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Non-consensual removal of condoms, colloquially referred to as 'stealthing', is the removal of a condom during sex by a sexual partner when consent has been given for sex with a condom only. We conducted a cross-sectional survey to determine how commonly women and men who have sex with men (MSM) attending Melbourne Sexual Health Centre had experienced stealthing, and analysed situational factors associated with the event. Responses were linked to demographic information extracted from patient files. 1189 of 2883 women (41.2%), and 1063 of 3439 MSM (30.9%) attending the clinic during the study period completed the survey. Thirty-two percent of women (95% CI: 29%,35%) and 19% of MSM (95% CI: 17%,22%) reported having ever experienced stealthing. Women who had been stealthed were more likely to be a current sex worker (Adjusted Odds Ratio [AOR] 2.87, 95% CI: 2.01,4.11, p <0.001). MSM who had experienced stealthing were more likely to report anxiety or depression (AOR 2.13, 95% CI: 1.25,3.60, p = 0.005). Both female and male participants who had experienced stealthing were three times less likely to consider it to be sexual assault than participants who had not experienced it (OR 0.29, 95% CI: 0.22,0.4 and OR 0.31, 95% CI: 0.21,0.45 respectively). A high proportion of women and MSM attending a sexual health service reported having experienced stealthing. While further investigation is needed into the prevalence of stealthing in the general community, clinicians should be aware of this practice and consider integrating this question into their sexual health consultation. Understanding situational factors would assist in the development of preventive strategies, particularly female sex workers and MSM.

The aim of this study was to determine the risk factors for HIV infection and the incidence in men who have sex with men (MSM). It is important to identify subgroups of MSM in which preventive interventions such as pre-exposure prophylaxis (PrEP) offered at the time of their last negative test would be considered cost-effective. We conducted a retrospective cohort study of MSM attending Melbourne Sexual Health Centre (MSHC) during 2007-2013 with at least two HIV tests within 12 months of each other. Demographic characteristics, sexual and other behaviours, and bacterial sexually transmitted infection (STI) diagnoses were extracted from the date of the last negative HIV test. HIV incidence rate (IR) per 100 person-years for each risk factor was calculated. Of the 13907 MSM who attended MSHC, 5256 MSM had at least two HIV tests and were eligible, contributing 6391 person-years follow-up. 81 new HIV diagnoses were identified within 12 months of an HIV negative test with an incidence of 1.3 (95% CI: 1.0-1.6) per 100 person-years. Significant associations with subsequent HIV infection were: rectal gonorrhea (HIV IR: 3.4 95% CI: 2.1-5.2), rectal chlamydia (HIV IR: 2.6 95% CI: 1.7-3.7), inconsistent condom use (HIV IR: 2.1 95% CI: 1.6-2.7), use of post-exposure prophylaxis (HIV IR: 2.3 95% CI: 1.7-3.1), and injecting drug use (HIV IR: 8.5 95% CI: 3.4-17.5). The incidence of HIV was above 2.0% in subgroups of MSM with specific characteristics at the last HIV negative test. PrEP is considered cost effective at this incidence and could potentially be used along with other preventive interventions for these individuals in more than half of the population.

Human papillomavirus (HPV)-associated oropharyngeal squamous cell carcinoma is becoming more common. We examined prevalence and risk factors for oral HPV among men who have sex with men (MSM) and compared sampling and transport methods. In 2010, 500 MSM (249 HIV-positive) attending Melbourne Sexual Health Centre answered a questionnaire, swabbed their mouth and throat and collected a gargled oral rinse sample. Half the oral rinse was transported absorbed in a tampon (to enable postage). HPV was detected by polymerase chain reaction, and genotyped by Roche Linear Array®. Men with HPV 16 or 18 were retested after six months. Any HPV genotype was detected in 19% (95% confidence intervals (CI) 15-25%) of HIV-infected men and 7% (95% CI 4-11%) of HIV-negative men (p<0.001), and HPV 16 was detected in 4.4% (95% CI 2-8%) of HIV-infected men and 0.8% (0.1-2.8%) of HIV-negative men. Oral HPV was associated with: current smoking (adjusted odds ratio (aOR) 2.2 (95%CI: 1.2-3.9)), time since tooth-brushing (aOR per hour 0.87, 95%CI: 0.8-0.96) and number of lifetime tongue-kissing partners aOR 3.2 95%CI: (1.2-8.4) for 26-100 partners and 4.9 95%CI: (1.9-12.5) for>100 partners. Lifetime oral-penile sex partner numbers were significantly associated in a separate model: aOR 2.8(1.2-6.3) for 26-100 partners and 3.2(1.4-7.2) for>100 partners. HPV 16 and 18 persisted in 10 of 12 men after a median six months. Sensitivities of sampling methods compared to all methods combined were: oral rinse 97%, tampon-absorbed oral rinse 69%, swab 32%. Oral HPV was associated with HIV infection, smoking, recent tooth-brushing, and more lifetime tongue-kissing and oral sex partners. The liquid oral rinse sample was more sensitive than a tampon-absorbed oral rinse or a self-collected swab.

Human papillomavirus (HPV) is a causative agent in oropharyngeal squamous cell carcinoma. The natural history of oral HPV in HIV-positive men who have sex with men (MSM) is unclear. Detection of oral human papillomavirus in 173 HIV-positive MSM using oral rinse samples 3 years apart was investigated. HPV DNA was detected by polymerase chain reaction, and genotyped by Roche Linear Array. Of 173 men tested in 2010, 30 had at least one HPV genotype (17%, 95% CI: 12-23), 15 at least one hr-HPV (9%, 95% CI: 5-14) and 8 had HPV 16 (5%, 95% CI: 2-9) detected. In 2013, 33 had at least one HPV genotype (19%, 95% CI: 14-26), 20 had at least one hr-HPV (12%, 95% CI: 7-17) and 7 had HPV 16 (4%, 95% CI: 2-8) detected. Of 30 men at baseline (2010) with any HPV detected, 14 (47%, 95% CI: 28-66) had at least one persistent genotype. Of the 15 men in 2010 with high risk (hr-) HPV, 6 men (40%, 95% CI: 16-68) had at least one persistent hr-HPV genotype. The incidence rate of detection of at least one new HPV genotype was 4.8 per 100 person years (95% CI: 3.1-7.0), of at least one hr-HPV genotype was 3.2 per 100 person years (95% CI: 1.8-5.1) and of HPV 16 was 0.8 per 100 person years (95% CI: 0.2-2.0). The clearance rate was 14.9 per 100 person years (95% CI: 8.2-24.2) for any HPV, 18.2 per 100 person years (95% CI: 8.2-32.7) for hr-HPV and 17.4 per 100 person years (95% CI: 5.0-38.8) for HPV-16. Persistent HPV detection was associated with duration of HIV (OR 1.13 (per additional year), 95% CI: 1.00-1.26) and tonsillectomy (OR 8.17, 95% CI: 1.30-51.40). The same oral HPV genotype was detected again after 3 years in nearly half of HIV-positive men who have sex with men.

BackgroundAustralia provided free quadrivalent human papillomavirus vaccines to 12–18-year-old girls and women aged ≤26 years from mid-2007 until the end of 2009. After this time, only girls aged 12–13 years had access to free vaccines.MethodsBefore and after the study, of the proportion of new patients attending Melbourne Sexual Health Centre from mid-2004 to mid-2011, diagnosed with genital warts (GW) by risk group.ResultsFrom July 2004 to June 2011, 52 454 new patients were seen at Melbourne Sexual Health Centre and 5021 (9.6%, 95% CI 9.3% to 9.8%) were diagnosed with GW. From July 2004 to June 2007, the proportions with GW either increased or did not change in all groups. Comparing the two 12-month periods of 2007/2008 and 2010/2011, GW declined in women under 21 years from 18.6% to 1.9% and in heterosexual men under 21 years from 22.9% to 2.9%. The ORs per year for diagnosis of GW adjusted for number of sexual partners from July 2007 until June 2011 in women and heterosexual men <21 years were 0.44 (95% CI 0.32 to 0.58) and 0.42 (95% CI 0.31 to 0.60), respectively. There was no significant change in GW in women ≥30 years (OR 0.97, 95% CI 0.84 to 1.12), heterosexual men ≥30 years (OR 0.97, 95% CI 0.89 to 1.06) or in homosexual men (OR 0.95, 95% CI 0.85 to 1.07).ConclusionThe dramatic decline and near disappearance of GW in women and men under 21 years of age, 4 years after commencing this programme, suggest that the basic reproductive rate has fallen below one.

Background. In the Strategic Timing of Antiretroviral Treatment (START) study, immediate combination antiretroviral therapy (cART) initiation reduced cancer risk by 64%. We hypothesized that risk reduction was higher for infection-related cancer and determined by differences in CD4 cell counts and human immunodeficiency virus (HIV) RNA between the study arms. Methods. Incident malignancies in START were categorized into infection-related and infection-unrelated cancer. We used Cox models to assess factors associated with both cancer categories. We used sequential adjustment for baseline covariates, cancer risk factors, and HIV-specific variables to investigate potential mediators of cancer risk reduction with immediate cART. Results. There were 14 cancers among persons randomized to immediate cART (6 infection-related and 8 infection-unrelated) and 39 cancers in the deferred arm (23 infection-related and 16 infection-unrelated); hazard ratios of immediate vs deferred cART initiation were 0.26 (95% confidence interval [CI], .11-.64) for infection-related and 0.49 (95% CI, .21-1.15) for infection-unrelated cancer. Independent predictors of infection-related cancer were older age, higher body mass index, low- to middle-income region, HIV RNA, and baseline CD8 cell count. Older age and baseline CD8 cell count were independent predictors of infection-unrelated cancer. Adjustment for latest HIV RNA level had little impact on the protective effect of immediate cART on infection-related cancer. Adjustment for latest HIV RNA level, but not for CD4 cell count or cancer risk factors, attenuated the effect of immediate cART on infection-unrelated cancer. Conclusions. Immediate cART initiation significantly reduces risk of cancer. Although limited by small sample size, this benefit does not appear to be solely attributable to HIV RNA suppression and may be also mediated by other mechanisms.

Computer assisted self interviewing (CASI) has been used at the Melbourne Sexual Health Centre (MSHC) since 2008 for obtaining sexual history and identifying patients' risk factors for sexually transmitted infections (STIs). We aimed to evaluate the impact of CASI operating at MSHC. The proportion of patients who decline to answer questions using CASI was determined. We then compared consultation times and STI-testing rates during comparable CASI and non-CASI operating periods. Patients and staff completed anonymous questionnaires about their experience with CASI. 14,190 patients completed CASI during the audit period. Men were more likely than women to decline questions about the number of partners they had of the opposite sex (4.4% v 3.6%, p=0.05) and same sex (8.9% v 0%, p<0.001). One third (34%) of HIV-positive men declined the number of partners they had and 11-17% declined questions about condom use. Women were more likely than men to decline to answer questions about condom use (2.9% v 2.3%, p=0.05). There was no difference in the mean consultation times during CASI and non-CASI operating periods (p≥0.17). Only the proportion of women tested for chlamydia differed between the CASI and non-CASI period (84% v 88% respectively, p<0.01). 267 patients completed the survey about CASI. Most (72% men and 69% women) were comfortable using the computer and reported that all their answers were accurate (76% men and 71% women). Half preferred CASI but 18% would have preferred a clinician to have asked the questions. 39 clinicians completed the staff survey. Clinicians felt that for some STI risk factors (range 11%-44%), face-to-face questioning was more accurate than CASI. Only 5% were unsatisfied with CASI. We have demonstrated that CASI is acceptable to both patients and clinicians in a sexual health setting and does not adversely affect various measures of clinical output.

Background. We evaluated the impact of extended azithromycin (1.5g over 5 days) on selection of macrolide resistance and microbiological cure in men with Mycoplasma genitalium urethritis during 2013–2015 and compared this to cases treated with azithromycin 1g in 2012–2013. Methods. Microbiological cure was determined for men with M. genitalium urethritis treated with azithromycin 1.5g using quantitative polymerase chain reaction specific for M. genitalium DNA on samples 14–100 days post-treatment. Pre- and post-treatment macrolide resistance mutations were detected by sequencing the 23 S gene. Results. There was no difference in proportions with microbiological cure between azithromycin 1.5g and 1g: 62/106 (58%; 95% confidence interval [CI], 49%, 68%) and 56/107 (52%; 95%CI 42–62%), P = .34, respectively. Also, there was no difference in the proportion of wild-type 23 S rRNA (presumed macrolide sensitive) infections cured after 1.5g and azithromycin 1g: 28/34 (82%; 95%CI 65–92%) and 49/60 (82%; 95%CI 70–90%), P=1.0, respectively. There was no difference between 1.5g and 1g in the proportions of wild-type infections with post-treatment resistance mutations: 4/34 (12%; 95%CI 3–27%) and 11/60 (18%; 95%CI 10–30%), respectively, P = .40. Pre-treatment resistance was present in 51/98 (52%; 95%CI 42–62%) cases in 2013–2015 compared to 47/107 (44%; 95%CI 34–54%) in 2012–2013, P = .25. Conclusions. Extended azithromycin 1.5g was no more effective than a single 1g dose at achieving cure of M. genitalium urethritis and importantly did not reduce the selection of macrolide resistance. Nonmacrolide and new approaches for the treatment of M. genitalium urethritis are required.

BACKGROUNDWe report clinical characteristics of proctitis caused solely by Mycoplasma genitalium (MG) compared with chlamydia and gonococcus. We determined the proportions cured with first-line (azithromycin) and second-line antimicrobials (moxifloxacin, pristinamycin). METHODSA total of 166 patients attending Melbourne Sexual Health Centre from 2012 to 2016 with symptoms of proctitis were tested for MG, Chlamydia trachomatis, and Neisseria gonorrhoeae. Demographic characteristics, sexual behaviors, clinical symptoms, and signs were recorded. Multinomial multivariable logistic regression was used to test for significant differences in symptoms and signs for the pathogens detected. RESULTSSeventeen percent of men had MG (95% confidence interval, 12–24), 21% had chlamydia (15–27), and 40% had gonococcal monoinfection (32–48), whereas 22% had MG coinfection (16–29). Relative to men with MG monoinfection, those with chlamydial monoinfection reported more anal pain (adjusted prevalence odds ratio (aPOR), 4.68 [1.41–14.19]), whereas men with gonococcal monoinfection reported more anal pain (aPOR, 6.75 [2.21–20.55]) and tenesmus (aPOR, 15.44 [1.62–146.90]), but less anal itch (aPOR, 0.32 [0.11–0.93]). The microbiological cure for MG using azithromycin was low at 35% (22–50), whereas moxifloxacin subsequently cured 92% (64–100) and pristinamycin cured 79% (54–94) of infections. CONCLUSIONSM. genitalium was almost as common as chlamydia in men presenting to a sexual health center with symptoms of proctitis. Men with anorectal MG monoinfection were less likely to have symptoms and signs compared with those with chlamydia or gonococcus monoinfection. Cure for men with symptomatic anorectal MG by azithromycin was low. We suggest routine testing for MG in cases of proctitis, with test of cure after treatment being essential.

Background We aimed to determine the incidence of Hepatitis C (HCV) infection among HIV-infected men who have sex with men (MSM) attending a Sexual Health Centre. Methods A retrospective cohort study was carried out among HIV-infected MSM seen at least once between February 2002 and March 2010. The analysis was restricted to MSM who had had a negative HCV antibody test at least 6 months after their diagnosis for HIV. Duration of follow up was taken from the date of HIV diagnosis to the first positive or last negative HCV antibody test. Results During the time 1445 HIV-infected men attended the clinic of whom 1065 (74%) were MSM. Of these, 869 (82%) were tested for HCV at any time after HIV diagnosis. Of these 869, 69% (620) tested HCV negative at least 6 months after their HIV diagnosis. These 620 men had a mean age of 34 years (range 17-72) at HIV diagnosis and a total of 4,359 person years (PY) of follow up. There were 40 incident cases of HCV, of which 16 were in injecting drug users (IDU) and 24 in non-IDU. The overall incidence of HCV among HIV-infected MSM was 0.9/100 PY (95% CI 0.6-1.2). The incidence among HIV-infected IDU was 4.7/100 PY (95% CI 2.7-7.5) while the incidence among HIV-infected non-IDU was 0.6/100 PY (95% CI 0.4-0.8) (hazard ratio of 8.7 and 95% CI 4.6-16.6, P < 0.001). The majority (78%) were tested for HCV because they developed abnormal liver transaminases (n = 31) or hepatitis symptoms (n = 2), while others (n = 7) were identified through routine HCV testing. Conclusion A considerable proportion of HIV-positive MSM who did not inject drugs contracted HCV, presumably via sexual transmission and the main trigger for investigation was abnormal liver transaminases.