Syphilis has re-emerged as a significant public health concern in Australia, with rising notification rates among both traditional and non-traditional risk groups. Declared a Communicable Disease Incident of National Significance, syphilis continues to pose a diagnostic challenge due to its myriad of different presentations and ability to mimic other diseases. The recent rise in cases of congenital syphilis is particularly concerning and highlights the urgent need for improvement in syphilis testing in antenatal care. This clinical perspective provides a contemporary and relevant summary of the evolving epidemiology, staging of syphilis infections, interpretation of serological tests, as well as management approaches including partner notification and follow-up testing. We also outline advances in syphilis diagnostics-including nucleic acid amplification tests and point-of-care tests-which have made it much easier to detect syphilis infections early. The recent availability of doxycycline as post-exposure prophylaxis is also discussed, which offers a promising tool to prevent infections and re-infections in at-risk populations, namely men who have sex with men and transgender women. Treatment for syphilis continues to rely primarily on long-acting injectable benzathine benzylpenicillin, with alternative regimens being used increasingly amid a continual global shortage of this formulation of penicillin. Encouragingly, there are early signs that suggest notification rates for syphilis are finally decreasing in some jurisdictions, likely in response to the multitude of interventions implemented as part of the national syphilis response. Physicians in all specialties should remain aware and confident in testing and managing syphilis in order to continue cementing this downward trend.

BackgroundIn January 2023, following a 20-year ban, the New South Wales (NSW) Needle and Syringe Program (NSP) Guidelines permitted NSPs to provide winged infusion sets (‘butterflies’) and larger-volume syringes (‘barrels’) commonly used for injecting methadone liquid intravenously.ApproachThe Kirketon Road Centre (KRC) integrated the distribution of ‘butterflies and barrels’ (referred to as ‘butterfly packs’) into its service delivery in April 2023 and developed resources in collaboration with the Uniting Medically Supervised Injecting Centre (MSIC) and the NSW Users and AIDS Association (NUAA). This case report presents an audit of service delivery and self-reported client outcomes following the introduction of ‘butterfly packs’.OutcomesSince April 2023, KRC has been consistently supplying ‘barrels’ and ‘butterflies’ to clients who inject methadone. The proportion of NSP visits by clients who reported methadone as the last drug injected increased significantly after the program’s introduction (from 2.2 to 4.0 methadone-related attendances per month), and so did the amount of corresponding injecting equipment and verbal education sessions. Among 18 survey respondents, the majority reported improved health or safety since accessing butterfly packs (89%).ConclusionEquipment for intravenous methadone administration can be safely and efficiently distributed by NSP programs. Access to harm reduction services should be based on vulnerability and need, with services tailored accordingly. The policy reversal allowing ‘butterflies and barrels’ and service innovations such as KRC’s program have addressed a longstanding gap, advancing equity in harm reduction for people who inject methadone in NSW.

In 2024, in response to a re-surge in mpox transmission in New South Wales, Australia, Kirketon Road Centre (KRC) partnered with an HIV and LGBTQI+ community organisation, ACON, to conduct outreach vaccination in two sex-on-premises venues (SOPVs), also known as “saunas”. SOPV attendees were approached by an ACON peer worker who offered health education and referral to on-site mpox vaccination (Jynneos®) by a registered nurse. We aim to describe the scope, the acceptability, and the outcomes of mpox vaccination outreach at SOPVs in Sydney, and compare characteristics of people who received mpox vaccination at SOPVs to those who were vaccinated for mpox at a KRC’s fixed-site vaccination clinic. In addition to a descriptive analysis of service records, we matched individual-level records with Australian Immunisation Register (AIR) and ran (comparative) descriptive and multivariate analyses; a subset of people who were matched on AIR was analysed. During the outreach period, KRC administered 639 mpox vaccines at its fixed-site and conducted 22 outreach sessions at SOPVs in collaboration with ACON. These sessions resulted in 840 engagements; 522 individuals were eligible for mpox vaccination, 407 (78

INTRODUCTION:Opioid agonist therapies (OAT) reduce adverse outcomes of illicit opioid use, with individual preferences potentially improving treatment outcomes. We explored preferences for OAT and associated factors in a national sample of people with opioid dependence. METHODS:This cross-sectional study recruited 400 participants (October 2020-April 2021) across Australia (excluding Tasmania) through snowball sampling. Participants completed an interviewer-administered questionnaire on sociodemographic and drug use characteristics. Multivariable logistic regression assessed factors associated with methadone preference (vs. buprenorphine). RESULTS:Among all participants (median age 45, 41% female, 87% ever received OAT), 92% (n = 366) indicated a preference for receiving OAT (vs. not receiving OAT) and 96% of those (n = 352) preferred a particular type of OAT. Among 366 with a stated preference, 61% (n = 216) preferred methadone and 39% (n = 136) preferred buprenorphine. Among those preferring buprenorphine (n = 136), 50% (n = 68) preferred buprenorphine ± naloxone and 50% (n = 68) preferred long-acting injectable buprenorphine. Independent correlates of preferring methadone included past month heroin use (aOR 1.78, 95% CI 1.06-3.00) and non-prescribed pharmaceutical opioid use (aOR 2.23, 95% CI 1.07, 4.95), and any prior receipt of methadone treatment (aOR 6.54, 95% CI 2.66, 17.91). Among those receiving OAT, a higher proportion of people currently receiving buprenorphine preferred their medication (61/66, 92%) compared to methadone recipients (180/235, 77%). DISCUSSION AND CONCLUSIONS:Nearly all participants preferred OAT, mostly reflecting prior experiences, underscoring the need for expanded access to OAT in Australia. Given the multiple stated preferences, OAT options should include a variety of treatment options aligned with patient preferences, including expanded take-home options.

Background Since 2022, clade IIb mpox outbreaks have occurred in non-endemic countries, primarily among men who have sex with men. WHO currently recommends two doses of modified vaccinia Ankara-Bavarian Nordic (MVA-BN) vaccine at least 4 weeks apart for people at risk of infection. Infections in fully vaccinated people have been infrequently reported, and the clinical significance of waning vaccine-induced antibodies is unknown. We aimed to determine whether vaccination was associated with attenuated disease. Methods We conducted an outbreak investigation and retrospective cohort study of people with mpox notified in New South Wales, Australia between June 20 and Nov 20, 2024, using routinely collected data extracted from the statewide surveillance system. As part of routine practice, people with mpox and clinicians were interviewed. People were classified as fully vaccinated when they had received two MVA-BN doses at least 14 days before symptom onset and partially vaccinated when they had received one dose. Risk ratios were calculated by the number of MVA-BN doses for the following clinical outcomes: anogenital lesions (ie, genital, perianal, buttock, or groin lesions or symptoms suggestive of involvement of the rectal or urethral mucosa), extragenital lesions (those present at any other site), systemic symptoms (at least one of the following: fever, lymphadenopathy, myalgia, arthralgia, backache, or headache), and hospitalisation (admission for inpatient management of mpox). A subset of mpox genomes were sequenced including all samples collected during Aug 17–24, 2024, with a monkeypox virus polymerase chain reaction cycle threshold of 25 or lower, and samples from individuals who were deemed to be at risk of clade I monkeypox virus infection. Findings During the study period, 674 people (673 [99%] assigned male at birth and 669 [99%] identified as men; 17 [3%] identified as Aboriginal or Torres Strait Islander) were diagnosed with mpox (excluding one reinfection). The median age was 36 years (IQR 31–44). Vaccination status was ascertained for 663 (98%) of 674 people, with 251 (37%) of 674 being fully vaccinated, 72 (11%) partially vaccinated, and 340 (50%) not vaccinated. In fully vaccinated people, the median time between dose two and symptom onset was 21·8 months (IQR 19·5–23·0). Compared with unvaccinated people, fully vaccinated people were less likely to be hospitalised (risk ratio 0·11 [95% CI 0·03–0·43]), have extragenital lesions (0·45 [0·36–0·56]) or systemic symptoms (0·72 [0·64–0·80]); however, they were more likely to have anogenital lesions (1·11 [1·05–1·18]). Sequencing of 102 (15%) of 674 outbreak cases showed they were all clade IIb. Interpretation A two-dose MVA-BN series continued to protect against extragenital lesions, systemic symptoms, and hospitalisation beyond the point at which antibodies have been found to wane. Funding None.

BACKGROUND:Individual- and structural-level factors place people who inject drugs at excess risk of sexually transmitted infections (STI). We reviewed existing evidence on STI prevalence and testing coverage among this population. METHODS:We conducted searches of peer-reviewed and grey literature for papers or reports published between January 2008 and April 2024. Data were summarised using narrative synthesis, and where appropriate, regional and global estimates weighted by population size of people who inject drugs were generated using random effects meta-analysis. Meta-regressions were undertaken to examine study- and country-level sources of heterogeneity. FINDINGS:Data on STI prevalence and testing coverage were sparse, which precluded meta-analysis except for syphilis prevalence. We estimated global active syphilis prevalence among people who inject drugs as 3.2 % (95 % confidence interval [CI]: 2.3-4.6). There was regional variation, with estimates ranging from 0.1 % (0-0.3) in North America to 7.2 % (3.6-11.7) in Latin America. Based on a small number of studies (n = 12) that stratified estimates by gender, active syphilis prevalence was higher among women (8.1 %, 3.6-13.7) than men (2.3 %, 1.4-3.5). Higher HIV prevalence among people who inject drugs at both study and country level were associated with higher syphilis prevalence. Chlamydia prevalence estimates (n = 22) ranged 0-12.5 %, gonorrhoea prevalence (n = 20) ranged 0-2 %, and past year STI testing uptake (n = 8) ranged 8-62 %. INTERPRETATION:More evidence on STI prevalence and testing uptake among people who inject drugs is urgently needed. Embedding STI diagnosis and treatment services within bloodborne virus programs could be an effective control measure.

BACKGROUND:Injecting drug use following treatment for hepatitis C virus (HCV) may result in reinfection, potentially reversing individual, and population benefits of HCV treatment. The aim of this study was to evaluate the incidence of HCV reinfection following successful direct acting antiviral (DAA) therapy among people with recent injecting drug use. METHODS:This analysis used data from an observational cohort study of people with recent injecting drug use (previous six months) following successful DAA treatment in Australia, Canada, and New Zealand. Participants were either recruited prior to commencing DAA therapy or after a documented sustained virological response (SVR). Participants were assessed three-monthly for HCV reinfection. Reinfection was defined as recurrence of virus distinct from the initial infecting strain or recurrence after confirmed cure at or after 12 weeks post-treatment. Person-time of observation and Cox proportional hazard models were used to calculate reinfection incidence and associated factors. RESULTS:Among 112 participants who contributed follow-up time at risk of reinfection (113 person-years of follow-up time), the median age was 43 years, 34 % were female, and 86 % reported injecting drug use in the month prior to enrolment. Eleven cases of reinfection were observed for an incidence of 9.7/100 person-years (95 % confidence interval [CI], 5.4-17.4) overall, 11.1/100 person-years (95 % CI, 6.1-20.0) among people who reported injecting drugs during follow-up, and 24.3/100 person-years (95 % CI, 7.8-75.3) among those who reported sharing needles/syringes during follow-up. All cases of HCV reinfection occurred among people reporting injecting drug use during the study. CONCLUSIONS:The relatively high incidence of reinfection seen in this study underscores the importance of targeted harm reduction measures and monitoring for HCV reinfections within the first year following successful treatment among people who inject drugs. Additional research into integrated models of care incorporating harm reduction and supporting reducing risk of reinfection and HCV treatment are needed.

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.

BACKGROUND:Unlike other high-income countries that experienced mpox outbreaks in 2022, Australia had low case numbers before a significant resurgence in 2024, with 99 % of cases occurring in males. Vaccine coverage among gay, bisexual, and other men who have sex with men (GBMSM) was estimated at 50 %. We identified drivers and barriers to vaccine uptake and discuss implications for mpox control in Australia. METHODS:The TraX study, established in 2022, was a mixed-method prospective observational study of GBMSM and their sexual partners tracking mpox vaccine uptake through weekly surveys. Two multivariable logistic regression models identified predictors of receiving one and two doses. We analyzed qualitative responses from unvaccinated participants using the Framework Method. RESULTS:A total of 3596 participants were recruited through a waitlist, vaccine hubs, and community networks. In 2024, 1224 responded and were included in this analysis. Among community-recruited participants, 82.8 % had received at least one dose, associated with living in areas where ≥5 % of residents were gay men, living with HIV, recent sexually transmitted infections (STIs), greater COVID-19 vaccine history, non-relationship sex, group sex, international travel, and mpox concern. Among all participants, 83.7 % had completed the second dose, associated with older age and non-relationship sex. In qualitative analysis of 57 unvaccinated participants, most cited low perceived risk based on geography or sexual behavior. Reported barriers included difficulty accessing services, limited vaccine knowledge, and concerns about side effects. CONCLUSIONS:This study found high uptake of the first mpox vaccine dose and a high rate of second dose completion. Most participants made decisions aligned with public health guidance, though some underestimated their risk. With low vaccine coverage and natural immunity, Australia's 2024 mpox outbreak likely reflected insufficient population-level protection. Australia likely entered 2024 with little infection induced immunity because few cases had occurred in 2022-2023, and with incomplete vaccine coverage among people at ongoing risk. Our findings point to practical steps to prevent future outbreaks by increasing vaccination rates, including addressing side-effect concerns, streamlining vaccination, and improving awareness of personal risk factors.

This paper examines: (i) the acceptability of, and behavioural outcomes associated with, take-home fentanyl test strips (FTS), and (ii) support for, and preferences regarding, drug checking services among people who use heroin. Data were obtained from 78 people who had used heroin in the past 6 months, recruited from treatment and harm reduction services in Sydney, Australia in 2020–21. Participants were provided with 10 BTNX Rapid Response™ single-use immunoassay FTS and surveyed 4 weeks later. Among those who completed the follow-up survey (n = 72), 81

BACKGROUND:Opioid dependence is a risk factor for bacterial sexually transmitted infections (STIs). The role of STI screening in opioid agonist treatment (OAT) services has not been evaluated. METHODS:We conducted a retrospective cohort study of all OAT recipients in New South Wales, Australia between 2001 and 2022 (N = 51,549), using linked administrative data. The main outcome was notification for chlamydia, gonorrhoea or infectious syphilis. Negative binomial regression models with generalised estimating equations were used to test whether STI notification rate was higher during periods on OAT. RESULTS:There were 2099 STI notifications among 1635 individuals (3.2 % of the cohort), equivalent to 4.30 (95 % confidence interval [CI]: 4.29-4.31) per 1000 person-years. There were more notifications for chlamydia (2.86 per 1000 person-years; 2.85-2.86), than gonorrhoea (1.30; 1.30-1.31) and syphilis (0.14; 0.14-0.14). Notifications increased over the study period and females experienced higher incidence than males (rate ratio: 1.69, 95 % CI: 1.55-1.84) Compared to periods off OAT, the incidence rate of STI notifications was elevated during the first 28 days of OAT (adjusted incidence rate ratio: 1.48, 95 % CI: 1.17-1.87) and lower during the remainder of time on OAT (0.58; 0.52-0.64). STI notification incidence was also elevated during incarceration (1.78; 1.55-2.06) and among people with meth/amphetamine recorded as a drug of concern (2.18; 1.86-2.55). INTERPRETATION:OAT services are well-positioned to offer STI screening to people with opioid dependence and detect undiagnosed or untreated infections early during treatment. Subsequent testing to identify further, incident infections should be informed by individual risk factors, including sex and meth/amphetamine use.

Background: The human papillomavirus (HPV) vaccine and regular (i.e., every five years) cervical screening are essential to prevent cervical cancer. Australia has high overall coverage of both interventions but little is known about coverage among people who inject drugs. and known barriers to preventive care among this population may extend to cervical cancer control measures. Methods: Data were obtained from the 2023 Illicit Drug Reporting System interviews, in which people who regularly inject drugs participated. The sample was restricted to people with a cervix, with participants aged 25-74 years eligible for the National Cervical Screening Program and participants born after 1980 eligible for HPV vaccination. Age-standardised prevalence ratios were used to compare coverage among this sample to the Australian general population; other results were summarised descriptively. Findings: Among participants eligible for screening (n = 243), most (96.7 %) reported lifetime uptake, while 70.2 % had been screened during the past five years, which was similar to the general population (prevalence ratio [PR]: 1.14,95% confidence interval [CI]: 0.96-1.31). Among those never or overdue for screening (n = 57), one third (31.7 %) were aware that self-sampling is available and barriers to screening varied, with similar numbers reporting personal (e.g., 'I didn't know I needed to'), logistical (e.g., 'I don't have time'), and test-related reasons (e.g., 'the test is uncomfortable/painful'). Among participants eligible for HPV vaccination (n = 99), coverage was 27.2 %, 38 % lower than the general population (PR: 0.62, 95 % CI: 0.39-0.86). Conclusions: Cervical screening coverage among this sample of people who inject drugs was similar to the Australian population. Health promotion messaging that focuses on the availability of self-sampling and the importance of regular screening may improve coverage among those overdue for screening. HPV vaccination was lower than the general population, warranting targeted efforts to offer the vaccine to eligible people who inject drugs.

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.

Background Chlamydia remains the most notified bacterial sexually transmissible infection in Australia with guidelines recommending testing for re-infection at 3 months post treatment. This paper aimed to determine chlamydia retesting and repeat positivity rates within 2–4 months among young women in Australia, and to evaluate what factors increase or decrease the likelihood of retesting. Methods Chlamydia retesting rates among 16–29-year-old women were analysed from Australian Collaboration for Coordinated Enhanced Sentinel Surveillance of sexually transmissible infection and bloodborne virus (ACCESS) sentinel surveillance data (n = 62 sites). Among women with at least one positive test between 1 January 2018 and 31 August 2022, retesting counts and proportions within 2–4 months were calculated. Logistic regression was performed to assess factors associated with retesting within 2–4 months. Results Among 8758 women who were positive before 31 August 2022 to allow time for follow up, 1423 (16.2%) were retested within 2–4 months, of whom 179 (12.6%) tested positive. The odds of retesting within 2–4 months were 25% lower if tested in a coronavirus disease 2019 (COVID-9) pandemic year (2020–2022) (aOR = 0.75; 95% CI 0.59–0.95). Among 9140 women with a positive test before 30 November 2022, 397 (4.3%) were retested too early (within 7 days to 1 month) and 81 (20.4%) of those were positive. Conclusions Chlamydia retesting rates remain low with around a sixth of women retested within 2–4 months in line with guidelines. Re-infection is common with around one in eight retesting positive. An increase in retesting is required to reduce the risk of reproductive complications and onward transmission.

Introduction:The COVID-19 pandemic disproportionally impacted people experiencing homelessness, including people sleeping rough, people in temporary accommodation and those living in boarding houses. This paper reports on intersectoral responses across six health and social care agencies in Inner Sydney, New South Wales, Australia. Prior to the pandemic the six agencies had established an Intersectoral Homelessness Health Strategy (IHHS), in recognition of the need for intersectoral collaboration to address the complex health needs of people experiencing homelessness.Description:The governance structure of the IHHS provided a platform for several innovative intersectoral responses to the pandemic. A realist informed framework was used to select, describe, and analyse case studies of intersectoral collaboration.Discussion:The resultant six critical success factors (trust, shared ways of working, agile collaboration, communication mechanisms, authorising environment, and sustained momentum), align with the existing literature that explores effective intersectoral collaboration in complex health or social care settings. This paper goes further by describing intersectoral collaboration 'in action', setting a strong foundation for future collaborative initiatives.Conclusion:While there is no single right approach to undertaking intersectoral collaboration, which is highly context specific, the six critical success factors identified could be applied to other health issues where dynamic collaboration and integration of healthcare is needed.