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Wang H, Molina JM, Dray-Spira R, Schmidt AJ, Hickson F, van de Vijver D, Jonas KJ. Spatio-temporal changes in pre-exposure prophylaxis uptake among MSM in mainland France between 2016 and 2021: a Bayesian small area approach with MSM population estimation. J Int AIDS Soc 2023; 26:e26089. [PMID: 37221971 PMCID: PMC10206410 DOI: 10.1002/jia2.26089] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 04/25/2023] [Indexed: 05/25/2023] Open
Abstract
INTRODUCTION In France, oral pre-exposure prophylaxis (PrEP) for HIV prevention has been publicly available since 2016, mainly targeting at men who have sex with men (MSM). Reliable and robust estimations of the actual PrEP uptake among MSM on a localized level can provide additional insights to identify and better reach marginalized MSM within current HIV prevention service provision. This study used national pharmaco-epidemiology surveillance data and regional MSM population estimations to model the spatio-temporal distribution of PrEP uptake among MSM in France 2016-2021 to identify marginalized MSM at risk for HIV and increase their PrEP uptake. METHODS We first applied Bayesian spatial analyses with survey-surveillance-based HIV incidence data as a spatial proxy to estimate the size of (1) regional HIV-negative MSM populations and (2) MSM who could be eligible for PrEP use according to French PrEP guidelines. We then applied Bayesian spatio-temporal ecological regression modelling to estimate the regional prevalence and relative probability of the overall- and new-PrEP uptake from 2016 to 2021 across France. RESULTS HIV-negative and PrEP-eligible MSM populations vary regionally across France. Île-de-France was estimated to have the highest MSM density compared to other French regions. According to the final spatio-temporal model, the relative probability of overall PrEP uptake was heterogeneous across France but remained stable over time. Urban areas have higher-than-average probabilities of PrEP uptake. The prevalence of PrEP use increased steadily (ranging from 8.8% [95% credible interval 8.5%;9.0%] in Nouvelle-Aquitaine to 38.2% [36.5%;39.9%] in Centre-Val-de-Loire in 2021). CONCLUSIONS Our results show that using Bayesian spatial analysis as a novel methodology to estimate the localized HIV-negative MSM population is feasible and applicable. Spatio-temporal models showed that despite the increasing prevalence of PrEP use in all regions, geographical disparities and inequalities of PrEP uptake continued to exist over time. We identified regions that would benefit from greater tailoring and delivery efforts. Based on our findings, public health policies and HIV prevention strategies could be adjusted to better combat HIV infections and to accelerate ending the HIV epidemic.
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Affiliation(s)
- Haoyi Wang
- Department of Work and Social Psychology, Maastricht University, Maastricht, the Netherlands
- Viroscience Department, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Jean-Michel Molina
- Department of Infectious Diseases, Hôpital Saint-Louis, University of Paris Cité, Paris, France
| | - Rosemary Dray-Spira
- EPI-PHARE, French National Agency for Medicines and Health Products Safety (ANSM) and French National Health Insurance (CNAM), Saint-Denis, France
| | - Axel J Schmidt
- Sigma Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Ford Hickson
- Sigma Research, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Kai J Jonas
- Department of Work and Social Psychology, Maastricht University, Maastricht, the Netherlands
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Assaf RD, Cunningham NJ, Adamson PC, Jann JT, Bolan RK. High proportions of rectal and pharyngeal chlamydia and gonorrhoea cases among cisgender men are missed using current CDC screening recommendations. Sex Transm Infect 2022; 98:586-591. [PMID: 35217590 PMCID: PMC9402804 DOI: 10.1136/sextrans-2021-055361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 02/06/2022] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES Pharyngeal and rectal Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections are often undiagnosed due to their asymptomatic nature. This study aims to determine (1) the prevalence of CT/NG infections by anatomical site among cisgender men; (2) the proportion of missed CT/NG rectal/pharyngeal infections if urogenital testing alone was performed or screening depended on self-reported behaviour alone; and (3) the predictive probability of self-reported behaviours for rectal CT/NG. METHODS This cross-sectional study used electronic health records collected at a sexual health clinic in Los Angeles from 18 November 2018 until 28 February 2020. The included patients were ≥18 years of age cisgender men who received CT/NG testing at least once during the study period. We calculated the proportion of missed pharyngeal/rectal CT/NG infections if only urogenital testing had been done and if testing was based only on self-reported anal sex. Separately, we ran logistic regressions for predictive probability of self-reported anal sex on CT/NG rectal infections. RESULTS Overall, there were 13 476 unique patients with 26 579 visits. The prevalence of any extragenital CT/NG infection was 37.28%. Over 80% rectal/pharyngeal CT cases and over 65% rectal/pharyngeal NG cases would be missed if urogenital testing alone was performed. Likewise, over 35% rectal CT/NG cases would be missed had testing relied on self-reported sexual behaviours alone. CONCLUSIONS The proportion of missed rectal and pharyngeal CT/NG infections is high. Our data from a sexual health clinic lend support to three-site opt-out testing for cisgender men attending a sexual health/Lesbian, Gay, Bisexual, Transgender, Queer/Questioning (LGBTQ+) specialty clinic regardless of their sexual orientation or reported sexual behaviours.
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Affiliation(s)
- Ryan D Assaf
- Health Services, Los Angeles LGBT Center, Los Angeles, California, USA
- Epidemiology, University of California Los Angeles Jonathan and Karin Fielding School of Public Health, Los Angeles, California, USA
| | | | - Paul C Adamson
- Division of Infectious Diseases, David Geffen School of Medicine, Los Angeles, California, USA
| | | | - Robert K Bolan
- Health Services, Los Angeles LGBT Center, Los Angeles, California, USA
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Brooks RA, Nieto O, Cabral A, Landrian A, Fehrenbacher AE. Delivering PrEP to adults with "low" or "no" HIV risk and youth: experiences and perspectives of PrEP providers. CULTURE, HEALTH & SEXUALITY 2020; 24:1-14. [PMID: 32996431 PMCID: PMC8007677 DOI: 10.1080/13691058.2020.1817560] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 08/25/2020] [Indexed: 06/11/2023]
Abstract
Health care providers have an important role to play in expanding PrEP uptake to populations disproportionately burdened by HIV. In this study, in-depth, semi-structured qualitative interviews were conducted with 20 PrEP providers in Los Angeles, California to explore their experiences and perspectives prescribing PrEP. Overall, the findings indicate that providers generally adhered to US CDC clinical guidelines in determining PrEP eligibility. However, they also identified special considerations with respect to adults with "low" or "no" HIV risk. Three themes were developed from the data related to the delivery of PrEP to such individuals: 1) patients may not disclose sexual behaviours; 2) patient autonomy and agency; and 3) the importance of PrEP in gay male monogamous relationships. Two additional themes were identified related to prescribing PrEP to young people under the age of consent: 4) the need for more PrEP and sexual health education with youth and 5) challenges in providing PrEP to youth without parental consent. Findings highlight the importance of providing PrEP to patients who could potentially benefit from adoption, whether or not they present with clear behavioural indicators for PrEP. Providers should also consider the potential barriers to delivering PrEP to youth to ensure successful adoption among members of this population.
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Affiliation(s)
- Ronald A. Brooks
- Department of Family Medicine, University of California, Los Angeles, CA, USA
- Center for HIV Identification, Prevention, and Treatment Services (CHIPTS), University of California, Los Angeles, CA, USA
| | - Omar Nieto
- Department of Family Medicine, University of California, Los Angeles, CA, USA
| | - Alejandra Cabral
- Department of Family Medicine, University of California, Los Angeles, CA, USA
- Department of Community Health Sciences, Fielding School of Public Health, University of California, Los Angeles, CA, USA
| | - Amanda Landrian
- Department of Family Medicine, University of California, Los Angeles, CA, USA
- Department of Community Health Sciences, Fielding School of Public Health, University of California, Los Angeles, CA, USA
| | - Anne E. Fehrenbacher
- Center for HIV Identification, Prevention, and Treatment Services (CHIPTS), University of California, Los Angeles, CA, USA
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, USA
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Meireles P, Plankey M, Rocha M, Brito J, Mendão L, Barros H. Different guidelines for pre-exposure prophylaxis (PrEP) eligibility estimate HIV risk differently: an incidence study in a cohort of HIV-negative men who have sex with men, Portugal, 2014-2018. Euro Surveill 2020; 25:1900636. [PMID: 32700673 PMCID: PMC7376846 DOI: 10.2807/1560-7917.es.2020.25.28.1900636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 05/15/2020] [Indexed: 11/20/2022] Open
Abstract
IntroductionGuidelines for pre-exposure prophylaxis (PrEP) provide criteria to identify individuals at higher risk of HIV infection. We compared the ability to predict HIV seroconversion of four guidelines: the World Health Organization (WHO), the United States Public Health Service and Centers for Disease Control and Prevention (US CDC), the European AIDS Clinical Society (EACS) and the Portuguese National Health Service (PNHS).AimWe aimed to measure the association between guideline-specific eligibility and HIV seroconversion.MethodsWe studied 1,254 participants from the Lisbon Cohort of men who have sex with men with at least two evaluations between March 2014 and March 2018, corresponding to 1,724.54 person-years (PY) of follow-up. We calculated incidence rates (IR) according to each guideline eligibility definition and incident rate ratios (IRR) to test the association between eligibility at baseline and HIV seroconversion.ResultsWe found 28 incident cases (IR: 1.62/100 PY; 95% confidence interval (CI) 1.12-2.35). Guidelines' sensitivity varied from 60.7% (EACS) to 85.7% (PNHS) and specificity varied from 31.8% (US CDC) to 51.5% (EACS). IR was highest among those defined as eligible by the PNHS guideline (2.46/100 PY; IRR = 4.61; 95% CI: 1.60-13.27) and lowest for the WHO guideline (1.89/100 PY; IRR = 1.52; 95% CI: 0.69-3.35).ConclusionsBeing identified as eligible for PrEP was associated with a higher risk of infection. The magnitude of risk varied according to the guideline used. However, the number of HIV infections identified among ineligible participants highlights the potential for missing people who need PrEP.
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Affiliation(s)
- Paula Meireles
- EPIUnit-Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
| | - Michael Plankey
- Georgetown University Medical Center, Georgetown University, Washington DC, United States
| | - Miguel Rocha
- GAT-Grupo de Ativistas em Tratamentos, Lisboa, Portugal
- Coalition PLUS Community-Based Research Laboratory, Patin, France
| | - João Brito
- GAT-Grupo de Ativistas em Tratamentos, Lisboa, Portugal
- Coalition PLUS Community-Based Research Laboratory, Patin, France
| | - Luís Mendão
- GAT-Grupo de Ativistas em Tratamentos, Lisboa, Portugal
- Coalition PLUS Community-Based Research Laboratory, Patin, France
| | - Henrique Barros
- EPIUnit-Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
- Departamento de Ciências da Saúde Pública e Forenses e Educação Médica, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
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Current US Guidelines for Prescribing HIV Pre-exposure Prophylaxis (PrEP) Disqualify Many Women Who Are at Risk and Motivated to Use PrEP. J Acquir Immune Defic Syndr 2020; 81:395-405. [PMID: 30973543 DOI: 10.1097/qai.0000000000002042] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND US Centers for Disease Control and Prevention clinical guidelines for HIV pre-exposure prophylaxis (PrEP) are widely used to assess patients' PrEP eligibility. The guidelines include 2 versions of criteria-guidance summary criteria and recommended indications criteria-that diverge in a potentially critical way for heterosexually active women: Both require women's knowledge of their own risk behavior, but the recommended indications also require women's knowledge of their partners' HIV risk or recognition of a potentially asymptomatic sexually transmitted infection. This study examined women's PrEP eligibility according to these 2 different versions of criteria across risk and motivation categories. SETTING/METHODS HIV-negative women (n = 679) recently engaged in care at Connecticut Planned Parenthood centers were surveyed online in 2017. The survey assessed PrEP eligibility by both versions of Centers for Disease Control and Prevention criteria, HIV risk indicators, PrEP motivation indicators, and sociodemographic characteristics. RESULTS Participants were mostly non-Hispanic white (33.9%) or black (35.8%) and had low income (<$30,000/year; 58.3%). Overall, 82.3% were eligible for PrEP by guidance summary criteria vs. 1.5% by recommended indications criteria. Women disqualified by recommended indications criteria included those reporting condomless sex with HIV-positive or serostatus-unknown male partners (n = 27, 11.1% eligible); 1 or more recent sexually transmitted infection(s) (n = 53, 3.8% eligible); multiple sex partners (n = 168, 3.0% eligible); intended PrEP use (n = 211, 2.8% eligible); and high self-perceived risk (n = 5, 0.0% eligible). CONCLUSION Current guidelines disqualify many women who could benefit from PrEP and may lead to discrepant assessments of eligibility. Guideline reform is needed to improve clarity and increase women's PrEP access and consequent HIV protection.
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Wirden M, De Oliveira F, Bouvier-Alias M, Lambert-Niclot S, Chaix ML, Raymond S, Si-Mohammed A, Alloui C, André-Garnier E, Bellecave P, Malve B, Mirand A, Pallier C, Poveda JD, Rabenja T, Schneider V, Signori-Schmuck A, Stefic K, Calvez V, Descamps D, Plantier JC, Marcelin AG, Visseaux B. New HIV-1 circulating recombinant form 94: from phylogenetic detection of a large transmission cluster to prevention in the age of geosocial-networking apps in France, 2013 to 2017. Euro Surveill 2019; 24:1800658. [PMID: 31576801 PMCID: PMC6774227 DOI: 10.2807/1560-7917.es.2019.24.39.1800658] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BackgroundEnding the HIV pandemic must involve new tools to rapidly identify and control local outbreaks and prevent the emergence of recombinant strains with epidemiological advantages.AimThis observational study aimed to investigate in France a cluster of HIV-1 cases related to a new circulating recombinant form (CRF). The confirmation this CRF's novelty as well as measures to control its spread are presented.MethodsPhylogenetic analyses of HIV sequences routinely generated for drug resistance genotyping before 2018 in French laboratories were employed to detect the transmission chain. The CRF involved was characterised by almost full-length viral sequencing for six cases. Cases' clinical data were reviewed. Where possible, epidemiological information was collected with a questionnaire.ResultsThe transmission cluster comprised 49 cases, mostly diagnosed in 2016-2017 (n = 37). All were infected with a new CRF, CRF94_cpx. The molecular proximity of this CRF to X4 strains and the high median viraemia, exceeding 5.0 log10 copies/mL, at diagnosis, even in chronic infection, raise concerns of enhanced virulence. Overall, 41 cases were diagnosed in the Ile-de-France region and 45 were men who have sex with men. Among 24 cases with available information, 20 reported finding partners through a geosocial networking app. Prevention activities in the area and population affected were undertaken.ConclusionWe advocate the systematic use of routinely generated HIV molecular data by a dedicated reactive network, to improve and accelerate targeted prevention interventions. Geosocial networking apps can play a role in the spread of outbreaks, but could also deliver local targeted preventive alerts.
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Affiliation(s)
- Marc Wirden
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique IPLESP, AP-HP, Hôpital Pitié Salpêtrière, Laboratoire de virologie, Paris, France
| | - Fabienne De Oliveira
- Normandie Université, UNIROUEN, EA2656 GRAM, CHU de Rouen, Laboratoire de virologie associé au CNR VIH, Rouen, France
| | | | | | - Marie-Laure Chaix
- AP-HP, Hôpital Saint-Louis, Laboratoire de virologie, INSERM U944, Paris, France
| | | | | | - Chakib Alloui
- Laboratoire de virologie, Hôpital Avicenne, Bobigny, France
| | | | | | - Brice Malve
- Laboratoire de virologie CHU de Nancy, Nancy, France
| | - Audrey Mirand
- Laboratoire de virologie CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | - Coralie Pallier
- Laboratoire de virologie, Hôpital P. Brousse, Villejuif, France
| | | | - Theresa Rabenja
- Laboratoire du Grand Hôpital de l’Est Francilien, Jossigny, France
| | | | | | - Karl Stefic
- Laboratoire de virologie CHU de Tours, Tours, France
| | - Vincent Calvez
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique IPLESP, AP-HP, Hôpital Pitié Salpêtrière, Laboratoire de virologie, Paris, France
| | - Diane Descamps
- Laboratoire de virologie, AP-HP, Hopital Bichat Claude Bernard, Univ Paris-Diderot, INSERM, IAME, CNR VIH, Paris, France
| | - Jean-Christophe Plantier
- Normandie Université, UNIROUEN, EA2656 GRAM, CHU de Rouen, Laboratoire de virologie associé au CNR VIH, Rouen, France
| | - Anne-Genevieve Marcelin
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique IPLESP, AP-HP, Hôpital Pitié Salpêtrière, Laboratoire de virologie, Paris, France
| | - Benoit Visseaux
- Laboratoire de virologie, AP-HP, Hopital Bichat Claude Bernard, Univ Paris-Diderot, INSERM, IAME, CNR VIH, Paris, France
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Harney BL, Agius PA, El-Hayek C, Fairley CK, Chow EPF, Roth N, Tee BK, Leslie D, Tachedjian G, Hellard M, Stoové M. Risk of Subsequent HIV Infection Following Sexually Transmissible Infections Among Men Who Have Sex With Men. Open Forum Infect Dis 2019; 6:ofz376. [PMID: 31660341 PMCID: PMC6785675 DOI: 10.1093/ofid/ofz376] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 08/20/2019] [Indexed: 11/30/2022] Open
Abstract
Background HIV and bacterial sexually transmissible infection (STI) notifications among men who have sex with men (MSM) have increased in Australia and many other countries. The relationship between HIV infection and other STIs has been demonstrated previously. However, the relationship between the cumulative history of STIs and subsequent HIV infection remains largely unexplored and limits our understanding of the mechanisms underpinning the elevated HIV risk. Methods Data from HIV-negative MSM who attended high–HIV caseload primary care clinics in Melbourne, Australia, from 2007 to 2014 with 2 or more HIV and STI tests were included. Controlling for sexual behaviors self-reported at clinic visits, discrete time survival analyses using generalized linear modeling estimated the effect of an STI at the prior test event and the cumulative history of STIs (none, 1, 2, or more [repeated]) on risk of HIV infection. Results A total of 8941 MSM met the study criteria; 227 (2.5%) were diagnosed with HIV over the follow-up period. Adjusting for sexual behaviors, a cumulative history of repeated rectal gonorrhea infections (adjusted hazard ratio [aHR], 6.27; 95% confidence interval [CI], 2.68–14.50) and a single rectal gonorrhea infection (aHR, 2.09; 95% CI, 1.15–3.79) were associated with increased HIV infection risk. Conclusions Repeated and single rectal gonorrhea infections were independently associated with increased HIV infection risk. These findings suggest that MSM with any history of rectal gonorrhea, particularly repeat rectal gonorrhea, represent a group for whom preventive interventions for HIV should be emphasized.
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Affiliation(s)
- Brendan L Harney
- Disease Elimination Program, Burnet Institute, Melbourne, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Paul A Agius
- Disease Elimination Program, Burnet Institute, Melbourne, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Judith Lumley Centre, La Trobe University, Bundoora, Australia
| | - Carol El-Hayek
- Disease Elimination Program, Burnet Institute, Melbourne, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Christopher K Fairley
- Melbourne Sexual Health Centre, Alfred Health, Carlton, Australia.,Central Clinical School, Monash University, Melbourne, Australia
| | - Eric P F Chow
- Melbourne Sexual Health Centre, Alfred Health, Carlton, Australia.,Central Clinical School, Monash University, Melbourne, Australia
| | | | - B K Tee
- Centre Clinic, Victorian AIDS Council, St Kilda, Australia
| | - David Leslie
- Victorian Infectious Disease Reference Laboratory, Doherty Institute, The University of Melbourne, Melbourne, Australia
| | - Gilda Tachedjian
- Disease Elimination Program, Burnet Institute, Melbourne, Australia.,Department of Microbiology, Monash University, Clayton, Australia.,Department of Microbiology and Immunology, Doherty Institute, The University of Melbourne, Melbourne, Australia
| | - Margaret Hellard
- Disease Elimination Program, Burnet Institute, Melbourne, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Mark Stoové
- Disease Elimination Program, Burnet Institute, Melbourne, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Cornelisse VJ, Wright EJ, Fairley CK, McGuinness SL. Sexual safety and HIV prevention in travel medicine: Practical considerations and new approaches. Travel Med Infect Dis 2018; 28:68-73. [PMID: 30562582 DOI: 10.1016/j.tmaid.2018.12.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 12/12/2018] [Accepted: 12/14/2018] [Indexed: 11/25/2022]
Abstract
Travellers who engage in sexual contact with a new sexual partner abroad may be at high risk of HIV and other sexually transmitted infections (STIs), but these risks can be reduced through appropriate planning during the pre-travel clinic visit. Here we discuss strategies available to the clinician to maximise travellers' sexual safety during travel. Strategies may include immunizations, condoms, HIV pre-exposure prophylaxis (PrEP), HIV post-exposure prophylaxis (PEP), self-initiated treatment of symptomatic bacterial STIs, post-exposure prophylaxis for bacterial STIs and hormonal contraception. We discuss the role of these different strategies for travellers, and provide resources to assist clinicians in making clinical decisions and in educating travellers about sexual safety.
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Affiliation(s)
- Vincent J Cornelisse
- Central Clinical School, Monash University, Melbourne, Australia; Melbourne Sexual Health Centre, Alfred Health, Melbourne, Australia; Department of Infectious Diseases, The Alfred Hospital, Alfred Health, Melbourne, Australia.
| | - Edwina J Wright
- Central Clinical School, Monash University, Melbourne, Australia; Department of Infectious Diseases, The Alfred Hospital, Alfred Health, Melbourne, Australia
| | - Christopher K Fairley
- Central Clinical School, Monash University, Melbourne, Australia; Melbourne Sexual Health Centre, Alfred Health, Melbourne, Australia
| | - Sarah L McGuinness
- Department of Infectious Diseases, The Alfred Hospital, Alfred Health, Melbourne, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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