Sexual safety and HIV prevention in travel medicine: Practical considerations and new approaches

Provider views of pre-exposure prophylaxis (PrEP) for cisgender women - where do women fit in HIV elimination in Australia?

BACKGROUND

HIV pre-exposure prophylaxis (PrEP) in Australia has largely been targeted at gay, bisexual and other men who have sex with men. In the context of HIV elimination, the aim of this qualitative study was to explore PrEP prescribing for Australian cisgender women from the provider's perspective.

METHODS

Semi-structured interviews were held with Australian prescribers in 2022. Participants were recruited through relevant clinical services, newsletter distribution and snowball sampling. Interviews were audio-recorded, transcribed and analysed thematically.

RESULTS

Seventeen prescribers participated, of whom 9 were sexual health physicians and 10 worked in New South Wales. All reported limited clinical experience prescribing PrEP for women. Potential enablers to PrEP prescribing to women included education for women and clinicians, easily identifiable risk factors, individualised risk assessment and expansion of existing services. Barriers were limited PrEP awareness among women and prescribers, difficulties with risk assessment and consult and service limitations. The type of service recommended for PrEP provision varied among participants.

CONCLUSIONS

Clinician experience of PrEP prescribing to Australian cisgender women is limited, with substantial barriers to access perceived by prescribers. Targeted education to PrEP prescribers, updated national PrEP guidelines to include women as a distinct group and further research regarding women's preferred model of PrEP access are required. Clarity of clinical ownership over PrEP implementation for women and, more broadly, women's sexual health, is essential in order to achieve HIV elimination in Australia.

Travelling with HIV in the XXI century: Case report and narrative review

The number of migrants and travellers has grown in recent decades. This phenomenon is also true of people living with HIV, given their much-improved life expectancy and quality of life. A significant number of travellers with HIV are migrants returning to their home countries to visit friends and relatives (VFRs). This population constitutes a high-risk group because they travel for longer and often to rural and remote areas and have closer contact with the local population. In this review we discuss the sociodemographic characteristics of travellers with HIV, the differences between conventional travellers and VFRs, and the risks of HIV acquisition and transmission during travel. We also present the most relevant travel-associated illnesses and highlight the particularities of pre-travel advice given to this population, including immunosuppression, responses to vaccines, high incidence of comorbidities, drug interactions, legal and language barriers. The need to integrate these factors based on far less evidence than that available for the general population makes pre-travel advice for travellers with HIV genuinely challenging.

Disparities in characteristics in accessing public Australian sexual health services between Medicare-eligible and Medicare-ineligible men who have sex with men

OBJECTIVES

Accessible health services are a key element of effective human immunodeficiency virus (HIV) and sexually transmitted infection (STI) control. This study aimed to examine whether there were any differences in accessing sexual health services between Medicare-eligible and Medicare-ineligible men who have sex with men (MSM) in Melbourne, Australia.

METHODS

We conducted a retrospective, cross-sectional study of MSM attending Melbourne Sexual Health Centre between 2016 and 2019. Demographic characteristics, sexual practices, HIV testing practices and STI diagnoses were compared between Medicare-eligible and Medicare-ineligible MSM.

RESULTS

We included 5,085 Medicare-eligible and 2,786 Medicare-ineligible MSM. Condomless anal sex in the past 12 months was more common in Medicare-eligible compared to Medicare-ineligible MSM (74.4% vs. 64.9%; p<0.001) although the number of partners did not differ between groups. There was no difference in prior HIV testing practices between Medicare-eligible and Medicare-ineligible MSM (76.1% vs. 77.7%; p=0.122). Medicare-ineligible MSM were more likely to have anorectal chlamydia compared to Medicare-eligible MSM (10.6% vs. 8.5%; p=0.004).

CONCLUSIONS

Medicare-ineligible MSM have less condomless sex but a higher rate of anorectal chlamydia, suggesting they might have limited access to STI testing or may be less willing to disclose high-risk behaviour. Implications for public health: Scaling up access to HIV and STI testings for Medicare-ineligible MSM is essential.

Antimicrobial resistance in sexually transmitted infections

RATIONALE FOR REVIEW

International travel facilitates the spread of drug-resistant infections, including sexually transmitted infections (STIs). In 2016, the World Health Organization highlighted the global burden of 'curable' STIs, estimating 376 million new infections of gonorrhoea, chlamydia, syphilis and trichomoniasis annually, with considerable geographic variation in both the burden of disease and prevalence of resistance. Travelers' risk of contracting and transmitting drug-resistant STIs depends in part on their geographic exposure. In this review, we describe the epidemiology of antimicrobial resistance (AMR) and the management of these four common STIs and Mycoplasma genitalium, an increasingly recognized cause of non-gonococcal urethritis.

KEY FINDINGS

Multi-drug and extensively drug resistant gonorrhoea strains have been associated with international spread, particularly in travelers returning from Southeast Asia. Chlamydia is the most common bacterial STI worldwide. Although in vitro resistance has been reported, surveillance data suggest that clinically significant resistance to macrolides and tetracyclines is rare. Macrolide resistance in syphilis is now endemic in much of the world but there is no documented penicillin resistance, which remains first-line therapy. Trichomoniasis is the most common non-viral STI worldwide. Although clinical failure after treatment occurs, resistance to metronidazole is thought to be uncommon. Mycoplasma genitalium exhibits intrinsic resistance to many antibiotics, and the prevalence of resistance to both first- and second-line regimens (macrolides and fluoroquinolones) is increasing worldwide, with limited alternative therapeutic options.

RECOMMENDATIONS

International travelers are at risk for acquiring resistant STIs with limited therapeutic options. Improved diagnostics are urgently needed to improve AMR surveillance and the management of infected patients. As no vaccinations are currently available for these STIs, and pre-exposure prophylaxis is an area of active study with limited data, condom use is critical for prevention. Travel medicine providers should incorporate STI risk reduction counselling, with an emphasis on condom use, into the routine pre-travel consultation.

Travel-associated STI amongst HIV and non-HIV infected travellers

BACKGROUND

The incidence of sexually transmitted infections (STI) is increasing in Western countries whilst travel plays a major role in STI dissemination worldwide. However, there is no study distinguishing HIV-positive and HIV-negative travellers.

METHODS

We retrospectively evaluated the epidemiological, clinical and biological characteristics of the patients diagnosed with a travel-related STI between 2008 and 2016. We describe and compare the spectrum of STI diagnosed amongst HIV-positive and negative travellers.

METHODS

Overall, 163 travel-related STI were identified in 140 patients (89% male, 54% men having sex with men, 40% HIV-positive). Symptoms occurred during travel in 39% of them, otherwise the median time between return and symptoms' onset was 13 days. Amongst the 84 HIV-negative travellers, the main STI were primary HIV infections (n = 36, 38%), Neisseria gonorrhoeae (NG) infections (17%) and primary herpes infection (14, vs 1.5% amongst HIV-positive travellers, P = 0.01). The regions of exposure to HIV were concordant with the known geographical distribution of HIV subtypes. Amongst the 56 HIV-positive travellers, the main STI were syphilis (43, vs 6% amongst HIV-negative travellers, P = 0.01), Chlamydia trachomatis (CT) infections (22, vs 13% amongst HIV-negative travellers, P = 0.08), NG infections (13%) and acute hepatitis C (12, vs 1% amongst HIV-negative travellers, P = 0.01), with a predominance of anal forms for both CT and NG infections.

CONCLUSIONS

The spectrum of STI diagnosed in returning travellers is broad with important differences according to HIV status. In our setting, primary HIV infection was the leading STI in non-HIV infected patients, which suggests that pre-exposure prophylaxis may have a role in HIV prevention in at-risk travellers.