts underlying these risk factors. How exposure to physical violence may encourage contraception and LARC use, in particular, warrants further attention as does the association with ecstasy use.