Carol El-Hayek

Does the frequency of HIV and STI testing among men who have sex with men in primary care adhere with Australian guidelines

Objectives Australian guidelines recommend annual testing for HIV and sexually transmitted infections (STIs) for all men who have sex with men (MSM) and 3–6 monthly testing for those at higher risk as defined by behavioural criteria. We assessed HIV/STI re-testing rates among MSM attending primary care clinics. Methods We conducted a retrospective follow-up of HIV negative MSM tested for HIV or STIs (chlamydia or syphilis) at four primary care clinics in the 9-month period: April to December 2006. Re-testing rates for these infections were calculated over 18 months. Logistic regression was undertaken to identify predictors of guideline adherence. Results Of the MSM requiring annual HIV testing according to the guidelines, the re-testing rates at 1 y were 35% (762/2163). Among the higher risk MSM, 6-monthly HIV re-testing rates were 15% (283/1862). Within the subgroup who reported 11 or more male sexual partners within the past 6 months, HIV re-testing rates within 6 months were 19%. Independent predictors of HIV re-testing within 6 months in higher-risk MSM were reporting 11 or more male sexual partners in the last 6 months (AOR 3.1, 95% CI 1.8 to 4.8); being born overseas (AOR 2.0, 95% CI 1.2 to 3.4); and previous HIV testing more than 12 months earlier (AOR 3.3, 95% CI 1.9 to 5.5). Conclusion There is poor adherence to national guidelines that recommend regular re-testing of MSM for STIs, particularly among those at higher risk who require more frequent testing. Clinical strategies are urgently needed to encourage more frequent HIV/STI testing among MSM, especially in the higher risk subgroup.

Stop the drama Downunder: a social marketing campaign increases HIV/sexually transmitted infection knowledge and testing in Australian gay men.

Introduction: Since 2000, notifications of HIV and other sexually transmitted infections (STIs) have increased significantly in Australian gay men. We evaluated the impact of a social marketing campaign in 2008–2009 aimed to increase health-seeking behavior and STI testing and enhance HIV/STI knowledge in gay men. Methods: A convenience sample of 295 gay men (18–66 years of age) was surveyed to evaluate the effectiveness of the campaign. Participants were asked about campaign awareness, HIV/STI knowledge, health-seeking behavior, and HIV/STI testing. We examined associations between recent STI testing and campaign awareness. Trends in HIV/STI monthly tests at 3 clinics with a high case load of gay men were also assessed. Logistic and Poisson regressions and &khgr;2 tests were used. Results: Both unaided (43%) and aided (86%) campaign awareness was high. In a multivariable logistic regression, awareness of the campaign (aided) was independently associated with having had any STI test within the past 6 months (prevalence ratio = 1.5; 95% confidence interval = 1.0–2.4. Compared with the 13 months before the campaign, clinic data showed significant increasing testing rates for HIV, syphilis, and chlamydia among HIV-negative gay men during the initial and continued campaign periods. Conclusion: These findings suggest that the campaign was successful in achieving its aims of increasing health-seeking behavior, STI testing, and HIV/STI knowledge among gay men in Victoria.

Risk factors for HIV seroconversion in men who have sex with men in Victoria, Australia: Results from a sentinel surveillance system

OBJECTIVES HIV diagnosis rates in men who have sex with men (MSM) began increasing in Australia 10 years ago, and there has been a major resurgence of syphilis. We determined predictors of HIV positivity and seroconversion among MSM in Victoria, Australia. METHODS We conducted a retrospective longitudinal analysis of data from MSM who underwent HIV testing between April 2006 and June 2009 at three primary care clinics. Logistic regression was used to determine predictors of HIV positivity and seroconversion. RESULTS During the study period, 7857 MSM tested for HIV. Overall HIV positivity was 1.86% (95% confidence interval (CI): 1.6-2.2). There were 3272 repeat testers followed for 4837 person-years (PY); 60 seroconverted and HIV incidence was 1.24 (95% CI: 0.96-1.60) per 100 PY. Independent predictors of HIV seroconversion were: an infectious syphilis diagnosis within the last 2 years (adjusted hazard ratio (AHR)=2.5, 95% CI: 1.1-5.7), reporting six or more anal sex partners in the past 6 months (AHR=3.3, 95% CI: 1.8-6.3), reporting an HIV-positive current regular partner (AHR=3.4, 95% CI: 1.1-10.6) and reporting inconsistent condom use with casual partners in the past 6 months (AHR=4.4, 95% CI: 1.7-11.5). CONCLUSION Our results call for HIV prevention to target high-risk MSM, including men with a recent syphilis diagnosis or a high numbers of partners, men who have unprotected anal sex with casual partners and men in serodiscordant relationships. The HIV incidence estimate will provide a baseline to enable public health officials to measure the effectiveness of future strategies.

Establishing a linked sentinel surveillance system for blood-borne viruses and sexually transmissible infections: methods, system attributes and early findings

OBJECTIVE To describe the attributes and key findings from implementation of a new blood-borne virus (BBV) and sexually transmissible infection (STI) sentinel surveillance system based on routine testing at clinical sites in Victoria, Australia. METHODS The Victorian Primary Care Network for Sentinel Surveillance (VPCNSS) on BBV and STI was established in 2006 at 17 sites. Target populations included men who have sex with men (MSM), young people and injecting drug users (IDU). Sites collected demographic and risk behaviour information electronically or using paper surveys from patients undergoing routine HIV or STI (syphilis, chlamydia (Chlamydia trachomatis)) or hepatitis C virus (HCV) testing. These data were linked with laboratory results. RESULTS Between April 2006 and June 2008, data were received for 67 466 tests and 52 042 questionnaires. In clinics providing electronic data, >90% of individuals tested for HIV, syphilis and chlamydia had risk behaviour information collected. In other clinics, survey response rates were >85% (HIV), 43.5% (syphilis), 42.7-66.5% (chlamydia) and <20% (HCV). Data completeness was >85% for most core variables. Over time, HIV, syphilis and chlamydia testing increased in MSM, and chlamydia testing declined in females (P = 0.05). The proportion of positive tests among MSM was 1.9% for HIV and 2.1% for syphilis. Among 16-24-year-olds, the proportion positive for chlamydia was 10.7% in males and 6.9% in females. Among IDU, 19.4% of HCV tests were antibody positive. CONCLUSIONS The VPCNSS has collected a large, rich dataset through which testing, risk behaviours and the proportion positive can be monitored in high-risk groups, offering a more comprehensive BBV and STI surveillance system for Victoria. Building system sustainability requires an ongoing focus.

Epidemiology of chlamydia and gonorrhoea among Indigenous and non-Indigenous Australians, 2000-2009.

Objectives: To assess notification trends for chlamydia and gonorrhoea infections in Indigenous Australians compared with non‐Indigenous Australians in 2000–2009.

Opt-Out and Opt-In Testing Increases Syphilis Screening of HIV-Positive Men Who Have Sex with Men in Australia

Background Since 2005, Australian clinicians were advised to undertake quarterly syphilis testing for all sexually active HIV-positive men who have sex with men (MSM). We describe differences in syphilis testing frequency among HIV-positive MSM by clinic testing policies since this recommendation. Methods Three general practices, two sexual health clinics and two hospital HIV outpatient clinics provided data on HIV viral load and syphilis testing from 2006–2010. Men having ≥1 viral load test per year were included; >95% were MSM. We used Chi-2 tests to assess changes in syphilis testing frequency over time, and differences by clinic testing policy (opt-out, opt-in and risk-based). Results The proportion of men having HIV viral loads with same-day syphilis tests increased from 37% in 2006 to 63% in 2007 (p<0.01) and 68–69% thereafter. In 2010, same-day syphilis testing was highest in four clinics with opt-out strategies (87%, range:84–91%) compared with one clinic with opt-in (74%, p = 0.121) and two clinics with risk-based strategies (22%, range:20–24%, p<0.01). The proportion of men having ≥3 syphilis tests per year increased from 15% in 2006 to 36% in 2007 (p<0.01) and 36–38% thereafter. In 2010, the proportion of men having ≥3 syphilis tests in a year was highest in clinics with opt-out strategies (48%, range:35–59%), compared with opt-in (39%, p = 0.121) and risk-based strategies (8.4%, range:5.4–12%, p<0.01). Conclusion Over five years the proportion of HIV-positive men undergoing syphilis testing at recommended frequencies more than doubled, and was 5–6 times higher in clinics with opt-out and opt-in strategies compared with risk-based policies.

Incidence and risk factors associated with chlamydia in men who have sex with men: a cohort analysis of Victorian Primary Care Network for Sentinel Surveillance data

Background Chlamydia is the most commonly notified sexually transmitted infection (STI) in Australia. Incidence studies of chlamydia in men who have sex with men (MSM) are rare and offer important public health information. Objective To determine chlamydia incidence in MSM presenting at high caseload clinics and describe predictors of infection. Methods The Victorian Primary Care Network for Sentinel Surveillance of bloodborne viruses and STIs (VPCNSS) links testing, demographic and behavioural data from individual testers at participating clinics. Data from MSM with more than one chlamydia test at the VPCNSS site between April 2006 and June 2010 were included. Chlamydia incidence per 100 person-years (PY) was calculated and Cox regression used to examine predictors of incidence. Results 1206 positive tests for chlamydia were detected among 6333 MSM across 11 409 PY of follow-up. Overall chlamydia incidence was 10.6/100 PY (95% CI 10.0 to 11.2) and was highest among MSM aged 16–29 years (12.9/100 PY, 95% CI 11.7 to 14.1), presenting with STI symptoms (16.0/100 PY, 95% CI 14.2 to 18.0), HIV positive (18.5/100 PY, 95% CI 16.6 to 20.6) and self-identified sex workers (14.3/100 PY, 95% CI 10.0 to 20.6). Significant predictors of chlamydia infection among MSM were younger age (adjusted hazard ratio (aHR)=1.9, 95% CI 1.5 to 2.3), self-identifying as a sex worker (aHR=1.6, 95% CI 1.0 to 2.6), being HIV positive (aHR=2.6, 95% CI 1.8 to 3.8), presenting with STI symptoms (aHR=1.7, 95% CI 1.4 to 2.1) and reporting >10 sex partners in the past 6 months (aHR=2.5 95% CI 1.4 to 4.6). Conclusion These results show that MSM represent a key risk population for chlamydia in Australia and identify a number of high-risk MSM subpopulations for whom clinical and public health interventions are warranted.

The Impact of a Social Marketing Campaign on HIV and Sexually Transmissible Infection Testing Among Men Who Have Sex With Men in Australia.

Background In response to increasing HIV and other sexually transmissible infection (HIV/STI) notifications in Australia, a social marketing campaign Drama Downunder (DDU) was launched in 2008 to promote HIV/STI testing among men who have sex with men (MSM). We analyzed prospective data from (1) an online cohort of MSM and (2) clinic-level HIV/STI testing to evaluate the impact of DDU on HIV, syphilis, gonorrhea, and chlamydia testing. Materials and Methods (1) Cohort participants who completed 3 surveys (2010–2014) contributed to a Poisson regression model examining predictors of recent HIV testing. (2) HIV, syphilis, gonorrhea, and chlamydia tests among MSM attending high caseload primary care clinics (2007–2013) were included in an interrupted time series analysis. Results (1) Although campaign awareness was high among 242 MSM completing 726 prospective surveys, campaign recall was not associated with self-reported HIV testing. Reporting previous regular HIV testing (adjusted incidence rate ratio, 2.4; 95% confidence interval, 1.3–4.4) and more than 10 partners in the previous 6 months (adjusted incidence rate ratio, 1.2; 95% confidence interval, 1.1–1.4) was associated with recent HIV testing. (2) Analysis of 257,023 tests showed increasing monthly HIV, syphilis, gonorrhea, and chlamydia tests pre-DDU. Post-DDU, gonorrhea test rates increased significantly among HIV-negative MSM, with modest and nonsignificant increasing rates of HIV, syphilis, and chlamydia testing. Among HIV-positive MSM, no change in gonorrhea or chlamydia testing occurred and syphilis testing declined significantly. Conclusions Increasing HIV/STI testing trends among MSM occurred pre- and post-DDU, coinciding with other plausible drivers of testing. Modest changes in HIV testing post-DDU suggest that structural changes to improve testing access may need to occur alongside health promotion to increase testing frequency.

Seek, test, treat lessons from Australia: a study of HIV testing patterns from a cohort of men who have sex with men

Objective:HIV diagnoses are increasing in Australia, mostly among men who have sex with men (MSM). Similar to many countries, Australias HIV prevention strategies emphasize a “seek, test, treat” approach including enhancing HIV testing frequency. We describe HIV testing among MSM and correlates of returning for testing within 12 months in the context of new HIV prevention paradigms. Methods:Testing and behavioral data (2007–2013) contributed by MSM aged ≥16 years were included. Total HIV tests by calendar year and repeat tests within 12 months were described, alongside negative binomial regression for trend. A 2-level mixed-effects logistic regression model examined correlates of testing within 12 months. Median (days) between HIV tests was compared between MSM diagnosed with HIV and persistently HIV-negative MSM. Results:The study included 46,060 tests from 17,904 MSM. There was an increase in annual tests (P < 0.01), repeat tests within 12 months (P < 0.01), and the proportion of tests within 12 months of an index test (P < 0.01), although only to 53.3% in 2013. Return rates were higher in MSM aged 16–29 years (adjusted odds ratio 1.30, 95% confidence interval: 1.1 to 1.5) and those reporting higher numbers of partners (adjusted odds ratio 3.5, 95% confidence interval: 3.0 to 4.0). Median time between tests among MSM diagnosed with HIV (233 days) was greater than for HIV-negative MSM (189 days) (P = 0.03). Conclusions:Although testing has increased, testing frequency among many MSM remains suboptimal. To optimize “seek, test, treat”–based HIV prevention strategies, new approaches to increase testing uptake and early HIV detection among MSM are needed.

Clinic Network Collaboration and Patient Tracing to Maximize Retention in HIV Care.

Background Understanding retention and loss to follow up in HIV care, in particular the number of people with unknown outcomes, is critical to maximise the benefits of antiretroviral therapy. Individual-level data are not available for these outcomes in Australia, which has an HIV epidemic predominantly focused amongst men who have sex with men. Methods and Findings A network of the 6 main HIV clinical care sites was established in the state of Victoria, Australia. Individuals who had accessed care at these sites between February 2011 and June 2013 as assessed by HIV viral load testing but not accessed care between June 2013 and February 2014 were considered individuals with potentially unknown outcomes. For this group an intervention combining cross-referencing of clinical data between sites and phone tracing individuals with unknown outcomes was performed. 4966 people were in care in the network and before the intervention estimates of retention ranged from 85.9%–95.8% and the proportion with unknown outcomes ranged from 1.3-5.5%. After the intervention retention increased to 91.4–98.8% and unknown outcomes decreased to 0.1–2.4% (p<.01 for all sites for both outcomes). Most common reasons for disengagement from care were being too busy to attend or feeling well. For those with unknown outcomes prior to the intervention documented active psychiatric illness at last visit was associated with not re-entering care (p = 0.04) Conclusions The network demonstrated low numbers of people with unknown outcomes and high levels of retention in care. Increased levels of retention in care and reductions in unknown outcomes identified after the intervention largely reflected confirmation of clinic transfers while a smaller number were successfully re-engaged in care. Factors associated with disengagement from care were identified. Systems to monitor patient retention, care transfer and minimize disengagement will maximise individual and population-level outcomes for populations with HIV.