There has been a rapid decline in the number of young heterosexuals diagnosed with genital warts at outpatient sexual health services since the national human papillomavirus (HPV) vaccination program started in Australia in 2007. We assessed the impact of the vaccination program on the number of in-patient treatments for genital warts.
Data on in-patient treatments of genital warts in all private hospitals were extracted from the Medicare website. Medicare is the universal health insurance scheme of Australia. In the vaccine period (2007–2011) and pre-vaccine period (2000–2007) we calculated the percentage change in treatment numbers and trends in annual treatment rates in private hospitals. Australian population data were used to calculate rates. Summary rate ratios of average annual trends were determined.
Between 2000 and 2011, 6,014 women and 936 men aged 15–44 years underwent in-patient treatment for genital warts in private hospitals. In 15–24 year old women, there was a significant decreasing trend in annual treatment rates of vulval/vaginal warts in the vaccine period (overall decrease of 85.3% in treatment numbers from 2007 to 2011) compared to no significant trend in the pre-vaccine period (summary rate ratio (SRR) = 0.33, p < 0.001). In 25–34 year old women, declining trends were seen in both vaccine and pre-vaccine periods (overall decrease of 33% vs. 24.3%), but the rate of change was greater in the vaccine period (SRR = 0.60, p < 0.001). In 35–44 year old women, there was no significant change in both periods (SRR = 0.91, p = 0.14). In 15–24 year old men, there was a significant decreasing trend in annual treatment rates of penile warts in the vaccine period (decrease of 70.6%) compared to an increasing trend in the pre-vaccine period (SRR = 0.76, p = 0.02). In 25–34 year old men there was a significant decreasing trend in the vaccine period compared to no change in the pre-vaccine period (SRR = 0.81, p = 0.04) and in 35–44 year old men there was no significant change in rates of penile warts both periods, but the rate of change was greater in the vaccine period (SRR = 0.70, p = 0.02).
The marked decline in in-patient treatment of vulval/vaginal warts in the youngest women is probably attributable to the HPV vaccine program. The moderate decline in in-patient treatments for penile warts in men probably reflects herd immunity.
To determine prevalence and incidence of bacterial vaginosis (BV) and risk factors in young sexually-active Australian women.
1093 women aged 16–25 years were recruited from primary-care clinics. Participants completed 3-monthly questionnaires and self-collected vaginal smears 6-monthly for 12-months. The primary endpoint was a Nugent Score = 7–10 (BV) and the secondary endpoint was a NS = 4–10 (abnormal flora [AF]). BV and AF prevalence estimates and 95% confidence intervals (95%CI) were derived, and adjusted odds ratios (AOR) calculated to explore epidemiological associations with prevalent BV and AF. Proportional-hazards regression models were used to examine factors associated with incident BV and AF.
At baseline 129 women had BV [11.8% (95%CI: 9.4–14.2)] and 188 AF (17.2%; 15.1–19.5). Prevalent BV was associated with having a recent female partner [AOR = 2.1; 1.0–4.4] and lack of tertiary-education [AOR = 1.9; 1.2–3.0]; use of an oestrogen-containing contraceptive (OCC) was associated with reduced risk [AOR = 0.6; 0.4–0.9]. Prevalent AF was associated with the same factors, and additionally with >5 male partners (MSP) in 12-months [AOR = 1.8; 1.2–2.5)], and detection of C.trachomatis or M.genitalium [AOR = 2.1; 1.0–4.5]. There were 82 cases of incident BV (9.4%;7.7–11.7/100 person-years) and 129 with incident AF (14.8%; 12.5–17.6/100 person-years). Incident BV and AF were associated with a new MSP [adjusted rate ratio (ARR) = 1.5; 1.1–2.2 and ARR = 1.5; 1.1–2.0], respectively. OCC-use was associated with reduced risk of incident AF [ARR = 0.7; 0.5–1.0].
This paper presents BV and AF prevalence and incidence estimates from a large prospective cohort of young Australian women predominantly recruited from primary-care clinics. These data support the concept that sexual activity is strongly associated with the development of BV and AF and that use of an OCC is associated with reduced risk.
In many countries, low Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) screening rates among young people in primary-care have encouraged screening programs outside of clinics. Nucleic acid amplification tests (NAATs) make it possible to screen people in homes with self-collected specimens. We systematically reviewed the strategies and outcomes of home-based CT/NG screening programs.
Electronic databases were searched for home-based CT and/or NG screening studies published since January 2005. Screening information (e.g. target group, recruitment and specimen-collection method) and quantitative outcomes (e.g. number of participants, tests and positivity) were extracted. The screening programs were classified into seven groups on the basis of strategies used.
We found 29 eligible papers describing 32 home-based screening programs. In seven outreach programs, people were approached in their homes: a median of 97% participants provided specimens and 76% were tested overall (13717 tests). In seven programs, people were invited to receive postal test-kits (PTKs) at their homes: a median of 37% accepted PTKs, 79% returned specimens and 19% were tested (46225 tests). PTKs were sent along with invitation letters in five programs: a median of 33% returned specimens and 29% of those invited were tested (15126 tests). PTKs were requested through the internet or phone without invitations in four programs and a median of 32% returned specimens (2666 tests). Four programs involved study personnel directly inviting people to receive PTKs: a median of 46% accepted PTKs, 21% returned specimens and 9.1% were tested (341 tests). PTKs were picked-up from designated locations in three programs: a total of 6765 kits were picked-up and 1167 (17%) specimens were returned for screening. Two programs used a combination of above strategies (2395 tests) but the outcomes were not reported separately. The overall median CT positivity was 3.6% (inter-quartile range: 1.7-7.3%).
A variety of strategies have been used in home-based CT/NG screening programs. The screening strategies and their feasibility in the local context need to be carefully considered to maximize the effectiveness of home-based screening programs.
Sexually transmitted infections; Chlamydia trachomatis; Screening; Home
HIV seroadaptive behaviours such as serosorting and strategic positioning are being increasingly practised by homosexual men, however, their impact on sexually transmissible infections (STIs) is unclear.
Participants were 1,427 initially HIV-negative men enrolled from 2001 to 2004 and followed to June 2007. Participants were tested annually for anal and urethral gonorrhoea and chlamydia, herpes simplex virus, and syphilis. In addition, they reported diagnoses of these conditions, and of genital and anal warts between annual visits, and sexual risk behaviours.
Compared with men who reported no unprotected anal intercourse (UAI), serosorting was associated with an increased risk of urethral (HR=1.97, 95% CI 1.43–2.72) and anal (HR=1.62, 95% CI 1.11–2.36) chlamydia. Compared with men who reported UAI with HIV non-concordant partners, men who practised serosorting had significantly lower risk of incident syphilis (HR=0.21, 95% CI 0.05–0.81) and urethral gonorrhoea (HR=0.61, 95% CI 0.39–0.96). Compared with men who reported no UAI, strategic positioning was associated with an increased risk of urethral gonorrhoea (HR=1.72, 95% CI 1.05–2.83) and chlamydia (HR=2.22, 95% CI 1.55–3.18). Compared with men who reported receptive UAI, the incidence of anal gonorrhoea (HR=0.38, 0.20–0.74) and chlamydia (HR= 0.44, 95% CI 0.27–0.69) was significantly lower in those who practised strategic positioning.
For men who reported seopadaptive behaviours, rates of some bacterial STIs were higher than in men who reported no UAI. However, rates were lower than for men who reported higher HIV risk behaviours.
Cohort study; STI; Homosexuality; male; HIV seroadaptive behaviour; Australia
We report the prevalence of penile implants among prisoners and determine the independent predictors for having penile implants. Questions on penile implants were included in the Sexual Health and Attitudes of Australian Prisoners (SHAAP) survey following concerns raised by prison health staff that increasing numbers of prisoners reported having penile implants while in prison.
Computer-Assisted Telephone Interviewing (CATI) of a random sample of prisoners was carried out in 41 prisons in New South Wales and Queensland (Australia). Men were asked, “Have you ever inserted or implanted an object under the skin of your penis?” If they responded Yes: “Have you ever done so while you were in prison?” Univariate logistic regression and logistic regression were used to determine the factors associated with penile implants.
A total of 2,018 male prisoners were surveyed, aged between 18 and 65 years, and 118 (5.8%) reported that they had inserted or implanted an object under the skin of their penis. Of these men, 87 (73%) had this done while they were in prison. In the multivariate analysis, a younger age, birth in an Asian country, and prior incarceration were all significantly associated with penile implants (p<0.001). Men with penile implants were also more likely to report being paid for sex (p<0.001), to have had body piercings (p<0.001) or tattoos in prison (p<0.001), and to have taken non-prescription drugs while in prison (p<0.05).
Penile implants appear to be fairly common among prisoners and are associated with risky sexual and drug use practices. As most of these penile implants are inserted in prison, these men are at risk of blood borne viruses and wound infection. Harm reduction and infection control strategies need to be developed to address this potential risk.
Syphilis is a growing public health problem among men who have sex with men (MSM) globally. Rapid and accurate detection of syphilis is vital to ensure patients and their contacts receive timely treatment and reduce ongoing transmission.
We evaluated a PCR assay for the diagnosis of Treponema pallidum using swabs of suspected early syphilis lesions in longitudinally assessed MSM.
We tested 260 MSM for T pallidum by PCR on 288 occasions: 77 (26.7%) had early syphilis that was serologically confirmed at baseline or within six weeks, and 211 (73.3%) remained seronegative for syphilis. Of 55 men with primary syphilis, 49 were PCR positive, giving a sensitivity of 89.1% (95% CI: 77.8%-95.9%) and a specificity of 99.1% (95% CI: 96.5%-99.9%). Of 22 men with secondary syphilis, 11 were PCR positive, giving a sensitivity of 50% (95% CI: 28.2%-71.8%) and a specificity of 100% (95% CI: 66.4%-71.8%). Of the 77 syphilis cases, 43 (56%) were HIV positive and the sensitivity and specificity of the PCR test did not vary by HIV status. The PCR test was able to detect up to five (10%) primary infections that were initially seronegative, including one HIV positive man with delayed seroconversion to syphilis (72 to 140 days) and one HIV positive man who did not seroconvert to syphilis over 14 months follow-up. Both men had been treated for syphilis within a week of the PCR test.
T pallidum PCR is a potentially powerful tool for the early diagnosis of primary syphilis, particularly where a serological response has yet to develop.
Syphilis; PCR; Evaluation
Background. Evidence suggests adherence to clinical guidelines for pelvic inflammatory disease (PID) diagnosis and management is suboptimal. We systematically reviewed the literature for studies describing strategies to improve the adherence to PID clinical guidelines. Methods. The databases MEDLINE and EMBASE, and reference lists of review articles were searched from January 2000 to April 2012. Only studies with a control group were included. Results. An interrupted time-series study and two randomised controlled trials (RCTs) were included. The interrupted time-series found that following a multifaceted patient and practitioner intervention (practice protocol, provision of antibiotics on-site, written instructions for patients, and active followup), more patients received the recommended antibiotics and attended for followup. One RCT found a patient video on PID self-care did not improve medication compliance and followup. Another RCT found an abbreviated PID treatment guideline for health-practitioners improved their management of PID in hypothetical case scenarios but not their diagnosis of PID. Conclusion. There is limited research on what strategies can improve practitioner and patient adherence to PID diagnosis and management guidelines. Interventions that make managing PID more convenient, such as summary guidelines and provision of treatment on-site, appear to lead to better adherence but further empirical evidence is necessary.
Surveillance designed to detect changes in the type-specific distribution of HPV in cervical intraepithelial neoplasia grade 3 (CIN-3) is necessary to evaluate the effectiveness of the Australian vaccination programme on cancer causing HPV types. This paper develops a protocol that eliminates the need to calculate required sample size; sample size is difficult to calculate in advance because HPV’s true type-specific prevalence is imperfectly known.
A truncated sequential sampling plan that collects a variable sample size was designed to detect changes in the type-specific distribution of HPV in CIN-3. Computer simulation to evaluate the accuracy of the plan at classifying the prevalence of an HPV type as low (< 5%), moderate (5-15%), or high (> 15%) and the average sample size collected was conducted and used to assess its appropriateness as a surveillance tool.
The plan classified the proportion of CIN-3 lesions positive for an HPV type very accurately, with >90% of simulations correctly classifying a simulated data-set with known prevalence. Misclassifying an HPV type of high prevalence as being of low prevalence, arguably the most serious kind of potential error, occurred < 0.05 times per 100 simulations. A much lower sample size (21–22 versus 40–48) was required to classify samples of high rather than low or moderate prevalence.
Truncated sequential sampling enables the proportion of CIN-3 due to an HPV type to be accurately classified using small sample sizes. Truncated sequential sampling should be used for type-specific HPV surveillance in the vaccination era.
This study aimed to estimate rates of chlamydia incidence and re-infection and to investigate the dynamics of chlamydia organism load in prevalent, incident and re-infections among young Australian women.
1,116 women aged 16 to 25 years were recruited from primary care clinics in Australia. Vaginal swabs were collected at 3 to 6 month intervals for chlamydia testing. Chlamydia organism load was measured by quantitative PCR.
There were 47 incident cases of chlamydia diagnosed and 1,056.34 person years of follow up with a rate of 4.4 per 100 person years (95% CI: 3.3, 5.9). Incident infection was associated with being aged 16 to 20 years [RR = 3.7 (95%CI: 1.9, 7.1)], being employed [RR = 2.4 (95%CI: 1.1, 4.9)] and having two or more new sex partners [RR = 5.5 (95%CI: 2.6, 11.7)]. Recent antibiotic use was associated with a reduced incidence [RR:0.1 (95%CI: 0.0, 0.5)]. There were 14 re-infections with a rate of 22.3 per 100 person years (95%CI: 13.2, 37.6). The median time to re-infection was 4.6 months. Organism load was higher for prevalent than incident infections (p<0.01) and for prevalent than re-infections (p<0.01).
Chlamydia is common among young women and a high proportion of women are re-infected within a short period of time, highlighting the need for effective partner treatment and repeat testing. The difference in organism load between prevalent and incident infections suggests prevalent infection may be more important for ongoing transmission of chlamydia.
Households with fixed-line telephones have decreased while mobile (cell) phone ownership has increased. We therefore sought to examine the feasibility of recruiting young women for a national health survey through random digit dialling mobile phones.
Two samples of women aged 18 to 39 years were surveyed by random digit dialling fixed and mobile numbers. We compared participation rates and responses to a questionnaire between women surveyed by each contact method.
After dialling 5,390 fixed-lines and 3,697 mobile numbers, 140 and 128 women were recruited respectively. Among women contacted and found to be eligible, participation rates were 74% for fixed-lines and 88% for mobiles. Taking into account calls to numbers where eligibility was unknown (e.g. unanswered calls) the estimated response rates were 54% and 45% respectively. Of women contacted by fixed-line, 97% reported having a mobile while 61% of those contacted by mobile reported having a fixed-line at home. After adjusting for age, there were no significant differences between mobile-only and fixed-line responders with respect to education, residence, and various health behaviours; however compared to those with fixed-lines, mobile-only women were more likely to identify as Indigenous (OR 4.99, 95%CI 1.52-16.34) and less likely to live at home with their parents (OR 0.09, 95%CI 0.03-0.29).
Random digit dialling mobile phones to conduct a health survey in young Australian women is feasible, gives a comparable response rate and a more representative sample than dialling fixed-lines only. Telephone surveys of young women should include mobile dialling.
Cellular phone; mobile phone; telephone surveys; survey methods; HPV vaccine
As most genital chlamydia infections are asymptomatic, screening is the main way to detect and cases for treatment. We undertook a systematic review of studies assessing the efficacy of interventions for increasing the uptake of chlamydia screening in primary care.
We reviewed studies which compared chlamydia screening in the presence and the absence of an intervention. The primary endpoints were screening rate or total tests.
We identified 16 intervention strategies; 11 were randomised controlled trials and five observational studies, 10 targeted females only, five both males and females, and one males only. Of the 15 interventions among females, six were associated with significant increases in screening rates at the 0.05 level including a multifaceted quality improvement program that involved provision of a urine jar to patients at registration (44% in intervention clinics vs. 16% in the control clinic); linking screening to routine Pap smears (6.9% vs. 4.5%), computer alerts for doctors (12.2% vs. 10.6%); education workshops for clinic staff; internet-based continuing medical education (15.5% vs. 12.4%); and free sexual health consultations (16.8% vs. 13.2%). Of the six interventions targeting males, two found significant increases including the multifaceted quality improvement program in which urine jars were provided to patients at registration (45% vs. 15%); and the offering by doctors of a test to all presenting young male clients, prior to consultation (29 vs. 4%).
Interventions that promoted the universal offer of a chlamydia test in young people had the greatest impact on increasing screening in primary care.
In Australia, HIV is concentrated in men who have sex with men (MSM) and rates have increased steadily over the past ten years. Health promotion strategies should ideally be informed by an understanding of both the prevalence of the factors being modified, as well as the size of the risk that they confer. We undertook an analysis of the potential population impact and cost saving that would likely result from modifying key HIV risk factors among men who have sex with men (MSM) in Sydney, Australia.
Proportional hazard analyses were used to examine the association between sexual behaviours in the last six months and sexually transmissible infections on HIV incidence in a cohort of 1426 HIV-negative MSM who were recruited primarily from community-based sources between 2001 and 2004 and followed to mid-2007. We then estimated the proportion of HIV infections that would be prevented if specific factors were no longer present in the population, using a population attributable risk (PAR) method which controls for confounding among factors. We also calculated the average lifetime healthcare costs incurred by the HIV infections associated with specific factors by estimating costs associated with clinical care and treatment following infection and discounting at 3% (1% and 5% sensitivity) to present value.
Unprotected anal intercourse (UAI) with a known HIV-positive partner was reported by 5% of men, the hazard ratio (HR) was 16.1 (95%CI:6.4-40.5), the PAR was 34% (95%CI:24-44%) and the average lifetime HIV-related healthcare costs attributable to UAI with HIV-positive partners were $AUD102 million (uncertainty range: $93-114 m). UAI with unknown HIV status partners was reported by 25% of men, the HR was 4.4 (95%CI:1.8-11.2), the PAR was 33% (95%CI:26-42%) and the lifetime incurred costs were $AUD99 million. Anal warts prevalence was 4%, the HR was 5.2 (95%CI:2.4-11.2), the PAR was 13% (95%CI:9-19%) and the lifetime incurred costs were $AUD39 million.
Our analysis has found that although UAI with an HIV-positive sexual partner is a relatively low-prevalence behaviour (reported by 5% of men), if this behaviour was not present in the population, the number of infections would be reduced by one third. No other single behaviour or sexually transmissible infections contributes to a greater proportion of infections and HIV-related healthcare costs.
Cohort studies are an important study design however they are difficult to implement, often suffer from poor retention, low participation and bias. The aims of this paper are to describe the methods used to recruit and retain young women in a longitudinal study and to explore factors associated with loss to follow up.
The Chlamydia Incidence and Re-infection Rates Study (CIRIS) was a longitudinal study of Australian women aged 16 to 25 years recruited from primary health care clinics. They were followed up via the post at three-monthly intervals and required to return questionnaires and self collected vaginal swabs for chlamydia testing. The protocol was designed to maximise retention in the study and included using recruiting staff independent of the clinic staff, recruiting in private, regular communication with study staff, making the follow up as straightforward as possible and providing incentives and small gifts to engender good will.
The study recruited 66% of eligible women. Despite the nature of the study (sexual health) and the mobility of the women (35% moved address at least once), 79% of the women completed the final stage of the study after 12 months. Loss to follow up bias was associated with lower education level [adjusted hazard ratio (AHR): 0.7 (95% Confidence Interval (CI): 0.5, 1.0)], recruitment from a sexual health centre as opposed to a general practice clinic [AHR: 1.6 (95% CI: 1.0, 2.7)] and previously testing positive for chlamydia [AHR: 0.8 (95% CI: 0.5, 1.0)]. No other factors such as age, numbers of sexual partners were associated with loss to follow up.
The methods used were considered effective for recruiting and retaining women in the study. Further research is needed to improve participation from less well-educated women.
To estimate the population attributable risk (PAR) for Chlamydia trachomatis infection in young men and women in Sydney, Australia.
Multivariate logistic regression was used to examine the association between demographic, sexual behaviour and other potential risk factors and chlamydia positivity in young (≤30 years) heterosexual international travellers (backpackers) and Australian residents attending a sexual health clinic. Point and interval estimates of PAR were calculated to quantify the proportion of chlamydia infections that can theoretically be prevented if a combination of risk factors is eliminated from a target population.
In males, the PAR associated with inconsistent condom use in the past 3 months was 65% (95% CI 56% to 71%) in backpackers compared to 50% (95% CI 41% to 56%) in non-backpackers and the PAR associated with reporting three or more female sexual partners in the past 3 months was similar between male backpackers and non-backpackers (33% (95% CI 28% to 40%) and 36% (95% CI 32% to 41%), respectively). In females, the PAR associated with inconsistent condom use in the past 3 months was 51% (95% CI 42% to 59%) in backpackers compared to 41% (95% CI 31% to 51%) in non-backpackers, and the PAR associated with reporting three or more male sexual partners in the past 3 months was 14% (95% CI 11% to 18%) in backpackers compared to 30% (95% CI 25% to 37%) in non-backpackers.
These findings suggest that the largest number of chlamydia infections could be avoided by increasing condom use, particularly in backpackers. Reporting multiple partners was also associated with a large proportion of infections and the risk associated with this behaviour should be considered in health promotion strategies.
Risk factors for chlamydia infection were determined among young, heterosexual backpackers and Australian residents.
A novel statistical methodology was used to investigate the potential impact of eliminating risk factors on chlamydia infection at a population level.
Results suggest that the majority of the chlamydia infections could be avoided by increased condom use, particularly among backpackers.
Multiple sex partners in past 3 months was also associated with a high proportion of chlamydia infections at the population level.
Strengths and limitations of this study
This is the first study to investigate the potential impact of sexual risk behaviours for chlamydia infection at the population level.
The study population was sexual health clinic attendees who are likely to be at higher risk for chlamydia infection compared to the general population.
Hepatitis C; HIV; HIV testing; homosexuality; infectious disease
To develop and validate a risk scoring tool to identify those who are at increased risk of chlamydia infection.
We used demographic data, sexual behaviour information and chlamydia positivity results from more than 45 000 individuals who attended Sydney Sexual Health Centre between 1998 and 2009. Participants were randomly allocated to either the development or internal validation data set. Using logistic regression, we created a prediction model and weighted scoring system using the development data set and calculated the odds ratio of chlamydia positivity for participants in successively higher quintiles of score. The internal validation data set was used to evaluate the performance characteristics of the model for five quintiles of risk scores including population attributable risk, sensitivity and specificity.
In the prediction model, inconsistent condom use, increased number of sexual partners in last 3 months, genital or anal symptoms and presenting to the clinic for sexually transmitted infections screening or being a contact of a sexually transmitted infection case were consistently associated with increased risk of chlamydia positivity in all groups. High scores (upper quintiles) were significantly associated with increased risk of chlamydia infection. A cut-point score of 20 or higher distinguished a increased risk group with a sensitivity of 95%, 67% and 79% among heterosexual men, women and men who have sex with men (MSM), respectively.
The scoring tool may be included as part of a health promotion and/or clinic website to prompt those who are at increased risk of chlamydia infection, which may potentially lead to increased uptake and frequency of testing.
The authors created a risk assessment tool that allows people to estimate their own chlamydia risk score based on simple non-invasive variables.
The tool described here will potentially provide a simple and cost-effective method of identifying and alerting individuals who would benefit from chlamydia screening.
This tool may be included as part of a health promotion and/or clinic website.
This tool may potentially lead to increased uptake and frequency of testing.
Strengths and Limitations
This is the first study to utilize statistical methods to derive a locally-specific assessment tool using 12 years of data from more than 45 000 men and women.
The Study population was sexual health clinic attendees who are likely to be at higher risk for Chlamydia infection compared to the general population.
Chlamydia infection; risk prediction; hepatitis C; HIV; HIV testing; homosexuality; infectious disease; epidemiology; sexual medicine; health informatics
Differences in the determinants of Chlamydia trachomatis ('chlamydia') and Mycoplasma genitalium (MG) genital infection in women are not well understood.
A cohort study of 16 to 25 year old Australian women recruited from primary health care clinics, aimed to determine chlamydia and MG prevalence and incidence. Vaginal swabs collected at recruitment were used to measure chlamydia and MG prevalence, organism-load and chlamydia-serovar a cross-sectional analysis undertaken on the baseline results is presented here.
Of 1116 participants, chlamydia prevalence was 4.9% (95% CI: 2.9, 7.0) (n = 55) and MG prevalence was 2.4% (95% CI: 1.5, 3.3) (n = 27). Differences in the determinants were found - chlamydia not MG, was associated with younger age [AOR:0.9 (95% CI: 0.8, 1.0)] and recent antibiotic use [AOR:0.4 (95% CI: 0.2, 1.0)], and MG not chlamydia was associated with symptoms [AOR:2.1 (95% CI: 1.1, 4.0)]. Having two or more partners in last 12 months was more strongly associated with chlamydia [AOR:6.4 (95% CI: 3.6, 11.3)] than MG [AOR:2.2 (95% CI: 1.0, 4.6)] but unprotected sex with three or more partners was less strongly associated with chlamydia [AOR:3.1 (95%CI: 1.0, 9.5)] than MG [AOR:16.6 (95%CI: 2.0, 138.0)]. Median organism load for MG was 100 times lower (5.7 × 104/swab) than chlamydia (5.6 × 106/swab) (p < 0.01) and not associated with age or symptoms for chlamydia or MG.
These results demonstrate significant chlamydia and MG prevalence in Australian women, and suggest that the differences in strengths of association between numbers of sexual partners and unprotected sex and chlamydia and MG might be due to differences in the transmission dynamics between these infections.
Knowledge of circulating Chlamydia trachomatis serovars can be beneficial for sexual network surveillance, monitoring treatment success, and associating specific clinical manifestations. Typically, C. trachomatis serovars are predicted by nucleotide sequencing of four variable domains within the ompA gene. However, sequencing procedures can be labor-intensive, are not readily available, and can lack the capacity to identify multiple serovars. This study describes the development and evaluation of a quantitative real-time PCR (qPCR) test algorithm for the rapid prediction of C. trachomatis serovars, including ocular (A to C) and anogenital (D to L3) strains. This test comprises a primary qPCR to confirm C. trachomatis positivity and the phylogenetic group(s) present and a secondary set of qPCRs to determine specific serovars. Cell culture isolates from 15 prototypic C. trachomatis serovars were correctly identified using this assay, with no cross-reactivity observed among serovars or with other common pathogenic microorganisms. Five hundred clinical specimens (previously diagnosed as being C. trachomatis positive) were evaluated by qPCR, with their results compared to results obtained by conventional sequencing. The qPCR identified 88.9% (423/476) complete matches (95% confidence interval [CI], 86 to 92%) of serovars compared to the results obtained using the sequence-based approach. Among the anogenital specimens, 2.4% (12/494) (95% CI, 1.3 to 4.2%) contained multiple serovars, categorized as single-serovar infections by conventional sequencing. Overall, this test exhibited high discriminatory success for predicting C. trachomatis serovars, particularly among anogenital infections. This is the first report of a qPCR typing assay offering differentiation of C. trachomatis serovars associated with both anogenital and ocular diseases.
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.
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.
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.
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.
sexually transmitted infections; homosexuality; Australia
To describe hospitalization rates, risk factors and associated diagnoses in people with HIV in Australia between 1999 and 2007.
Retrospective cohort study of people with HIV (n = 842) using data linkage between the Australian HIV Observational Database and administrative hospital morbidity data collections.
Incidence rate ratios with 95% confidence intervals were estimated using Poisson regression models to assess risk factors for hospitalization. Predictors of length of stay were assessed using generalized mixed models. The association between hospitalization and mortality was assessed using Cox regression.
In 4519 person-years of observation, there were 2667 hospital admissions; incidence rate of 59 per 100 person-years. Hospitalization rates were 50–300% higher in this cohort than comparable age and sex strata in the general population. Older age (incidence rate ratio 1.46, 95% confidence interval 1.28–1.65 per 10-year increase) and prior AIDS (incidence rate ratio 1.71, 95% confidence interval 1.24–2.35) were significantly associated with hospitalization. Other predictors of hospitalization included lower CD4 cell counts, higher HIV RNA, longer duration of HIV infection and experience with more drug classes. Lower CD4 cell counts, older age and hepatitis C virus antibody positivity were independently associated with longer hospital stay. Non-AIDS diseases were the principle reason for admission in the majority of cases. Mortality was associated with more frequent hospitalization during the study period.
Hospitalization rates are higher in people with HIV than the general population in Australia and are associated with markers of advanced HIV disease despite the widespread use of combination antiretroviral therapy.
AIDS; antiretroviral therapy; HIV; hospitalization; incidence
Concerns raised by opponents to condom provision in prisons have not been objectively examined and the issue continues to be debated. The long‐term effects of the introduction of condoms and dental dams into New South Wales (NSW) prisons in 1996 was examined, focusing on particular concerns raised by politicians, prison officers, prison nurses and prisoners. These groups were worried that (a) condoms would encourage prisoners to have sex, (b) condoms would lead to an increase in sexual assaults in prisons, (c) prisoners would use condoms to hide and store drugs and other contraband and (d) prisoners would use condoms as weapons.
Data sources included the NSW Inmate Health Survey (IHS) from 1996 and 2001 and official reports from the NSW Department of Corrective Services. The 1996 IHS involved 657 men and 132 women randomly selected from all prisons, with a 90% response rate. The 2001 survey involved 747 men and 167 women inmates, with an 85% response rate.
There was a decrease in reports of both consensual male‐to‐male sex and male sexual assaults 5 years after the introduction of condoms into prisons in 1996. The contents of condom kits were often used for concealing contraband items and for other purposes, but this was not associated with an increase in drug injecting in prison. Only three incidents of a condom being used in assaults on prison officers were recorded between 1996 and 2005; none was serious.
There exists no evidence of serious adverse consequences of distributing condoms and dental dams to prisoners in NSW. Condoms are an important public health measure in the fight against HIV and sexually transmitted diseases; they should be made freely available to prisoners as they are to other high‐risk groups in the community.
Although studies have shown reductions in mortality from AIDS after the introduction of combination antiretroviral treatment (cART), little is known about cause-specific mortality in low income settings in the cART era. We explored predictors of AIDS and non-AIDS mortality and compared cause-specific mortality across high and low income settings in the Asia Pacific region.
We followed patients in the Asia Pacific HIV Observational Database from the date they started cART (or cohort enrolment if cART initiation was identified retrospectively), until the date of death or last follow-up visit. Competing risks methods were used to estimate the cumulative incidence, and to investigate predictors, of AIDS and non-AIDS mortality.
Of 4252 patients, 215 died; 89 from AIDS, 97 from non-AIDS causes and 29 from unknown causes. Age >50 years (hazard ratio (HR), 4.29; 95%CI, 2.10-8.79) and CD4 counts ≤100 cells/μL (HR, 8.59; 95%CI, 5.66-13.03) were associated with an increased risk of non-AIDS mortality. Risk factors for AIDS mortality included CD4 counts ≤100 cells/μL (HR, 34.97; 95%CI, 18.01-67.90) and HIV RNA ≥10,001 (HR 4.21; 95%CI 2.07-8.55). There was some indication of a lower risk of non-AIDS mortality in Asian high, and possibly low, income countries compared to Australia.
Immune deficiency is associated with an increased risk of AIDS and non-AIDS mortality. Older age predicts non-AIDS mortality in the cART era. Less conclusive was the association between country-income level and cause-specific mortality because of the relatively high proportion of unknown causes of death in low income settings.
HIV; cohort studies; AIDS; antiretroviral therapy, highly active; causes of death; survival analysis, competing-risks models
To characterise patients who decline to provide their surname at a public sexual health centre.
A case–control study of all patients first attending the Sydney Sexual Health Centre from 1998 to 2004, using proforma‐collected electronic data to compare patients who did not provide their surname with those who did. In addition, the frequencies of the 10 most common surnames in the Sydney telephone directory were compared with the frequency of those names in the patient database.
Of 27 241 patients, 1350 (5%) declined to provide their surname. The most common surnames were also over‐represented, suggesting that aliases remained pervasive among the centre's patients. Sex workers, married people and people requesting HIV, hepatitis or sexually transmissible infection (STI) screening were all more likely to decline to provide a surname. By contrast, patients with symptoms, patients who were referred with a prior STI diagnosis and patients with a new bacterial or non‐HIV viral STI or were a known contact with STI were all significantly more likely to provide a surname. Among patients who declined to provide a surname, 20 tested HIV positive.
The anonymous option did not seem to eliminate the use of aliases. Although limited, there seems to be a market for anonymous sexual health screening, particularly for the asymptomatic.
To determine if the provision of condoms to prisoners in two Australian state prison systems with different policies affects sexual behaviour. In New South Wales’ (NSW) prisons, condoms are freely distributed, while in Queensland prisons none are distributed.
We used a computer-assisted telephone interview to survey randomly selected prisoners in both states about their sexual behaviour in prison.
Two thousand and eighteen male prisoners participated. The proportion of prisoners reporting anal sex in prison was equally low in NSW (3.3%) and Queensland (3.6%; p=0.8). A much higher proportion of prisoners who engaged in anal sex in NSW (56.8%) than Queensland (3.1%; p<0.0001) reported they had used a condom if they had had anal sex in prison. Sexual coercion was equally rare in both prison systems.
We found no evidence that condom provision to prisoners increased consensual or non-consensual sexual activity in prison. If available, condoms were much more likely to be used during anal sex. Condoms should be made available to prisoners as a basic human right.
PRISONERS; CONDOMS; PREVENTION