David J. Templeton

Incidence and risk factors for urethral and anal gonorrhoea and chlamydia in a cohort of HIV-negative homosexual men: the Health in Men Study

Background: Early detection and treatment of bacterial sexually transmitted infections has been advocated as an HIV prevention strategy. Aim: To inform screening guidelines, the incidence and risk factors for urethral and anal gonorrhoea and chlamydia were studied in a prospective cohort of community-based HIV negative homosexual men in Sydney, New South Wales, Australia. Methods: All participants were offered annual screening for gonorrhoea and chlamydia (study-visit diagnoses) on urine and anal swabs using nucleic acid amplification. Participants also reported diagnoses of gonorrhoea and chlamydia made elsewhere between interviews (interval diagnoses). All diagnoses were summed to create a combined incidence rate, and detailed data on specific sexual practices with casual and regular partners were collected. Results: Among 1427 men enrolled, the combined incidence rates were 3.49 and 2.96 per 100 person-years for urethral and anal gonorrhoea, respectively; and 7.43 and 4.98 per 100 person-years for urethral and anal chlamydia, respectively. Urethral infections were associated with unprotected anal intercourse (UAI) with HIV-positive partners (hazard ratio (HR) = 2.58, 95% CI 1.10 to 6.05 for urethral gonorrhoea) and with frequent insertive oral sex (p for trend 0.007 for urethral chlamydia). Anal infections were associated with receptive UAI (p for trend 0.001 for both anal gonorrhoea and chlamydia) and other receptive anal sexual practices. Stratified analyses showed the independence of the associations of insertive oral sex with urethral infections and of non-intercourse receptive anal practices with anal infections. Conclusion: Incident gonorrhoea and chlamydia were common. Risk behaviours for both urethral and anal infections were not restricted to UAI. Screening that includes tests for anal and urethral infections should be considered for all sexually active homosexual men, not just for those who report UAI.

High rates of sexually transmitted infections in HIV positive homosexual men: data from two community based cohorts

Background/objectives: Higher levels of sexual risk behaviours have been reported in HIV positive than in HIV negative homosexual men. In clinic based studies, higher rates of sexually transmitted infections (STIs) have also been reported. We compared rates of common STIs between HIV positive and HIV negative homosexual men from two ongoing community based cohort studies in Sydney, Australia. Methods: Participants in the two cohorts were recruited using similar community based strategies. They were interviewed face to face annually after enrolment. Comprehensive sexual health screening, including hepatitis A and B, syphilis, gonorrhoea, and chlamydia (in urethra and anus) was offered to participants in both cohorts. Results: In participants in the HIV positive cohort, 75% were hepatitis A seropositive, 56% had serological evidence of previous or current hepatitis B infection, and 24% had evidence of vaccination against hepatitis B infection. 19% of men tested positive for syphilis and 4% had evidence of recent infections. Compared with men in the HIV negative cohort, after adjustment for age, HIV positive participants had significantly higher prevalence of previous or current hepatitis B infection, syphilis, and anal gonorrhoea. Conclusion: This finding supports the need for frequent STI testing in HIV positive men to prevent morbidity and to decrease the risk of ongoing HIV transmission.

Anal sexually transmitted infections and risk of HIV infection in homosexual men.

Background:We examined a range of common bacterial and viral sexually transmitted infections as risk factors for HIV seroconversion in a community-based cohort of HIV-negative homosexual men in Sydney, Australia. Methods:Detailed information about HIV risk behaviors was collected by interview twice yearly. Participants were tested annually for HIV, anal and urethral gonorrhea and chlamydia, herpes simplex virus types 1 and 2, and syphilis. In addition, they reported annual diagnoses of these conditions and of genital and anal warts. Results:Among 1427 enrolled participants, 53 HIV seroconverters were identified, giving an incidence of 0.78 per 100 person-years. After controlling for number of episodes of insertive and receptive nonseroconcordant unprotected anal intercourse, there were independent associations with anal gonorrhea (adjusted hazard ratio = 7.12, 95% confidence interval: 2.05 to 24.79) and anal warts (hazard ratio = 3.63, 95% confidence interval: 1.62 to 8.14). Conclusions:Anal gonorrhea and anal warts were independently associated with HIV acquisition. The added HIV prevention value of more frequent screening of the anus to allow early detection and treatment of anal sexually transmitted infections in homosexual men should be considered.

Transmission of Herpes Simplex Virus Types 1 and 2 in a Prospective Cohort of HIV-Negative Gay Men: The Health in Men Study

BACKGROUND Despite increasing reports of herpes simplex virus (HSV) type 1 (HSV-1)-associated anogenital herpes, there are very limited data comparing the seroepidemiological profile of and risk factors for HSV-1 and HSV type 2 (HSV-2) infection. METHODS Sexual behaviors were examined as risk factors for prevalent and incident HSV-1 and HSV-2 infections in a community-based cohort of 1,427 HIV-negative gay men in Australia. RESULTS The prevalence of HSV-1 and HSV-2 at baseline was 75% and 23%, respectively. The rate of prevalent infection with HSV-1, as well as the rate of prevalent infection with HSV-2, was much lower in individuals <25 years of age, and each type of infection was associated with a higher number of both male and female sex partners. The median duration of follow-up of the cohort was 2.0 years. Among participants who were susceptible to infection, the incidence rates for HSV-1 and HSV-2 infection were 5.58 and 1.45 cases per 100 person-years, respectively. In multivariate analysis, incident infection with HSV-1 was significantly associated with younger age (P=.027) and reports of frequent insertive oral sex with casual partners (hazard ratio, 3.91 [95% confidence interval, 1.23-12.44]; P=.021). Incident infection with HSV-2 was significantly associated with a variety of anal sex practices with casual partners. CONCLUSIONS Both HSV-1 and HSV-2 were commonly sexually transmitted, and there were more HSV-1 than HSV-2 seroconversions. Public-health strategies targeted against anogenital herpes increasingly need to take into account the importance of HSV-1 infection.

The epidemiology of anal cancer

Anal cancer comprises malignancies of the anal canal principally of two morphologic variants: squamous cell carcinoma (SCC) and adenocarcinoma. In most settings, SCC compromises more than 70% of cases. In the general population, anal cancer is uncommon, with age-standardised incidence rates mostly between 1 and 2 per 100000 per year. However, incidence of anal SCC is increasing by 1-3% per year in developed country settings. High-risk human papillomavirus (HPV) types can be detected in 80-90% of all anal SCC cases, making it second only to cervical cancer in the closeness of its association with this virus. HPV-16 can be detected in ~90% of HPV-positive cases of anal SCC. Case-control studies have demonstrated that sexual risk factors (homosexuality in men and multiple sexual partners in women) are strongly associated with anal cancer risk. Other risk factors include immune deficiency and tobacco exposure. Anal cancer rates are highest in homosexual men, particularly in those who are HIV-positive, in whom anal cancer is among the most common of all cancers. Vaccination against HPV holds great promise for anal cancer prevention for those not already HPV-infected. For the current generation of adult high-risk populations, screening programs to allow early detection and treatment are under investigation.

Australian sexually transmissible infection and HIV testing guidelines for asymptomatic men who have sex with men 2014: a review of the evidence

Men who have sex with men (MSM) in Australia and overseas are disproportionately affected by sexually transmissible infections (STIs), including HIV. Many STIs are asymptomatic, so regular testing and management of asymptomatic MSM remains an important component of effective control. We reviewed articles from January 2009-May 2013 to inform the 2014 update of the 2010 Australian testing guidelines for asymptomatic MSM. Key changes include: a recommendation for pharyngeal chlamydia (Chlamydia trachomatis) testing, use of nucleic acid amplification tests alone for gonorrhoea (Neisseria gonorrhoeae) testing (without gonococcal culture), more frequent (up to four times a year) gonorrhoea and chlamydia testing in sexually active HIV-positive MSM, time required since last void for chlamydia first-void urine collection specified at 20min, urethral meatal swab as an alternative to first-void urine for urethral chlamydia testing, and the use of electronic reminders to increase STI and HIV retesting rates among MSM.

Circumcision and risk of HIV infection in Australian homosexual men.

Objective:To assess circumcision status as a risk factor for HIV seroconversion in homosexual men. Design, setting and participants:The Health in Men (HIM) study was a prospective cohort of homosexual men in Sydney, Australia. HIV-negative men (n = 1426) were recruited primarily from community-based sources between 2001 and 2004 and followed to mid-2007. Participants underwent annual HIV testing, and detailed information on sexual risk behaviour was collected every 6 months. Main outcome measure:HIV incidence in circumcised compared with uncircumcised participants, stratified by whether or not men predominantly practised the insertive role in anal intercourse. Results:There were 53 HIV seroconversions during follow-up; an incidence of 0.78 per 100 person-years. On multivariate analysis controlling for behavioural risk factors, being circumcised was associated with a nonsignificant reduction in risk of HIV seroconversion [hazard ratio 0.78, 95% confidence interval (CI) 0.42–1.45, P = 0.424]. Among one-third of study participants who reported a preference for the insertive role in anal intercourse, being circumcised was associated with a significant reduction in HIV incidence after controlling for age and unprotected anal intercourse (UAI) (hazard ratio 0.11, 95% CI 0.03–0.80, P = 0.041). Those who reported a preference for the insertive role overwhelmingly practised insertive rather than receptive UAI. Conclusions:Overall, circumcision did not significantly reduce the risk of HIV infection in the HIM cohort. However, it was associated with a significant reduction in HIV incidence among those participants who reported a preference for the insertive role in anal intercourse. Circumcision may have a role as an HIV prevention intervention in this subset of homosexual men.

Risk factors for genital and anal warts in a prospective cohort of HIV-negative homosexual men: the HIM study.

Objective: The objective of this study was to determine the prevalence, incidence, and risk factors for genital and anal warts in HIV-negative homosexual men in Sydney. Study Design: The authors conducted a prospective cohort study. Participants were asked whether they had had genital and anal warts at each interview. Details of lifetime sexual contacts and sexual behaviors in the last 6 months were collected. Results: Among 1,427 men recruited, 8.9% and 19.6% reported a history of genital and anal warts at baseline, respectively. Incidence rates for genital and anal warts were 0.94 and 1.92 per 100 person-years, respectively. In multivariate analysis, both incident genital and anal warts were associated with younger age. In addition, incident genital warts was associated with insertive fingering (P trend = 0.018), whereas incident anal warts was associated with insertive fingering (P trend = 0.007) and insertive fisting (P trend = 0.039). Conclusions: Anal warts were twice as common as genital warts. Fingering and other manual sexual practices may be an important transmission route for both.

Male circumcision to reduce the risk of HIV and sexually transmitted infections among men who have sex with men.

Purpose of review The success of male circumcision in reducing HIV acquisition among African heterosexuals has led to renewed interest in this biological intervention for HIV/sexually transmissible infection (STI) prevention in men who have sex with men (MSM). This review summarizes the available data on the association of circumcision and HIV/STI among MSM populations. Recent findings Results of observational studies indicate that circumcision has limited impact on HIV/STI acquisition among MSM populations overall. Longitudinal data suggest that circumcision may reduce the risk of incident syphilis, but there is little evidence of a protective effect for other STIs. The subgroup of MSM who predominantly practise the insertive role in anal intercourse may be at lower risk of HIV, although the relative inefficiency of HIV acquisition for insertive compared with receptive partners has resulted in imprecise estimates of effect. Summary The evidence that circumcision reduces HIV and other STIs among MSM is weak and inconsistent. However, recent studies have found that circumcised MSM who predominantly take the insertive role in anal intercourse may be at a lower risk of HIV infection. Although MSM may be willing to undergo adult circumcision, should it be proven to reduce HIV acquisition risk, there is substantial potential that behavioural disinhibition could offset any benefits achieved by a circumcision intervention.

Prevalence, incidence and risk factors for pharyngeal gonorrhoea in a community-based HIV-negative cohort of homosexual men in Sydney, Australia

Background Pharyngeal gonorrhoea is common in homosexual men and may be important in maintaining community prevalence of anogenital infections. Methods From 2003, all participants in the Health in Men cohort of HIV-negative homosexual men in Sydney were offered annual pharyngeal gonorrhoea screening by BD ProbeTec nucleic acid amplification (NAAT) assay with supplementary porA testing. Participants self-reported diagnoses of pharyngeal gonorrhoea made elsewhere between interviews. Detailed sexual behavioural data were collected 6-monthly. Results Among 1427 participants enrolled, 65 study-visit-diagnosed pharyngeal gonorrhoea infections were identified (incidence 1.51 per 100 person-years, 95% CI 1.19 to 1.93) of which seven infections were identified on baseline testing (prevalence 0.57%, 95% CI 0.23 to 1.17%). Almost 85% of study-visit-diagnosed pharyngeal infections occurred without concurrent anogenital gonorrhoea. The combined incidence of study-visit-diagnosed and self-reported pharyngeal gonorrhoea (n=193) was 4.45 per 100 person-years (95% CI 3.86 to 5.12). On multivariate analysis, incident infection was associated with younger age (p-trend=0.001), higher number of male partners (p-trend=0.002) and reported contact with gonorrhoea (p<0.001). Insertive oro-anal sex (‘rimming’) was the only sexual behaviour independently associated with incident pharyngeal gonorrhoea (p-trend=0.044). Conclusions The majority of pharyngeal gonorrhoea occurred without evidence of concurrent anogenital infection, and the high incidence-to-prevalence ratio suggests frequent spontaneous resolution of NAAT-detected infection. The association of pharyngeal gonorrhoea with oro-anal sex indicates that a broader range of sexual practices are likely to be involved in transmission of gonorrhoea to the pharynx than previously acknowledged. Screening the pharynx of sexually active homosexual men could play a role in reducing the prevalence of anogenital Neisseria gonorrhoeae.