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: Mycoplasma genitalium (MG) is implicated in non-gonococcal urethritis (NGU), cervicitis, pelvic inflammatory disease (PID), and adverse pregnancy outcomes. Australia has high levels of antimicrobial-resistant MG, but lacks comprehensive data to guide clinical and public health responses. Methods: Routine data from 66 clinics in a national sentinel surveillance network were analysed for trends in annual MG testing and diagnoses among attendees aged ≥15 years (2014–2024). Trends in macrolide resistance mutations (MRMs) were examined from 2016 onward. Findings: Between 2014 and 2024, MG testing increased from 1·5% (5801/376678) to 4·6% (16088/351792) (p-trend<0·001), with significant increases for females (p-trend<0·001), heterosexual males (p-trend<0·001), and gay, bisexual, and other men-who-have-sex-with-men (GBM) without HIV (p-trend<0·001), but not for GBM living with HIV (p-trend=0·77). MG positivity among females increased from 5·6% (101/1799) to 9·4% (644/6859), among heterosexual males from 6·6% (140/2131) to 10·5% (400/3811), and GBM without HIV from 7·5% (125/1662) to 13·8% (687/4981) (p-trend<0·001 each), while remaining stable in GBM with HIV (p-trend=0·33). Testing increased for cervicitis (27·5% [90/327] to 80·6% [100/124]), PID (33·9% [287/847] to 84·7% [546/645]), and NGU (48·5% [2105/4344] to 84·3% [3494/4144]) (p<0·001 for each). Overall, 67·3% (7067/10493) of MG-positive tests exhibited MRMs. In 2024, resistance proportions were 58·7% (376/641) in females, 73·1% (274/375) in heterosexual males, 78·1% (549/703) in GBM without HIV, and 68·5% (37/54) in GBM with HIV. Interpretations: Australia’s first national MG surveillance data show increased MG testing and detection, along with very high antimicrobial resistance, emphasising the urgent need for coordinated national surveillance to guide testing and treatment approaches.

BACKGROUND:Gay and bisexual men who have sex with men (GBMSM) and trans and gender diverse people (TGD) are disproportionately affected by several vaccine-preventable diseases. However, research on vaccine uptake for both sexually transmitted and non-sexually transmitted infections among GBMSM and TGD remains limited. Understanding differences in uptake between selective (e.g. hepatitis A; meningococcal; human papillomavirus; HPV; mpox) and universal (e.g. influenza, COVID-19) is important for informing future immunisation policy and strategies. METHODS:We surveyed past vaccine uptake among GBMSM and TGD people living in Australia in July-November 2024. Participants were asked to self-report their vaccination status for the following six vaccines: COVID-19, influenza, hepatitis A, hepatitis B, HPV, meningococcal disease, and mpox. Vaccine uptake was calculated for each vaccine and stratified by age group, HIV status and PrEP use, gender, education, Medicare status, world region of birth, and jurisdiction of residence. RESULTS:The median age of the 2095 participants was 39 years (IQR: 31-50). The majority of the participants identified as cisgender men (94.7%). Overall, the COVID-19 vaccine had the highest uptake (97.5%), followed by hepatitis A/B (80.6%), influenza (72.8%), mpox (64.0%), HPV (35.9%), and meningococcal disease (30.3%). HIV-negative participants not using pre-exposure prophylaxis (PrEP) had lower vaccine uptake compared with HIV-negative PrEP users and people living with HIV. Higher education and having a Medicare card were associated with an overall increased vaccine uptake. CONCLUSION:Factors that increase vaccine uptake included being PLHIV and using PrEP, increased education, and having a Medicare card. Public health policies should consider targeted outreach, integration of vaccination into routine care and innovative health communication strategies.

BACKGROUND:Long-acting cabotegravir (CAB-LA) was approved as HIV preexposure prophylaxis (PrEP) in the United States in December 2021, but data are limited on uptake, adherence, and persistence in clinical practice. METHODS:We extracted electronic health records of adults receiving oral or injectable PrEP during December 2021 to June 2024 at Kaiser Permanente (KP) Northern California and Mid-Atlantic States, 2 large integrated healthcare systems. We used χ 2 tests to compare characteristics of CAB-LA users and oral-PrEP-only users. Among CAB-LA users, we assessed adherence to bimonthly injections after lead-in doses (weeks 0 and 4) and used Kaplan-Meier methods to estimate persistence. RESULTS:Among 23,311 individuals accessing oral or injectable PrEP, 180 (0.8%) received CAB-LA, with 23.9% having no documentation of previous PrEP use at KP. Compared with oral-PrEP-only users, a lower proportion of CAB-LA users were commercially insured (82.2% vs 89.2%; P = 0.014) and a higher proportion were Black (18.9% vs 10.2%) or Hispanic (34.4% vs 23.6%; P < 0.001 across race/ethnicity categories). Of 688 non-lead-in CAB-LA injections, 90.4% were administered within 8 weeks +7 days after the previous injection. Persistence on CAB-LA was 87.9% and 74.9% at 6 and 12 months, respectively. There were no incident HIV infections during CAB-LA use. CONCLUSIONS:CAB-LA is engaging new users, including populations traditionally underrepresented in PrEP uptake, and adherence and persistence are high in clinical practice. However, uptake of CAB-LA is extremely low, suggesting population affect will be limited without efforts to expand implementation and use.

BACKGROUND:Neisseria gonorrhoeae is a significant public health concern due to rising antimicrobial resistance. Current strategies for N gonorrhoeae among gay and bisexual men (GBM) include 3-month screening; however, high-frequency screening may increase ceftriaxone consumption, potentially contributing to antimicrobial resistance. METHODS:We conducted a retrospective cohort study of GBM screened for N gonorrhoeae at 16 Australian public sexual health services between 2016 and 2023. We classified N gonorrhoeae tests and ceftriaxone prescriptions as screening-related (asymptomatic screening) or nonscreening-related (testing/treatment of contacts, symptomatic testing, or empirical treatment). We explored trends in annual ceftriaxone prescription rates and used multivariable Poisson regression to examine the association between individuals' annual asymptomatic screening frequency and ceftriaxone consumption, adjusted for age, year, pre-exposure prophylaxis, HIV status, injecting drug use, and syphilis and chlamydia diagnoses. RESULTS:In total, 65 261 GBM contributed 133 846 person-years. From 2016 to 2023, the total ceftriaxone prescription rate rose from 2.92 defined daily doses per 100 person-years at risk to 5.25: screening-related ceftriaxone increased from 0.91 to 2.96 (P < .001) while nonscreening-related ceftriaxone remained stable (P = .570). When compared with having 1 screening test per year, having ≥4 tests was associated with a higher rate of screening-related ceftriaxone prescriptions (adjusted incident rate ratio, 5.47; 95% CI, 5.16-5.79). CONCLUSIONS:Ceftriaxone consumption rose among GBM, largely driven by increased screening rather than nonscreening-related treatment. Our findings highlight the association between high-frequency screening and antibiotic consumption, providing real-world data to guide discussions on the benefits and risks of screening.

The optimal implementation of doxycycline post-exposure prophylaxis (doxy-PEP) for preventing bacterial sexually transmitted infections (STIs) among Australian men who have sex with men is unclear due to concerns about antimicrobial resistance and cost-effectiveness. We developed an individual-based model, calibrated to Australian national data, to compare five targeted doxy-PEP strategies with a base case from 2025 to 2034, using a multi-criteria ranking framework to evaluate their epidemiological, resistance, and economic outcomes. All evaluated strategies reduced STIs by 13.0% to 47.8% and were cost-saving. However, compared to the high 73.5% baseline projection for high-level tetracycline resistance by 2034, all strategies yielded higher proportions. This proportion was highest (97.4%) when targeting all HIV pre-exposure prophylaxis users, and lowest (81.2%) for the syphilis diagnosis strategy. This syphilis-focused strategy reduced overall STIs by 16.4%, had the highest benefit-cost ratio (9.2), and ranked highest in 9 of 11 evaluation frameworks. Here, we show that doxy-PEP is an effective, cost-saving intervention, with the syphilis diagnosis strategy representing the most recommended approach to optimally balance benefits and risks.

OBJECTIVE:To examine the awareness, usage and perceptions of doxycycline post-exposure prophylaxis (doxyPEP) for sexually transmitted infection (STI) prevention among gay and bisexual men and transgender (trans) and gender diverse people in Australia. DESIGN:Cross-sectional online survey. SETTING, PARTICIPANTS:National multi-site survey in Australia from 1 July 2024 to 30 November 2024, recruiting from 13 sexual health and community clinics, 6 general practices, social media, dating applications, and university portals. Gay and bisexual men and trans and gender diverse people aged ≥ 18 years living in Australia were included in the study. MAIN OUTCOME MEASURES:DoxyPEP awareness, ever use, recent use (past 12 months), dosage regimens, sourcing methods and planned future use. RESULTS:Among 2095 participants, half (1080/2095, 51.6%) had heard of doxyPEP. Of those aware, 323/1080 (29.9%) had ever used doxyPEP, and 306/1080 (28.3%) were recent users. DoxyPEP awareness and usage varied by HIV status and pre-exposure prophylaxis (PrEP) use (p < 0.0001). Nearly two-thirds of users had taken the recommended 200 mg within 72 h after sex (205/323, 63.5%). Among recent users, 29/306 (9.5%) reported recent syphilis diagnoses, and 85/306 (27.8%) had ≥ 2 STI diagnoses in the past 12 months. Of those who had ever used doxyPEP, 135/323 (41.8%) obtained prescriptions from clinicians, 17/323 (5.3%) obtained it online, and 28/323 (8.7%) purchased it in person overseas without a prescription. Of those aware of doxyPEP, 490/1080 (45.4%) planned to use doxyPEP in the next 12 months, primarily to prevent chlamydia (460/490, 93.9%), gonorrhoea (422/490, 86.1%) or syphilis (386/490, 78.8%). Some intended to prevent Mycoplasma genitalium (92/490, 18.8%) or mpox (36/490, 7.4%). Among non-users, 306/756 (40.5%) worried about antibiotic resistance. CONCLUSIONS:DoxyPEP use was happening quickly but often involved non-recommended regimens and unsupervised sourcing. Urgent educational interventions and improved clinical access are needed for safe implementation.

Background:The hospital-led interventions yielding the best hepatitis C virus (HCV) testing and treatment uptake are poorly understood. Methods:We searched Medline, Embase, and Cochrane databases for studies assessing outcomes of hospital-led interventions for HCV antibody or RNA testing uptake, linkage to care, or direct-acting antiviral commencement compared with usual care, a historical comparator, or control group. We systematically reviewed hospital-led interventions delivered in inpatient units, outpatient clinics, or emergency departments. Random-effects meta-analysis estimated pooled odds ratios [pORs] measuring associations between interventions and outcomes. Subgroup analyses explored outcomes by intervention type. Results:A total of 7872 abstracts were screened with 23 studies included. Twelve studies (222 868 participants) reported antibody testing uptake, 5 (n = 4987) reported RNA testing uptake, 7 (n = 3185) reported linkage to care, and 4 (n = 1344) reported treatment commencement. Hospital-led interventions were associated with increased antibody testing uptake (pOR, 5.83 [95% confidence interval {CI}, 2.49-13.61]; I 2 = 99.9%), RNA testing uptake (pOR, 10.65 [95% CI, 1.70-66.50]; I 2 = 97.9%), and linkage to care (pOR, 1.75 [95% CI, 1.10-2.79]; I 2 = 79.9%) when data were pooled and assessed against comparators. Automated opt-out testing (5 studies: pOR, 16.13 [95% CI, 3.35-77.66]), reflex RNA testing (4 studies: pOR, 25.04 [95% CI, 3.63-172.7]), and care coordination and financial incentives (4 studies: pOR, 2.73 [95% CI, 1.85-4.03]) showed the greatest increases in antibody and RNA testing uptake and linkage to care, respectively. No intervention increased uptake at all care cascade steps. Conclusions:Automated antibody and reflex RNA testing increase HCV testing uptake in hospitals but have limited impact on linkage to treatment. Other interventions promoting linkage must be explored.

Importance:Doxycycline postexposure prophylaxis (doxyPEP) has been shown to decrease the incidence of bacterial sexually transmitted infections (STIs) among people assigned male sex at birth in clinical trials, but data from clinical practice are limited. Objective:To describe early uptake of doxyPEP and evaluate changes in STI incidence following doxyPEP initiation. Design, Setting, and Participants:This retrospective cohort study of adults (aged ≥18 years) dispensed HIV preexposure prophylaxis (PrEP) at Kaiser Permanente Northern California during November 1, 2022, to December 31, 2023, examined electronic health record data to compare HIV PrEP users dispensed and not dispensed doxyPEP and rates of bacterial STIs before and after starting doxyPEP. Individuals were followed up from their first recorded STI test on or after November 1, 2020, until December 31, 2023, or discontinuation of health plan membership. Exposure:Pharmacy dispensing data were used to define doxyPEP recipients. Main Outcomes and Measures:Demographic and clinical characteristics were compared between individuals dispensed and not dispensed doxyPEP. Primary outcomes were incident chlamydia, gonorrhea, or infectious syphilis measured as quarterly STI positivity (proportion of individuals testing positive at least once per quarter). Among doxyPEP recipients, rate ratios (RRs) compared mean quarterly STI positivity from 24 months before to 12 months after starting doxyPEP. In an exploratory analysis, STI trends were evaluated for the full cohort, stratified by receipt of doxyPEP. Results:Among 11 551 HIV PrEP users (mean [SD] age, 39.9 [12.1] years; 95.1% male), 2253 (19.5%) were dispensed doxyPEP, of whom 2228 (98.9%) were male and 1096 (48.6%) had an STI in the year before starting doxyPEP. Compared with individuals not dispensed doxyPEP, doxyPEP recipients were older (mean [SD] age, 40.4 [10.8] vs 39.8 [12.4] years; P = .04) and had used HIV PrEP longer (mean [SD], 4.2 [2.8] vs 3.4 [2.6] years; P < .001), and a higher proportion were commercially insured (2091 [92.8%] vs 8270 [88.9%]; P < .001). Among doxyPEP recipients, quarterly chlamydia positivity decreased from 9.6% (95% CI, 9.0%-10.3%) before starting doxyPEP to 2.0% (95% CI, 1.5%-2.6%) after starting doxyPEP (RR, 0.21; 95% CI, 0.16-0.27; P < .001), with significant declines for each anatomic site of infection. Quarterly gonorrhea positivity decreased from 10.2% (95% CI, 9.6%-10.9%) before starting doxyPEP to 9.0% (95% CI, 8.0%-10.1%) after starting doxyPEP (RR, 0.88; 95% CI, 0.77-1.00; P = .048); site-specific declines were significant for rectal (RR, 0.81; 95% CI, 0.67-0.97; P = .02) and urethral (RR, 0.56; 95% CI, 0.40-0.79; P = .001) gonorrhea, but not pharyngeal gonorrhea. Quarterly syphilis positivity decreased from 1.7% (95% CI, 1.4%-1.9%) before starting doxyPEP to 0.3% (95% CI, 0.2%-0.6%) after starting doxyPEP (RR, 0.20; 95% CI, 0.11-0.37; P < .001). Positivity for STIs remained stable in individuals not dispensed doxyPEP. Conclusions and Relevance:This study found that receipt of doxyPEP was associated with substantial declines in chlamydia and syphilis incidence and modest declines in urethral and rectal gonorrhea incidence among individuals using HIV PrEP. These findings suggest that doxyPEP may offer substantial benefits for reducing population-level STI transmission with broader implementation.

Background Doxycycline used as postexposure prophylaxis (doxyPEP) within 72 hours of sex reduces the risk of bacterial sexually transmitted infections (STIs) in people assigned male sex at birth. Little is known about current use of antibiotics as STI prophylaxis in US populations likely to benefit from doxyPEP. Methods We conducted an online survey in September 2023 of US adults recruited via sexual networking apps used mainly by gay and bisexual men (GBM). Respondents were asked about the use of antibiotics around the time of sex to prevent bacterial STIs. Results Of 903 respondents, most (96.2%) identified as GBM; 19.0% were living with HIV and 42.5% were using HIV preexposure prophylaxis (PrEP). Half (49.1%) had heard of using antibiotics to prevent STIs, and 95.6% were interested in use. Overall, 21.0% had used antibiotic STI prophylaxis, and 15.9% had done so in the past year. Among those reporting any use, most (78.1%) had used doxycycline; some used amoxicillin (16.7%), azithromycin (14.5%), or other antibiotics (14.1%). Among those reporting use in the past year, 46.9% used it for some, 28.1% for most, and 25.0% for all sex acts with casual partners during that period. Most (78.3%) of STI prophylaxis users reported their condom use did not change during periods of STI prophylaxis use, 17.2% indicated their condom use declined, and 4.5% indicated their condom use increased. For doxyPEP specifically, 35.7% had heard of it, and 13.0% had used it in the past year, of whom 21.0% had used a dosage other than the 200-mg dose shown to be effective. Conclusions In this sample of primarily GBM, interest in bacterial STI prophylaxis was nearly universal. However, some of the use was not informed by current clinical guidance or evidence from research studies. Efforts are needed to increase awareness of effective dosing and monitor real-world use.

Background In Australia, the incidence of hepatitis C virus (HCV) has declined among gay and bisexual men (GBM) with human immunodeficiency virus (HIV) since 2015 and is low among GBM using HIV preexposure prophylaxis (PrEP). However, ongoing HCV testing and treatment remains necessary to sustain this. To assess the potential utility of sexually transmissible infections (STIs) to inform HCV testing among GBM with HIV and GBM using PrEP, we examined the association between bacterial STI diagnoses and subsequent primary HCV infection.Methods Data were from a national network of 46 clinics participating in the Australian Collaboration for Coordinated Enhanced Sentinel Surveillance. GBM included had >= 1 HCV antibody negative test result and >= 1 subsequent HCV antibody and/or RNA test. Discrete time survival analysis was used to estimate the association between a positive syphilis, rectal chlamydia, and rectal gonorrhea diagnosis in the previous 2 years and a primary HCV diagnosis, defined as a positive HCV antibody or RNA test result.Results Among 6529 GBM with HIV, 92 (1.4%) had an incident HCV infection. A prior positive syphilis diagnosis was associated with an incident HCV diagnosis (adjusted hazard ratio, 1.99 [95% confidence interval, 1.11-3.58]). Among 13 061 GBM prescribed PrEP, 48 (0.4%) had an incident HCV diagnosis. Prior rectal chlamydia (adjusted hazard ratio, 2.75 [95% confidence interval, 1.42-5.32]) and rectal gonorrhea (2.54 [1.28-5.05]) diagnoses were associated with incident HCV.Conclusions Diagnoses of bacterial STIs in the past 2 years was associated with HCV incidence. These findings suggest that STIs might be useful for informing HCV testing decisions and guidelines for GBM with HIV and GBM using PrEP. Sexually transmissible infections (STIs) are a marker of hepatitis C virus (HCV) risk among gay and bisexual men with human immunodeficiency virus (HIV) and those prescribed HIV preexposure prophylaxis in the context of declining HCV incidence. These STIs may be useful for guiding more tailored HCV testing.

Background The World Health Organization seeks to eliminate viral hepatitis as a public health threat by 2030. This review and meta -analysis aims to evaluate the effectiveness of programs for hepatitis B and C testing and treatment in community pharmacies. Methods Medline, Embase, Cochrane CENTRAL, and Global Health were searched from database inception until 12 November 2023. Comparative and single arm intervention studies were eligible for inclusion if they assessed delivery of any of the following interventions for hepatitis B or C in pharmacies: (1) pre -testing risk assessment, (2) testing, (3) pre-treatment assessment or (4) treatment. Primary outcomes were proportions testing positive and reaching each stage in the cascade. Random effects meta -analysis was used to estimate pooled proportions stratified by recruitment strategy and setting where possible; other results were synthesised narratively. This study was preregistered (PROSPERO: CRD42022324218). Findings Twenty-seven studies (4 comparative, 23 single arm) were included, of which 26 reported hepatitis C outcomes and four reported hepatitis B outcomes. History of injecting drug use was the most identified risk factor from pre -testing risk assessments. The pooled proportion hepatitis C antibody positive from of 19 studies testing 5096 participants was 16.6% (95% CI 11.0%-23.0%; heterogeneity I2 = 96.6%). The pooled proportion antibody positive was significantly higher when testing targeted people with specified risk factors (32.5%, 95% CI 24.8%-40.6%; heterogeneity I2 = 82.4%) compared with non -targeted or other recruitment methods 4.0% (95% CI 2.1%-6.5%; heterogeneity I2 = 83.5%). Meta -analysis of 14 studies with 813 participants eligible for pre-treatment assessment showed pooled attendance rates were significantly higher in pharmacies (92.7%, 95% CI 79.1%-99.9%; heterogeneity I2 = 72.4%) compared with referral to non -pharmacy settings (53.5%, 95% CI 36.5%-70.1%; heterogeneity I2 = 92.3%). The pooled proportion initiating treatment was 85.6% (95% CI 74.8%-94.3%; heterogeneity I2 = 75.1%). This did not differ significantly between pharmacy and non -pharmacy settings. Interpretation These findings add pharmacies to the growing evidence supporting community -based testing and treatment for hepatitis C. Few comparative studies and high degrees of statistical heterogeneity were important limitations. Hepatitis B care in pharmacies presents an opportunity for future research. Funding None. Copyright (c) 2024 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY -NC -ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

HIV prevention programs typically focus on changing individuals’ risk behaviors, often without considering the socioecological factors that can moderate this risk. We characterized HIV risk among men who have sex with men (MSM) in Indonesia (n = 1314) using latent class analysis and used multinomial logistic regression to identify latent class relationships with demographics, social/sexual networks, and community-level socioecological indicators of HIV risk. Three HIV risk latent classes were identified—“Sexually Moderate” (n = 333), “Sexual Explorative” (n = 575), and “Navigating Complexities” (n = 406). Using “Sexually Moderate” (lowest risk) as the reference group, MSM in the “Sexual Explorative” class had additional social/sexual network-level risks (meeting partner(s) using both online and offline methods [RR = 3.8; 95%CI 1.7–8.6] or general social media and gay-specific online platforms [RR = 2.6; 95%CI 1.9–3.6] to meet partners, group sex [RR = 10.9; 95%CI 4.5–25.4], transactional sex [RR = 1.6; 95%CI 1.2–2.2]), and community-level risks (experiencing homosexual-related assaults [RR = 1.4; 95%CI 1.1–1.9]). MSM in the “Navigating Complexities” class had additional social/sexual network-level risks (low social support [RR = 1.6; 95%CI 1.1–2.5], less disclosure of their sexuality [RR = 1.4; 95%CI 1.0–1.9]) and community-level risks (higher internalized homonegativity scores [RR = 1.2; 95%CI 1.1–1.4], ever experiencing homosexual-related assaults [RR = 1.4:95%CI 1.1–1.9], less exposure to HIV/STI health promotion [RR = 0.7; 95%CI 0.5–0.9], attending STI-related services in the past 6 months [RR = 0.6; 95%CI 0.4–0.8]). Co-occurring individual and socioecological risk recommend holistic HIV prevention strategies tailored to consider the social and structural conditions of MSM in Indonesia are needed.

Background Gay and bisexual men (GBM) remain overrepresented among syphilis diagnoses in Australia and globally. The extent to which changes in sexual networks associated with HIV pre-exposure prophylaxis (PrEP) and treatment as prevention (TasP) may have influenced fl uenced syphilis transmission among GBM at the population-level is poorly understood. We describe trends in syphilis testing and incidence among GBM in Australia over eleven years spanning widespread uptake of HIV PrEP and TasP. Methods We analysed linked clinical data from GBM aged 16 years or older across a sentinel surveillance network in Australia from January 1, 2012, to December 31, 2022. Individuals with at least two clinic visits and with at least two syphilis tests during the observations period were included in testing and incidence analyses, respectively. Annual rates of testing and infectious syphilis incidence from 2012 to 2022 were disaggregated by HIV status and PrEP use (record of PrEP prescription; retrospectively categorised as ever or never-PrEP user). Cox regression explored associations between demographics, PrEP use and history of bacterial sexually transmissible infections (STIs) and infectious syphilis diagnosis. Findings Among 129,278 GBM (mean age, 34.6 years [SD, 12.2]) included in testing rate analyses, 7.4% were living with HIV at entry and 31.1% were prescribed PrEP at least once during the study period. Overall syphilis testing rate was 114.0/100 person-years (py) and highest among GBM with HIV (168.4/100 py). Syphilis testing increased from 72.8/100 py to 151.8/100 py; driven largely by increases among ever-PrEP users. Among 94,710 GBM included in incidence analyses, there were 14,710 syphilis infections diagnosed over 451,560 person-years (incidence rate = 3.3/100 py). Syphilis incidence was highest among GBM with HIV (6.5/100 py), followed by ever-PrEP users (3.5/100 py) and never-PrEP users (1.4/100 py). From 2012 to 2022, syphilis incidence increased among ever-PrEP users from 1.3/100 py to 5.1/100 py, and fl uctuated between 5.4/100 py and 6.6/100 py among GBM with HIV. In multivariable Cox regression, previous syphilis diagnosis (adjusted hazard ratio [aHR] = 1.98, 95% CI = 1.83-2.14), - 2.14), living with HIV (aHR = 1.83, 95% CI = 1.12-1.25) - 1.25) and recent (past 12 m) prescription of PrEP (aHR = 1.78, 95% CI = 1.61-1.97) - 1.97) were associated with syphilis diagnosis. Interpretation Syphilis trends between GBM with HIV and GBM with evidence of PrEP use have converged over the past decade in Australia. Our fi ndings recommend targeting emergent syphilis control strategies (e.g. doxycycline post-exposure prophylaxis) to GBM with prior syphilis diagnoses, using HIV PrEP or who are living with HIV.

Objective Guidelines recommend annual hepatitis C virus (HCV) testing for gay and bisexual men (GBM) with HIV and GBM prescribed HIV pre-exposure prophylaxis (PrEP). However, there is a limited understanding of HCV testing among GBM. We aimed to examine trends in HCV testing and positivity from 2016 to 2022. Methods Using sentinel surveillance data, we examined the proportion of GBM with at least one test and the proportion with a positive test in each year for HCV antibody testing among GBM with no previous HCV positive test, HCV RNA testing among GBM with a positive antibody test but no previous positive RNA test (naïve RNA testing), and HCV RNA testing among people who had a previous RNA positive test and a subsequent negative test (RNA follow-up testing). Trends were examined using logistic regression from 2016 to 2019 and 2020 to 2022. Results Among GBM with HIV, from 2016 to 2019 antibody testing was stable averaging 55% tested annually. Declines were observed for both naïve HCV RNA testing (75.4%–41.4%: p<0.001) and follow-up HCV RNA testing (70.1%–44.5%: p<0.001). Test positivity declined for HCV antibody tests (2.0%–1.3%: p=0.001), HCV RNA naïve tests (75.4%–41.4%: p<0.001) and HCV RNA follow-up tests (11.3%–3.3%: p=0.001). There were minimal or no significant trends from 2020 to 2022. Among GBM prescribed PrEP, antibody testing declined from 2016 to 2019 (79.4%–69.4%: p<0.001) and was stable from 2020 to 2022. Naïve and follow-up HCV RNA testing was stable with an average of 55% and 60% tested each year, respectively. From 2016–2019, the proportion positive from HCV RNA naïve tests declined (44.1%–27.5%: p<0.046) with no significant change thereafter. Positive follow-up HCV RNA tests fluctuated with no or one new positive test among this group in most years. Conclusion The proportion of GBM with positive HCV tests has declined, however a substantial proportion are not tested annually. A renewed focus on HCV testing, and treatment where required, is warranted to achieve HCV elimination among GBM in Australia.

BACKGROUND:There is some concern that hepatitis C virus (HCV) reinfection might impact HCV micro-elimination efforts among gay and bisexual men (GBM) with HIV. However, there is a limited understanding of reinfection incidence in the context of unrestricted government-funded HCV treatment. We aimed to estimate HCV reinfection incidence among GBM with HIV in Australia from 2016 to 2020. METHODS:Data were from 39 clinics participating in ACCESS, a sentinel surveillance network for blood borne viruses and sexually transmissible infections across Australia. GBM with HIV who had evidence of treatment or spontaneous clearance with at least one positive HCV RNA test, a subsequent negative HCV RNA test, and at least one additional HCV RNA test between 1st January 2016 and 31st December 2020 were eligible for inclusion. A new HCV RNA positive test and/or detectable viral load was defined as a reinfection. Generalised linear modelling was used to examine trends in reinfection. RESULTS:Among 12 213 GBM with HIV who had at least one HCV test, 540 were included in the reinfection incidence analysis, of whom 38 (7%) had evidence of reinfection during the observation period. Over 1124 person-years of follow-up, the overall rate of reinfection was 3.4/100PY (95% CI 2.5-4.6). HCV reinfection incidence declined on average 30% per calendar year (Incidence Rate Ratio 0.70, 95% CI 0.54-0.91). CONCLUSION:HCV reinfection incidence has declined among GBM with HIV in Australia since government-funded unrestricted DAAs were made available. Ongoing HCV RNA testing following cure and prompt treatment for anyone newly diagnosed is warranted to sustain this.

Introduction: HIV preexposure prophylaxis (PrEP) is highly effective at preventing HIV. We aimed to assess mental and physical health among long-term PrEP users in Australia's X-PLORE cohort. Methods: In early 2021, 1485 X-PLORE participants were emailed a survey covering demographics, sexual practices, ongoing PrEP use, physical and psychological diagnoses received since commencing PrEP, substance use, and impacts of the COVID-19 pandemic. Current anxiety and depression were assessed using GAD-7 and PHQ-9 questionnaires. Results: Of 476 participants (completion rate 32.1%), 99.8% were cis-gender men. Median PrEP use duration was 48 months (2002 person-years), with 81.7% currently using PrEP. PrEP-related toxicity was uncommon: 2.9% reported bone fractures, 1.3% low bone density, and 4.0% reported kidney problems, largely not necessitating PrEP cessation. Most (92.0%) rated their health as ‘good’ to ‘excellent’, and 22.6% reported improved health since starting PrEP, often because of improved mental health. Only 6.2% reported deterioration in health since starting PrEP, largely unrelated to PrEP. The most common diagnoses were hypertension (9.9%), depression (13.2%) and anxiety (14.9%); 17% had PHQ-9 scores indicating current moderate-to-severe depression, which was associated with unemployment [adjusted odds ratio (aOR) 3.90], regular cannabis use (aOR 2.49), and having ceased PrEP (aOR 2.13). Conclusion: Among long-term PrEP users, of which over 80% were currently using PrEP, self-reported PrEP toxicity was uncommon. With almost one in five PrEP users categorized as having depression, and with higher risk among those having ceased PrEP, we recommend routine screening for depression and anxiety in PrEP users and corresponding follow-up of patients no longer attending for PrEP.