BACKGROUND:Modern assays for the detection of Chlamydia trachomatis (CT) rely on nucleic acid amplification testing (NAAT) of DNA or ribosomal RNA. However, it is also known that both viable ("living") and non-viable ("dead") CT can be detected by NAAT. Multiple laboratory techniques to measure CT viability have emerged. METHODS:We searched PubMed, EMBASE, Scopus, and Dimensions as well as conference abstracts for entries between January 2000 and May 2023. We included any studies that measured CT viability among NAAT-positive samples. Viability assays include enhanced cell culture, direct fluorescent antibody (DFA), messenger RNA (mRNA) detection via digital droplet polymerase chain reaction (PCR, ddPCR), viability PCR (V-PCR), and real-time PCR measuring RNA-to-DNA ratio (RDR) (eg, InSignia®). A meta-analysis was performed on the proportions of non-viable CT by anatomical site. RESULTS:We screened 31 342 records and included 16 studies in the analysis. The pooled proportions of non-viable CT by site were: 33% (95% confidence interval [CI]: 19%-47%) in rectal swabs (8 studies), 17% (95% CI: 7%-27%) in cervical swabs (6 studies), 15% (95% CI: 6%-25%) in vaginal swabs (6 studies), and 11% (95% CI: 9%-17%) in urine/urethral swabs (2 studies). CONCLUSIONS:All included studies found that a proportion of NAAT-detected CT is non-viable. The findings have far-reaching implications for screening programs and studies evaluating new STI tests and antimicrobial regimens.

Sexual health has always been a social matter. While the science of disease transmission remains a focus for public health stakeholders, for social scientists, the sociality of infections, both enduring and emerging, remains central. That is, friendships and relationships are core to health, risk and illness. Yet, there has been virtually no work on how friendships and their varying contours are interplaying with (increasingly) antibiotic resistant STIs. Drawing on 49 interviews with sexuality and/or gender diverse people in Australia, we argue that the sociality of sexual health is central to the development of antibiotic resistance. Our analysis highlights the importance of friends to this, including de(stigmatising) STIs, deployment of humour to regularise important meanings, striking a balance between autonomy and mutuality, and role of friends as sexual health educators. These hitherto under-recognised relational dimensions of sexual health are critical to working with communities in addressing the rise of resistant STIs.

Often, research takes place once a health issue is already at 'crisis' point. However, health professionals and populations can have different understandings of 'urgency'. At present, health authorities, scientists and other medical professionals are increasingly concerned about escalating antimicrobial resistance (AMR) in the context of STIs. Clinicians worry about Neisseria gonorrhoeae becoming progressively resistant to last-line treatment, as well as the very limited treatment options for resistant Mycoplasma genitalium. This paper explores how states of 'urgency' and 'crisis' are socially produced within people's everyday contexts. Drawing on semi-structured interviews with 49 gay and bisexual cisgender men and trans and gender diverse people, we explore contemporary GBTQ+ (gay, bisexual, trans and queer+) understandings of antibiotic-resistant STIs and people's perceptions of urgency. Findings reveal that urgency is shaped by pre-existing understandings of resistance, spatial-temporal dimensions, histories and experiences of pleasure. We conceptualise this as a relation of mediated urgency, which centres the multidimensional production and reception of crisis rather than making a priori assumptions that 'crisis' has already arrived. This theoretically and empirically recentres the everyday, relational and contextualised manifestations of how people relate to 'crisis', critical to working with communities to address it/them.

Antimicrobial resistance (AMR) in Neisseria gonorrhoeae poses a pressing public health threat. Current surveillance programs via antimicrobial susceptibility testing (AST) depend on successfully cultivating the organism via bacterial culture. However, AST is more challenging in extragenital sites and in remote clinical settings where there is a delay between sample collection and testing. This study evaluated whether an enhanced specimen transport system involving direct plating of samples onto selective agar with carbon dioxide enrichment (Bio-BagTM Type C, Becton Dickinson) improved N. gonorrhoeae recoverability compared to the standard method of rayon swabs in Amies gel (TransystemTM, Copan Diagnostics). Men with urethral or rectal gonorrhoea confirmed by nucleic acid amplification testing were consecutively recruited from an urban Sydney clinic. Among 33 rectal samples, enhanced transport yielded a slightly higher culture positivity rate (72.7%) than the standard method (69.7%), though this difference was not statistically significant (p = 0.790). Notably, rectal specimens arriving at the laboratory within five hours had significantly higher culture yields (100%) than those with longer transport times (61.5%; p = 0.049). Future studies of the impact of enhanced transport in rural and remote settings are critical to enhance AMR surveillance.

Infrastructures fundamentally shape sexual health, but their gaps and failings often only come into view during moments of crisis. Antimicrobial resistance (AMR) is a looming microbiological and global societal crisis, and one that is posing increasing challenges and risks for medical practice and public health alike. In sexual health, concerns have been raised about growing resistance in Neisseria gonorrhoeae and the less well-known Mycoplasma genitalium. In this article, we examine contemporary sexual health infrastructures and their adequacy in the context of rising antibiotic-resistant STIs. To do this, we draw on 49 semi-structured interviews with cisgender gay and bisexual men, and trans and gender diverse people (GBTQ+) in Australia. Findings reveal that growing costs, a lack of access to sexual healthcare services, complexities in navigating these services and lengthy wait times all present challenges to optimal care, and that growing resistance may further strain these socio-material-temporal arrangements. We argue that greater investment in sexual health infrastructures will increase capacity to accommodate complex lives, multiple subjectivities and ensure easier access to services. In the context of resistance, this frames sexual health infrastructures beyond ideas of simply 'coping with crisis' to being able to care well for people within a shifting environment.

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.

BACKGROUND:The decentralisation of hepatitis C virus (HCV) point-of-care testing is a core part of Australia's strategy to meet WHO elimination targets. However, little is known about the experiences of providers implementing these interventions and thus what is needed to improve integration. The study aim was to understand operator experiences, including the challenges and enablers, of implementing point-of-care testing as part of a National Point-of-Care Testing Program. METHODS:Providers who were enrolled in the National Program and qualified to perform point-of-care testing were invited to participate in semi-structured qualitative interviews between April and August 2023. Data were analysed according to iterative categorisation and themes were organised according to Service delivery, Resources, and Governance-elements of the Health Systems Dynamics Framework. RESULTS:Of the 31 participants, most were from New South Wales (n = 17), were practicing clinicians (n = 18), worked in outpatient or community health clinics (n = 21), and had no previous experience using a molecular point-of-care testing device (n = 24). Many participants struggled to deliver HCV testing and treatment according to national HCV management guidelines. Some participants avoided using the point-of-care testing device altogether. Others found it challenging to manage the administrative load of delivering the National Program, including planning outreach and following-up clients. These challenges were exacerbated by workforce shortages, difficult-to-navigate IT systems, and a lack of specific implementation advice from Program leadership. CONCLUSIONS:This study illustrates several challenges to and enablers of adopting a decentralised HCV point-of-care testing program, highlighting the need to further explore what providers require to effectively implement these interventions.

Few studies have explored community experiences of our increasingly resistant bacterial landscape, and, in the sphere of sexually transmissible infections (STIs) and antimicrobial resistance, there is even greater absence of community-centred research. This is despite a growth in STI transmission worldwide, which, alongside accelerated resistance, will disproportionately affect GBTQ+ (gay, bisexual, trans, queer+) populations. In this article, drawing on semi-structured interviews conducted in 2024 with 49 cisgender and trans gay and bisexual men, trans women and gender diverse people, we explore contemporary GBTQ+ safe sex practices as they relate to the growing threat of antibiotic resistant STIs in Australia. Key themes identified were the pharmaceutical turn in safe sex practices, the tensions this produced, the complexities of condom use, and the influence of biographies on safe sex practices. We illustrate how the turn toward pharmaceutical solutions has reconfigured and continues to reconfigure safe sex, giving rise to pleasures that were hitherto 'off-limits' to many. However, escalating antibiotic resistance threatens to again alter community practices and relationships to STI prevention measures. Drawing on Barad, we develop these themes to theoretically conceptualise safe sex as not fixed, but as an entanglement that is relationally and iteratively (re)configured through the connections between objects, subjectivities, practices, temporalities, and the human-microbial dynamics entailed therein. Findings suggest public health and clinical communication about resistance should speak to population concerns about gut health, resistance vis-à-vis Doxy-PEP, changing definitions of safe sex, and the importance of pleasure.

OBJECTIVES:To quantify the amount of unnecessary antibiotics, in particular ceftriaxone, given to men who have sex with men (MSM) with anogenital symptoms as part of presumptive management in an urban sexual health clinic and examine factors associated with unnecessary ceftriaxone. METHODS:This is a retrospective cross-sectional analysis of electronic records from all visits involving MSM reporting symptoms of bacterial sexually transmitted infection (STI) and who received presumptive antibiotics at Sydney Sexual Health Centre. The following variables were extracted: demographic and sexual behaviour data, presenting symptoms, prior STI diagnoses, use of anoscopy, use of point-of-care microscopy, prescriptions of antibiotics and subsequent nucleic acid amplification testing (NAAT) results for chlamydia and gonorrhoea in all anatomical sites (urethra, pharynx and rectum). We defined unnecessary antibiotic as an agent prescribed to treat an STI organism that was subsequently not detected. RESULTS:Among 1061 visits in this analysis, 41.8% yielded negative NAAT results for both chlamydia and gonorrhoea in all anatomical sites. There were 44.3% of visits which had positive gonorrhoea NAAT result in at least one anatomical site. There were 187 courses of ceftriaxone prescribed in patients who tested negative for gonorrhoea in all anatomical sites and therefore were unnecessary. Unnecessary ceftriaxone prescribing occurred in 50.2% of visits with anorectal symptoms, 19.6% of scrotal symptoms and 7.3% of urethral symptoms. Microscopy was associated with significantly less unnecessary ceftriaxone in urethral but not anorectal or scrotal presentations. In multivariable analysis, the following factors were associated with a higher likelihood of unnecessary ceftriaxone use: anorectal symptoms, scrotal symptoms, gonorrhoea in the preceding year, contact of a bacterial STI and living with HIV. CONCLUSIONS:This study highlights the significant amount of unnecessary ceftriaxone used for STI symptoms in MSM. A new pathway incorporating rapid point-of-care molecular testing in symptomatic patients may improve the precision of antibiotic prescribing and reduce unnecessary use.

IntroductionProgress toward hepatitis C virus (HCV) elimination is impeded by low testing and treatment due to the current diagnostic pathway requiring multiple visits leading to loss to follow-up. Point-of-care testing technologies capable of detecting current HCV infection in one hour are a 'game-changer.' These tests enable diagnosis and treatment in a single visit, overcoming the barrier of multiple visits that frequently leads to loss to follow-up. Combining point-of-care HCV antibody and RNA tests should improve cost-effectiveness, patient/provider acceptability, and testing efficiency. However, implementing HCV point-of-care testing programs at scale requires multiple considerations.Areas coveredThis commentary explores the need for point-of-care HCV tests, diagnostic strategies to improve HCV testing, key considerations for implementing point-of-care HCV testing programs, and remaining challenges for point-of-care testing (including operator training, quality management, connectivity and reporting systems, regulatory approval processes, and the need for more efficient tests).Expert OpinionIt is exciting that single-visit testing, diagnosis, and treatment for HCV infection have been achieved. Innovations afforded through COVID-19 should facilitate the accelerated development of low-cost, rapid, and accurate tests to improve HCV testing. The next challenge will be to address barriers and facilitators for implementing point-of-care testing to deliver them at scale.

In this article, we examine the current management of sexually transmitted infections (STIs), in the context of rising antimicrobial resistance (AMR), through the lens of 'treatment cultures'. Prevailing treatment cultures-including the prominence of syndromic care for STIs-foster certain possibilities and foreclose others, with important consequences for countering AMR. Drawing on qualitative interviews with STI professionals, experts and industry representatives, we unpack these stakeholders' accounts of STI treatment cultures, drawing out the importance of socio-historical (i.e. taboo and stigma), political-economic (i.e. perceptions of significance, profit-making and prioritisation) and subjective (i.e. patient contexts and reflexivity) dimensions therein. In developing this critical account of how treatment cultures are formed, reproduced and indeed resisted, we reveal how such discourses and practices render the reining in of AMR and shifting antibiotic use difficult, and yet, how productive engagement remains key to any proposed solutions. As such, the article contributes to our understanding of AMR as a highly diversified field, through our exploration of the bio-social dimensions of resistance as they relate to the case of STIs.

IntroductionSimplified hepatitis C virus (HCV) diagnostic strategies have the potential to improve HCV diagnoses and treatment. We aimed to investigate the impact of simplified HCV diagnostic strategies on HCV incidence and its effect on HCV diagnosis and treatment among men who have sex with men (MSM) regardless of HIV status and use of HIV pre-exposure prophylaxis (PrEP) in Taiwan.MethodsA compartmental deterministic model was developed to describe the natural history of HCV disease progression, the HCV care cascade and the HIV status and PrEP using among MSM. The model was calibrated to available data for HCV and HIV epidemiology and population demographics in Taiwan. We simulated the epidemic from 2004 and projected the impact of simplified testing strategies on the HCV epidemic among MSM over 2022-2030.ResultsUnder the current testing approach in Taiwan, total HCV incidence would increase to 12.6 per 1000 person-years among MSM by 2030. Single-visit point-of-care RNA testing had the largest impact on reducing the number of new HCV infections over 2022-2030, with a 31.1% reduction (interquartile range: 24.9%-32.8%). By 2030, single-visit point-of-care HCV testing improved HCV diagnosis to 90.9%, HCV treatment to 87.7% and HCV cure to 81.5% among MSM living with HCV. Compared to status quo, prioritized simplified HCV testing for PrEP users and MSM living with diagnosed HIV had considerable impact on the broader HCV epidemic among MSM. A sensitivity analysis suggests that reinfection risk would have a large impact on the effectiveness of each point-of-care testing scenario.ConclusionsSimplified HCV diagnostic strategies could control the ongoing HCV epidemic and improve HCV testing and treatment among Taiwanese MSM. Single-visit point-of-care RNA testing would result in large reductions in HCV incidence and prevalence among MSM. Efficient risk-reduction strategies will need to be implemented alongside point-of-care testing to achieve HCV elimination among MSM in Taiwan.

Antimicrobial resistance (AMR) is recognised as one of the greatest scientific challenges of the 21st century, disproportionately affecting people living in low- and middle-income countries. With bacterial pathogens becoming increasingly resistant to antibiotics, there is an urgent need for innovative approaches to combat this growing threat. The World Health Organization has recognised this need and prioritised further research to enhance diagnostics, surveillance and our understanding the epidemiology and drivers of AMR. The Industrial Transformation Research Hub to Combat AMR, or the AMR Hub, is an Australian collaborative private–public research partnership involving over 20 organisations. It aims to foster multidisciplinary collaborations across sectors and develop wholistic solutions that address barriers to the commercialisation of tools to minimise the risks of AMR. The AMR Hub’s research is focusing on sexually transmitted infections, which are increasingly resistant to antibiotics and have few alternative candidates in the pipeline. Investigators are together developing novel diagnostics, optimising treatment, identifying tools to detect active bacterial infections, and engaging stakeholders to optimise AMR innovation. Through a multidisciplinary ecosystem across sectors, the AMR Hub seeks to fast-track the development of adaptable technologies, new antibiotics and stewardship innovations for prevention, while also addressing societal, economic and commercial aspects of AMR solutions.

Abstract Background There exist multiple regulatory layers for point-of-care (POC) testing to be implemented within Australia. This qualitative analysis sought to understand the pre-market barriers and facilitators to scale-up infectious diseases POC testing in primary care settings at the national level. Methods Key informant interviews were undertaken with people (n = 30) working in high- level positions relevant to infectious diseases POC testing in Australia. Participants were recruited from federal and state health departments, industry, and nongovernment national peak bodies. The Unitaid scalability framework informed this analysis to understand barriers and enablers to creating access conditions and establishing country readiness for market access of POC tests. Results Participants identified regulatory frameworks as significant barriers to market access. National strategies and advocacy were viewed as potential enablers to establishing country readiness. It was recommended that the national system for universal health care should fund infectious disease POC tests to ensure financial sustainability, though the existing pathology infrastructure was regarded as a likely inhibitor. Conclusions Current regulatory frameworks inhibit market access for infectious disease POC testing devices for use in the primary care setting. National advocacy is urgently needed to gain government support and align national policies with regulatory frameworks.

The stage is set for a new era of precariousness in modern medicine, driven by the increasing failure of a key pharmaceutical pillar—antimicrobials. In the context of sexually transmitted infections (STIs), the rise of antimicrobial resistance is introducing urgent questions around what might constitute “best practice” in a rapidly evolving scene, including the value of asymptomatic screening (test and treat), and the consequent downstream collateral damage emerging from over-use of our diminishingly effective antimicrobial resources. Drawing on interviews with clinicians, experts, and industry representatives, we examine resistance as a site of emerging and co-constitutive moral, temporal, and economic dilemmas. Such dilemmas, as illustrated in participants’ accounts, involve complexities regarding prioritization between competing health demands; doing good work while meeting business requirements; considering trade-offs between visibility and amplifying the problem; difficulties balancing presents and futures; reconciling divergent clinical opinions and expertise; and managing patient subjectivities, while considering the implications of clinical practices for resistance. Importantly, centering dilemmas in context of antibiotic-resistant STIs open greater theoretical scope to consider the challenging spaces that key actors such as clinicians and decision-makers occupy, as they attempt to curb resistance while caring for individuals and the community.