Antimicrobial-resistant Neisseria gonorrhoeae poses a serious public health threat. In Australia, N. gonorrhoeae isolates with ceftriaxone MICs >0.125 mg/L or azithromycin MICs >256 mg/L required follow-up by public health officials. Odds of culture-positive notifications meeting those criteria increased from 2017-2019 (n = 11) to 2022-2024 (n = 94) (odds ratio 8.58 [95% CI 4.81-17.0]). Local acquisition was frequent (78.7%). Isolates with decreased ceftriaxone susceptibility were more common in female and heterosexual patients than were isolates with high-level azithromycin resistance. We identified 9 genomically linked clusters (<15 single-nucleotide polymorphisms), 3 with sizable clonal expansion. Initial test of cure was negative for 81/94 (86.2%) 2022-2024 cases; of the rest, 9 cases had no follow-up visits, 2 were reinfected, and 2 failed initial treatment. Improving follow-up and reporting of treatment failure would strengthen case management protocols. Culture-based diagnostics remain essential to detect antimicrobial resistance, inform surveillance, and curb the rising resistance trend.

Background:Syphilis is increasing worldwide, and secondary syphilis may represent its most infectious stage. Scarce data exist on Treponema pallidum clearance after treatment. We aimed to determine the frequency and load of T. pallidum mucosal shedding, and time to clearance following treatment of secondary syphilis. Methods:Men-who-have-sex-with-men (MSM) and transgender women with secondary syphilis were recruited from Australian clinics between January 27, 2023, and August 19, 2024. Oral, anal or genital lesions were swabbed, and non-lesion samples (blood, oral cavity and anal canal swabs were collected on the day of treatment (baseline). Non-lesion oral cavity and anal canal swabs were repeated 3, 7, 14 and 30 days post-treatment. T. pallidum bacterial load was determined by quantitative PCR. Findings:78 cis-men and one trans-woman, who reported sex with men, were included. At baseline, T. pallidum was detected in the participants' oral cavity, anal canal and blood of 81% (64/79), 70% (55/79) and 24% (19/79), respectively. When detected at oral and anal sites, 22/64 (36%) had oral lesions and 31/55 (59%) had anal lesions, respectively. The median oral and anal bacterial loads decreased significantly from baseline to day 3, [cycle thresholds 35.7-37.7, (1.7-1.2 copies/μL), (p = 0.013), and 30.2-38.2 (3.3-1.0 copies/μL), (p < 0.001), respectively]. T. pallidum cleared from 99% (96/97) of non-lesion, paired samples from 58 participants by day 7, 95% confidence interval (94-100%). Interpretation:During secondary syphilis, most MSM had T. pallidum DNA detected in oral and anal mucosa. Bacterial load dropped markedly 3 days post-treatment and cleared in almost all samples by 7 days. Funding:Australian National Health and Medical Research Council.

Antimicrobial-resistant Neisseria gonorrhoeae poses a serious public health threat. In Australia, N. gonorrhoeae isolates with ceftriaxone MICs >0.125 mg/L or azithromycin MICs >256 mg/L required follow-up by public health officials. Odds of culture-positive notifications meeting those criteria increased from 2017-2019 (n = 11) to 2022-2024 (n = 94) (odds ratio 8.58 [95% CI 4.81-17.0]). Local acquisition was frequent (78.7%). Isolates with decreased ceftriaxone susceptibility were more common in female and heterosexual patients than were isolates with high-level azithromycin resistance. We identified 9 genomically linked clusters (<15 single-nucleotide polymorphisms), 3 with sizable clonal expansion. Initial test of cure was negative for 81/94 (86.2%) 2022-2024 cases; of the rest, 9 cases had no follow-up visits, 2 were reinfected, and 2 failed initial treatment. Improving follow-up and reporting of treatment failure would strengthen case management protocols. Culture-based diagnostics remain essential to detect antimicrobial resistance, inform surveillance, and curb the rising resistance trend.

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.

Congenital syphilis remains a significant public health threat in Australia, warranting national efforts to reduce syphilis incidence overall, focusing on women of reproductive age. To identify priority actions to eliminate congenital syphilis, ASHM convened a national multidisciplinary roundtable with attendance from organisations, colleges, and bodies across the healthcare sector with a focus on Aboriginal and Torres Strait Islander peoples' health, sexual and reproductive health, antenatal health, primary care, pathology, and pharmacy, as well as research institutes and community organisations. This position statement outlines the immediate, short-term and long-term actions identified by roundtable participants to eliminate congenital syphilis in Australia.

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.

To evaluate the acceptability of MyCheck for asymptomatic sexually transmissible infections (STIs) testing. Regular testing for STIs in at-risk populations is recommended by Australian guidelines as many STIs are asymptomatic. Consequently, MyCheck was developed to enhance access by combining a telehealth consultation with direct referral to pathology, avoiding the need for in-person clinic visits. MyCheck was piloted at Sydney Sexual Health Centre (SSHC)—the largest publicly funded urban sexual health clinic in New South Wales—between June 2021 and February 2022. MyCheck integrated telehealth assessment with electronic referrals to over 500 pathology centres and automated result entry into the clinic’s patient management system. Staff initiated MyCheck testing offers to asymptomatic clients without complex care needs. Evaluation was based on clinic data and client surveys. Staff offered MyCheck to 9.8

Background The study describes the capacity of publicly funded sexual health clinics in Australia and explores the challenges they face. Methods We sent a survey to the directors of publicly funded sexual health clinics across Australia between January and March 2024. The survey asked about how their clinics were managing the current clinical demand. Results Twenty-seven of 35 directors of sexual health clinics responded. These 27 clinics offered a median of 35 (IQR: 20-60) bookings each day, but only a median of 10 (IQR: 2-15) walk-in consultations for symptomatic patients. The average proportion of days that clinics were able to see all patients who presented with symptoms was 70.1% (95% CI 55.4, 84.9) during summer versus 75.4% (95% CI 62.2, 88.5) during winter. For patients without symptoms, the corresponding proportions were 53.3% (95% CI 37.9, 68.8) during summer versus 57.7% (95% CI 41.7, 73.7) during winter. If these percentages were adjusted for the number of consultations that the clinic provided, then the corresponding numbers for symptomatic individuals was 51.0% for summer and 65.2% for winter, and for asymptomatic individuals it was 48.1% and 49.8%, respectively. The catchment population of the clinics for each consultation they provided ranged from as low as 3696 to a maximum of 5 million (median 521,077). Conclusions The high proportion of days on which sexual health clinics were not able to see all patients is likely to delay testing and treatment of individuals at high risk of STIs and impede effective STI control.

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.

In 2023, an increased number of urogenital and anorectal infections with Neisseria meningitis serogroup Y (MenY) were reported in New South Wales (NSW). Whole genome sequencing (WGS) found a common sequence type (ST-1466), with limited sequence diversity. Confirmed outbreak cases were NSW residents with a N. meningitidis isolate matching the cluster sequence type; probable cases were NSW residents with MenY isolated from a urogenital or anorectal site from 1 July 2023 without WGS testing. Of the 41 cases, most were men (n = 27), of whom six reported recent contact with women in sex work. Five cases were men who have sex with men and two were women in sex work. Laboratory alerts regarding the outbreak were sent to all Australian jurisdictions through the laboratories in the National Neisseria Network. Two additional states identified urogenital MenY ST-1466 infections detected in late 2023. Genomic analysis showed all MenY ST-1466 sequences were interspersed, indicative of a multi-jurisdictional outbreak. The incidence of these infections remains unknown, due to varied testing and reporting practices both within and across jurisdictions. Isolates causing invasive meningococcal disease (IMD) in Australia are typed, and there has been no MenY ST-1466 IMD recorded in Australia to end of March 2024. Concerns remain regarding the risk of IMD, given the similarity of these sequences with a MenY ST-1466 IMD strain causing a concurrent outbreak in the United States of America.

Background Sydney Sexual Health Centre (SSHC) is the largest sexual health clinic in New South Wales (NSW), servicing clients at high risk of sexually transmissible infections and bloodborne viruses. SSHC piloted a direct-to-pathology pathway that facilitated bloodborne virus/sexually transmissible infection testing at one of the ~500 participating pathology collection centres located across NSW. This qualitative study sought to understand SSHC client and provider perspectives of acceptability of the MyCheck intervention. Methods Semi-structured in-depth interviews were conducted with 11 clients who underwent testing via the MyCheck pathway and eight staff members involved in implementing MyCheck. The seven components of Sekhon’s Theoretical Framework of Acceptability informed this analysis. Results Participants broadly conveyed ‘affective attitude’ toward the MyCheck pathway. The telehealth intervention reduced client ‘burden’ and ‘opportunity cost’ through enabling greater testing convenience at a location suitable to them and provided timely results. Issues of ‘ethicality’ were raised by clients and staff as pathology centre staff were, on a few occasions, regarded as being judgmental of SSHC clients. ‘Intervention coherence’ issues were largely attributed to pathology centre personnel being unfamiliar with the intervention, with billing issues being a recurrent concern. Participants perceived MyCheck as an ‘effective’ testing pathway. SSHC staff were able to offer the intervention with ease through seamless IT integration (‘self-efficacy’). Conclusion The MyCheck intervention was perceived by both SSHC clients and staff as an acceptable bloodborne virus/sexually transmissible infection testing pathway. However, further work is required to address stigma experienced by some clients when attending pathology collection centres.

OBJECTIVES:To estimate notification rates for infectious syphilis in women of reproductive age and congenital syphilis in Australia. STUDY DESIGN:Retrospective cohort study; analysis of national infectious syphilis and enhanced congenital syphilis surveillance data. SETTING, PARTICIPANTS:Women aged 15-44 years diagnosed with infectious syphilis, and babies with congenital syphilis, Australia, 2011-2021. MAIN OUTCOME MEASURES:Numbers and rates of infectious syphilis notifications, by Indigenous status and age group; numbers and rates of congenital syphilis, by Indigenous status of the infant; antenatal care history for mothers of infants born with congenital syphilis. RESULTS:During 2011-2021, 5011 cases of infectious syphilis in women aged 15-44 years were notified. The notification rate for Aboriginal and Torres Strait Islander women rose from 56 (95% confidence interval [CI], 45-65) cases per 100 000 in 2011 to 227 (95% CI, 206-248) cases per 100 000 population in 2021; for non-Indigenous women, it rose from 1.1 (95% CI, 0.8-1.4) to 9.2 (95% CI, 8.4-10.1) cases per 100 000 population. The notification rate was higher for Aboriginal and Torres Strait Islander women than for non-Indigenous women (incidence rate ratio [IRR], 23.1; 95% CI, 19.7-27.1), lower for 15-24- (IRR, 0.7; 95% CI, 0.6-0.9) and 35-44-year-old women (IRR, 0.6; 95% CI, 0.5-0.7) than for 25-34-year-old women, and higher in remote regions than in major cities (IRR, 2.7; 95% CI, 2.2-3.8). During 2011-2021, 74 cases of congenital syphilis were notified, the annual number increasing from six in 2011 to a peak of 17 in 2020; the rate was consistently higher among Aboriginal and Torres Strait Islander infants than among non-Indigenous infants (2021: 38.3 v 2.1 per 100 000 live births). The mothers of 32 infants with congenital syphilis (43%) had not received antenatal care. CONCLUSIONS:The number of infectious syphilis notifications for women of reproductive age increased in Australia during 2011-2021, as did the number of cases of congenital syphilis. To avert congenital syphilis, antenatal screening of pregnant women, followed by prompt treatment for infectious syphilis when diagnosed, needs to be improved.