Catherine C. O'Connor

Sexual health and use of condoms among local and international sex workers in Sydney.

OBJECTIVES: To compare indicators of sexual health and predictors of condom use for commercial sex among local and international female sex workers first attending an STD clinic. SETTING: A public STD clinic in Sydney, Australia. SUBJECTS: All sex workers first attending between June 1991 and May 1993. METHODS: Cross-sectional analysis of demographic, behavioural and morbidity data from proforma medical records. RESULTS: 91 local sex workers and 123 international sex workers (predominantly from Thailand, Malaysia and China) first presented during the study period. There were significantly higher prevalences of chlamydia (0 v. 15%, p = 0.0002), gonorrhoea (0 v. 14%, p = 0.0006), syphilis (0 v. 10%, p = 0.006) and clinical genital herpes (0 v. 5%, p = 0.04) among international sex workers. The only case of HIV infection was in an international sex worker. Inconsistent condom use for commercial sex was significantly more common among international sex workers (RR = 4.5; 95% CI 3.1-6.5). On multivariate analysis, inconsistent condom use in international sex workers was associated with a recent history of prostitution outside Australia (p = 0.04), while inconsistent condom usage among local sex workers was associated with increasing age (p = 0.003). CONCLUSIONS: These data illustrate the efficacy of condoms and the success of targeted education programmes in local sex workers in Sydney. By contrast, international sex workers continued to be at high risk of STDs. The international sex industry in Sydney requires enhanced culture-specific interventions. Immigration laws as they affect sex workers should also be reviewed.

Long-Term Survival in HIV Positive Patients with up to 15 Years of Antiretroviral Therapy

Background Life expectancy has increased for newly diagnosed HIV patients since the inception of combination antiretroviral treatment (cART), but there remains a need to better understand the characteristics of long-term survival in HIV-positive patients. We examined long-term survival in HIV-positive patients receiving cART in the Australian HIV Observational Database (AHOD), to describe changes in mortality compared to the general population and to develop longer-term survival models. Methods Data were examined from 2,675 HIV-positive participants in AHOD who started cART. Standardised mortality ratios (SMR) were calculated by age, sex and calendar year across prognostic characteristics using Australian Bureau of Statistics national data as reference. SMRs were examined by years of duration of cART by CD4 and similarly by viral load. Survival was analysed using Cox-proportional hazards and parametric survival models. Results The overall SMR for all-cause mortality was 3.5 (95% CI: 3.0–4.0). SMRs by CD4 count were 8.6 (95% CI: 7.2–10.2) for CD4<350 cells/µl; 2.1 (95% CI: 1.5–2.9) for CD4 = 350–499 cells/µl; and 1.5 (95% CI: 1.1–2.0) for CD4≥500 cells/µl. SMRs for patients with CD4 counts <350 cells/µL were much higher than for patients with higher CD4 counts across all durations of cART. SMRs for patients with viral loads greater than 400 copies/ml were much higher across all durations of cART. Multivariate models demonstrated improved survival associated with increased recent CD4, reduced recent viral load, younger patients, absence of HBVsAg-positive ever, year of HIV diagnosis and incidence of ADI. Parametric models showed a fairly constant mortality risk by year of cART up to 15 years of treatment. Conclusion Observed mortality remained fairly constant by duration of cART and was modelled accurately by accepted prognostic factors. These rates did not vary much by duration of treatment. Changes in mortality with age were similar to those in the Australian general population.

Re-testing for chlamydia at sexual health services in Australia, 2004–08

OBJECTIVE To describe the frequency of the 3-month test for re-infection among sexual health service patients in Australia. METHODS We assessed the re-testing rates at 30-120 days after chlamydia infection in men who have sex with men (MSM), heterosexual males and females attending sexual health services across Australia between 2004 and 2008. A χ(2)-test was used to determine significant differences in re-testing rates according to demographic characteristics and trends over time. RESULTS In the 5-year period, 10207 MSM, 28530 heterosexual males and 31190 heterosexual females were tested for chlamydia. Of those tested, 9057 (13.0%) were positive. The proportion of patients with chlamydia infection who were re-tested in 30-120 days was 8.6% in MSM, 11.9% in heterosexual males and 17.8% in heterosexual females. Among MSM, chlamydia re-testing rates were lower in men aged <30 years (8.4%) than ≥30 years (12.5%) (P=0.04) and lower in travellers and migrants (2.9%) than non-travellers (9.9%) (P=0.002). In heterosexual males, chlamydia re-testing rates were lower in men in regional and rural areas (10.5%) than metropolitan areas (13.5%) (P=0.017). There was no increasing trend in re-testing rates between 2004 and 2008 (P=0.787). Of the patients re-tested, 44.1% of MSM were positive, 21.0% of heterosexual males and 16.1% of females. DISCUSSION The high chlamydia positivity at 30-120 days support recommendations that call for a 3-month test for re-infection following a positive test. The low re-testing rates highlight the need for innovative strategies to increase re-testing.

Demographic, migration status, and work-related changes in Asian female sex workers surveyed in Sydney, 1993 and 2003.

Objective: To compare demography, sexual health awareness, migration and workplace conditions of Asian female sex workers in Sydney in 1993 and 2003.

Understanding trends in genital Chlamydia trachomatis can benefit from enhanced surveillance: findings from Australia

Objectives To determine trends and correlates of chlamydia positivity among young heterosexuals attending Australian sexual health services and to compare these with population-based notification data. Methods Data from 18 sexual health services and the national notification scheme were analysed. A χ2 test assessed trends in chlamydia positivity among young heterosexuals tested from 2006 to 2010, and logistic regression was used to determine correlates of positivity. Nucleic acid amplification tests were used throughout the study period. Results During 2006–2010, 64 588 heterosexuals aged 15–29 years attended the sexual health services for the first time and the annual chlamydia testing rate was consistently >80%. Overall, chlamydia positivity increased by 12%, by 8.3% in heterosexual men (from 13.2% in 2006 to 14.3% in 2010; p-trend=0.04) and by 15.9% in women (from 11.3% in 2006 to 13.1% in 2010; p-trend<0.01). Independent correlates of chlamydia positivity in sexual health service patients were being aged 15–24 years, residing in a regional/rural area, being Aboriginal and/or Torres Strait Islander, being a non-Australian resident and attending in 2010 compared with 2006. Over the same period, the population-based notification rate increased by 43% against a background of a >100% increase in testing. Conclusions The sexual health service network suggests a moderate increase in chlamydia prevalence in young heterosexuals tested at sexual health services, in contrast to the steep increase shown by notifications. This highlights the caution needed in interpreting chlamydia trends without a corresponding testing denominator.

Low knowledge and high infection rates of hepatitis in Vietnamese men in Sydney

OBJECTIVE To describe hepatitis B and C knowledge and self-reported infection and risk behaviour in a group of Vietnamese men living in inner-urban Sydney, in order to assist with future program planning. METHODS Data were collected through telephone interviews conducted in Vietnamese using a structured questionnaire from 499 of 761 eligible men contacted, giving a response rate of 66%. The data were weighted to be consistent with the age distribution of Vietnamese men in the area. The findings were compared with a published national telephone study. RESULTS Low knowledge levels of hepatitis B and C were found when compared with data from a published national telephone study. The factors associated with higher mean knowledge scores for hepatitis B were being highly acculturated (P < 0.001), ever having been tested for HIV (P < 0.001) and knowing someone with HIV (P < 0.0001). For hepatitis C, the factors were being highly acculturated (P < 0.001), ever injecting drugs (P < 0.05) and being vaccinated for hepatitis B (P < 0.001). Knowledge regarding hepatitis B was particularly poor. High rates of self-reported hepatitis B infection were noted. Of the participants, 7.2% were aware that they had ever been infected with hepatitis B, more than 10 times the rate in the national telephone study. CONCLUSION Lower levels of hepatitis B knowledge have been identified in a community with higher numbers of people living with chronic hepatitis B. Targeted community-wide awareness-raising campaigns and health care worker education is required to improve knowledge of hepatitis B and rates of screening in the Australian Vietnamese community.

Ageing and long-term CD4 cell count trends in HIV-positive patients with 5 years or more combination antiretroviral therapy experience

The aim of this study was to describe the long‐term changes in CD4 cell counts beyond 5 years of combination antiretroviral therapy (cART). If natural ageing leads to a long‐term decline in the immune system via low‐grade chronic immune activation/inflammation, then one might expect to see a greater or earlier decline in CD4 counts in older HIV‐positive patients with increasing duration of cART.

Determining the cost of genital warts: A study from Ireland

Objectives: To determine the average cost of a case of genital warts, for both males and females, with a view to informing the current debate as to which Human papillomavirus vaccine would have maximum cost-effectiveness in the Irish population. Methods: Contact time between patients and healthcare professionals was prospectively measured at five genitourinary medicine clinics in the south-west of Ireland, over a period of 3 weeks. By identifying all those with genital warts, it was possible to calculate the proportion of total time taken by patients with this condition, and from this to calculate a cost per incident case, by gender. Results: A total of 25.5% of attendances were for genital warts, and these patients used 26.2% of total clinic time (CI 25.4 to 27.0%). The average cost calculated for genital warts was €335 per incident case, and by gender €300 per male case and €366 per female case. Conclusions: There are considerable costs associated with the treatment of genital warts, with female cases representing a higher cost than males. By vaccinating with the quadrivalent HPV vaccine, there are significant savings to be made.

Sexual behaviour and risk in Vietnamese men living in metropolitan Sydney.

Objective: To describe sexual risk in Vietnamese men who have sex with female sex workers by describing the prevalence of sexual risk behaviours among Vietnamese men living in inner Sydney and comparing this prevalence with national data. Method: Telephone interviews were completed with a random sample of 499 Vietnamese men, selected from the electronic telephone book using a list of common Vietnamese surnames. Results: Of the 761 eligible men contacted, data were obtained from 499 men, giving a response rate of 66%. 20% reported having had sex with a sex worker, including 12% of Vietnamese men who had had sex with a sex worker outside Australia, predominantly in Vietnam. Of the men who had had sex with a sex worker in the past year, 28% had unprotected vaginal or anal sex at their most recent commercial sexual encounter. Ever having paid for sex was significantly associated with a higher lifetime number of sexual partners (p<0.001), history of a sexually transmitted infection (p<0.001) and ever having an HIV test. 1% of respondents reported injecting non-prescription drugs. Less than 1% said they had had sex with another man. Conclusion: Vietnamese men living in Sydney generally show lower levels of sexual and related risk behaviours than other Australian men. However, sex with a sex worker is common among Vietnamese men in Sydney and also when they travel outside Australia. Unprotected vaginal sex with sex workers is surprisingly common. Programmes are needed to deal with vulnerabilities in these areas.

Human papillomavirus vaccination and genital warts in young Indigenous Australians: national sentinel surveillance data.

Objectives: To examine the impact of the national human papillomavirus (HPV) vaccination program (available to girls and women [12–26 years] since 2007 and to boys [12–15 years] since 2013) on the number of diagnoses of genital warts in Australian Aboriginal and Torres Strait Islander (Indigenous) people.