BACKGROUND:Significant social, technological and medical changes highlight a need for timely and representative sexual and reproductive health surveys, while also posing challenges to their design. This paper describes methods of the Third Australian Study of Health and Relationships (ASHR3). METHODS:From March 2023 to April 2024, data were collected from people aged 16-69 years via an anonymous survey of holistic sexual and reproductive health. ASHR3 collected data via random selection of mobile phone numbers for an interviewer-administered survey and via an online probability panel for a self-administered digital survey. Potential differences between the two modes of sampling and data collection were investigated. Sample-specific design weights were applied and calibrated to the 2021 Australian Census regarding gender, country of birth, education, religion and area of residence. RESULTS:The final sample was 12,833 people: 5693 men (48.63% weighted proportion), 6984 women (49.98%), and 156 non-binary people (1.39%) from every state and territory. Telephone interviews were conducted with 7226 participants and online surveys with 5607. The survey cooperation and response rates for the telephone sample were 86.11% and 3.54%, respectively, whereas the online completion rate was 98.73%. Few participants said the survey made them feel embarrassed (10.96%) and most said they were very honest in their responses (96.54%). Comparisons with the most recent Census found the weighted ASHR3 sample was generally representative of the general population of Australia, with a mean of 1.22% difference across key sociodemographic characteristics (s.d. 2.37). There were no differences observed in sociodemographic characteristics and other responses between the telephone and online samples. CONCLUSIONS:ASHR3 compiled rich, robust, and representative data on sexual and reproductive health from a large national sample. The inclusion of an online probability panel complemented the more traditional telephone-based methods. With more than 20 years of data, ASHR is an important resource for monitoring trends in sexual and reproductive health.

BACKGROUND:The use of preexposure prophylaxis (PrEP) for the prevention of human immunodeficiency virus (HIV) has raised concerns of increased sexual risk behaviors. These behaviors may be associated with increased incidence of sexually acquired hepatitis C virus (HCV) among gay and bisexual men. METHODS:The Expanded PrEP Implementation in Communities-New South Wales (EPIC-NSW) study was a cohort study of daily coformulated tenofovir disoproxil fumarate and emtricitabine for HIV prevention. We recruited 9596 people at high risk of HIV acquisition from 31 clinics across New South Wales and the Australia Capital Territory in Australia. We report prior exposure to HCV and incidence in this cohort between 2016 and 2019. RESULTS:At least 1 HCV test result was available for 8658 (90.2%) participants. These individuals had a median age of 34 years (interquartile range, 28-43), most of whom were male (8530, 98.5%), identified as gay (7944, 91.8%), and were born in Australia (51.8%). Prior exposure to HCV was detected among 81 participants at baseline (0.9%; 95% confidence interval [CI]: .71.2). Twenty of 8577 participants were diagnosed with incident infection (rate 0.2/100 person-years [95% CI: .1-.3/100 person-years]). They were significantly older (median age 41 years vs 34 years, P = .044), and more likely to report methamphetamine use at baseline (incidence rate ratio, 2.7 [95% CI: 1.00-7.2]) than those without incident infection. CONCLUSIONS:In this population of PrEP users, HCV prior exposure and incidence were low. With high levels of HCV and HIV testing and treatment, the dual goals of HIV and HCV elimination could be achieved in this population. Clinical Trials Registration: number NCT02870790.

Videoconferencing focus groups have emerged as a popular method for collecting qualitative data. However, its use in sexual and reproductive health research is still very much in its infancy. Based on participants' feedback and researchers' reflections on using videoconferencing focus groups to collect sexual and reproductive health data with 39 heterosexual and non-heterosexual Chinese im/migrants in Australia, we discuss some of the key lessons learned, and considerations involved in shifting from face-to-face to online focus groups. Overall, videoconferencing focus groups appeared to be a highly feasible and acceptable way to discuss "sensitive" topics with Chinese im/migrants. Importantly, researchers need to be both creative and reflexive during the research process and must not forget that the success of a study lies not only in troubleshooting technical issues but also in cultivating and maintaining a trusting relationship with research participants.

Objectives: To examine patterns of long-term pre-exposure prophylaxis (PrEP) adherence and its association with HIV seroconversion in NSW, Australia. Design: Population-based HIV PrEP implementation study. Methods: Expanded PrEP Implementation in Communities in New South Wales was an open-label study of daily oral PrEP which recruited participants from March 2016 to April 2018. Adherence was measured using dispensing records. PrEP discontinuation was defined as an at least 120-day period without PrEP coverage. Long-term adherence patterns were identified using group-based trajectory modelling. Results: Participants dispensed at least once ( n = 9586) were almost all male (98.5%), identified as gay (91.3%), with a median age of 34 years (range: 18–86). Of the 6460 (67.4%) participants who had at least 9 months of follow-up since first dispensing, 1942 (30.1%) discontinued. Among these, 292 (15.0%) restarted later. Four distinct groups were identified [‘Steep decline’ in adherence (15.8%), ‘Steady decline’ (11.6%), ‘Good adherence’ (37.4%), and ‘Excellent adherence’ (35.2%)]. Older ( P < 0.001) and gay-identified ( P < 0.001) participants were more likely to have higher adherence, so were those living in postcodes with a higher proportion of gay-identified male residents ( P < 0.001). Conversely, those who at baseline reported recent crystal methamphetamine use and had a recent diagnosis of sexually transmitted infection (STI) had lower adherence ( P < 0.001). Overall HIV incidence was 0.94 per 1000 person-years (95% confidence interval: 0.49–1.81; n = 9) and was highest in the ‘steep decline’ group (5.45 per 1000 person-years; P = 0.001). Conclusion : About 15% of participants stopped PrEP during study follow-up and were at increased risk of HIV infection. They were more likely to be younger and report a recent STI or methamphetamine use prior to PrEP initiation.

Background Daily pre-exposure prophylaxis (PrEP) is effective in preventing HIV, but few long-term data are available on effectiveness and adherence in real-world settings. Here, we report trends in HIV incidence over 3 years in individuals at high risk who were prescribed PrEP in New South Wales (NSW), as well as adherence before the transition to subsidised PrEP. Methods Expanded PrEP Implementation in Communities-New South Wales (EPIC-NSW) was a pragmatic, prospective, single-arm, implementation study of daily, oral PrEP in 31 sites (sexual health clinics, general practices, and a hospital) in NSW, Australia. Eligible participants were HIV-negative adults (aged >= 18 years) who were at high risk of HIV infection as defined in local PrEP guidelines. Participants were prescribed coformulated (once-daily, oral tablet) tenofovir disoproxil fumarate (300 mg) and emtricitabine (200 mg) as HIV PrEP and were followed up with HIV testing, sexually transmitted infection testing, and PrEP dispensing. Originally planned for 3700 participants followed for 1 year, the study was expanded so that all eligible participants in the state could obtain PrEP and extended until publicly subsidised PrEP became available in Australia. The primary outcome was new HIV infection among all participants who were dispensed PrEP at least once and had at least one follow-up HIV test result. Adherence was estimated by medication possession ratio (MPR), defined as the proportion of PrEP pills dispensed in 90 days, assuming daily dosing. This study is registered with ClinicalTrials.gov, NCT02870790. Findings Between March 1, 2016, and April 30, 2018, we enrolled 9709 participants. 9596 participants were dispensed PrEP, of whom 9448 (98.3%) were gay or bisexual men. Participants were followed up until March 31, 2019, with at least one follow-up HIV test available in 9520 (99.2%) participants. Mean MPR declined from 0.93 to 0.64 from the first to the ninth quarter. There were 30 HIV seroconversions over 18 628 person-years, an incidence of 1.61 per 1000 person-years (95% CI 1.13-2.30). Being younger, living in a postcode with fewer gay men, reporting more risk behaviours at baseline, and having an MPR of less than 0.6 were each univariately associated with increased HIV incidence. In the final year of follow-up, when PrEP was mostly purchased rather than provided free by the study, HIV incidence remained low at 2.24 per 1000 person-years (1.46-3.44). Interpretation HIV incidence remained low over up to 3 years of follow-up, including during a transition from study-provided to publicly subsidised PrEP. In a setting of affordable PrEP and associated health-care services, very low HIV incidence of 1 to 2 per 1000 person-years can be maintained in gay and bisexual men who were previously at high risk.

This cohort study examines trends in sexually transmitted infection (STI) test positivity among high-risk men who have sex with men before and after the start of preexposure prophylaxis (PrEP) for HIV. Importance There have been concerns that HIV preexposure prophylaxis (PrEP) may be associated with increases in sexually transmitted infections (STIs) because of subsequent reductions in condom use and/or increases in sexual partners. Objective To determine trends in STI test positivity among high-risk men who have sex with men (MSM) before and after the start of HIV PrEP. Design, Setting, and Participants A before-after analysis was conducted using a subcohort of a single-group PrEP implementation study cohort in New South Wales, Australia (Expanded PreEP Implementation in Communities in New South Wales [EPIC-NSW]), from up to 1 year before enrollment if after January 1, 2015, and up to 2 years after enrollment and before December 31, 2018. STI testing data were extracted from a network of 54 sexual health clinics and 6 primary health care clinics Australia-wide, using software to deidentify, encrypt, and anonymously link participants between clinics. A cohort of MSM dispensed PrEP for the first time during the study, with 2 or more STI tests in the prior year and who tested during follow-up, were included from the EPIC-NSW cohort of HIV-negative participants with high-risk sexual behavior. Data analysis was performed from June to December 2019. Exposures Participants were dispensed coformulated tenofovir disoproxil fumarate (300 mg) and emtricitabine (200 mg) as HIV PrEP. Main Outcomes and Measures The main outcome was STI, measured using test positivity, defined as the proportion of participants testing positive for an STI at least once per quarter of follow-up. Outcomes were calculated for Chlamydia trachomatis and Neisseria gonorrhoea by site of infection (anorectal, pharyngeal, urethral, or any) and for syphilis. Results Of the EPIC-NSW cohort of 9709 MSM, 2404 were included in the before-after analysis. The mean (SD) age of the participants was 36 (10.4) years, and 1192 (50%) were Australia-born. STI positivity was 52% in the year after PrEP (23.3% per quarter; 95% CI, 22.5%-24.2% per quarter) with no significant trend (mean rate ratio [RR] increase of 1.01 per quarter [95% CI, 0.99-1.02]; P = .29), compared with 50% positivity in the year prior to PrEP (20.0% per quarter [95% CI, 19.04%-20.95% per quarter]; RR for overall STI positivity, 1.17 [95% CI, 1.10-1.24]; P < .001), with an increase in quarterly STI positivity (mean RR of 1.08 per quarter, or an 8% increase per quarter [95% CI, 1.05-1.11]; P < .001; RR, 0.93 [95% CI, 0.90-0.96]; P < .001). Findings were similar when stratified by specific STIs and anatomical site. Conclusions and Relevance STI rates were high but stable among high-risk MSM while taking PrEP, compared with a high but increasing trend in STI positivity before commencing PrEP. These findings suggest the importance of considering trends in STIs when describing how PrEP use may be associated with STI incidence. Question Is access to HIV preexposure prophylaxis (PrEP) associated with the trajectory of preexisting trends in sexually transmitted infections (STIs) among high-risk men who have sex with men (MSM)? Findings In a before-after cohort study of high-risk MSM participating in a population-based PrEP implementation project, STI positivity was high while men were taking PrEP with no increasing trend in quarterly STI positivity, compared with similar high positivity before PrEP but an increase of 8% per quarter. Meaning These findings suggest that studies that do not consider preexisting STI trends may overestimate the association of PrEP with STI incidence.

Background HIV PrEP is highly effective at preventing HIV, but not STI, acquisition. We examined the use of condoms to prevent STIs among PrEP-users in the EPIC-NSW trial. Methods Between March 2016 and April 2018, 9,708 individuals were enrolled. Analysis was restricted to participants who completed the optional end-of-study survey and were on-study for ≥1 year prior. STI diagnoses came from medical records; other data were from the end-of-study survey. We used multivariate logistic regression to assess independent associations between those agreeing with the statement, “I use condoms to avoid getting STIs” (“STI-condom-users”) and those disagreeing. Results 2,915 participants were included; 92.5% were gay men. In the previous year, 54.2%, 25.6%, and 20.2% were diagnosed with no, one, and ≥2 STIs, respectively. 1,127 (38.7%) reported being STI-condom-users. In multivariate analysis, there was no difference in mean STIs diagnosed in the previous year (0.7 vs 0.8, p=0.244). STI-condom-users were younger (39 vs 41 years, p=0.004), less likely to live in a suburb with ≥10% gay men (24.8% vs 35.5%, p<0.001), less likely to report any condomless sex in the previous 6 months (85.9% vs 93.3%, p<0.001), and had been on-study less time (1.4 vs 1.6 years, p=0.003). STI-condom-users were more: concerned about acquiring STIs (95.1% vs 88.9%, p=0.025), likely to discuss STI results with partners (88.3% vs 79.8%, p<0.001), and likely to believe condoms prevent STI transmission (96.7% vs 89.6%, p<0.001). Fewer STI-condom-users had rejected a sexual partner for wanting to use condoms (9.6% vs 32.7%, p<0.001), while more had been rejected for wanting to use condoms (45.0% vs 26.2%, p<0.001). Conclusion Most PrEP-users did not use condoms for STI prevention, despite strong beliefs in its effectiveness. STI-condom-users did not have fewer STIs, reflecting high levels of condomless sex. Our results suggest alternative methods of STI prevention should be trialled for PrEP-users. Disclosure No significant relationships.