Sexual health service adaptations to the coronavirus disease 2019 (COVID-19) pandemic in Australia: a nationwide online survey

Near-to-patient-testing to inform targeted antibiotic use for sexually transmitted infections in a public sexual health clinic: the NEPTUNE cohort study

Background

Empiric treatment of sexually transmitted infections can cause unnecessary antibiotic use. We determined if near-to-patient-testing (NPT) for Neisseria gonorrhoeae, Chlamydia trachomatis and Mycoplasma genitalium (MG) improved antibiotic-use for a range of clinical presentations.

Methods

Clients attending with non-gonococcal urethritis (NGU), proctitis, as STI-contacts, or for an MG-test-of-cure (MG-TOC) between March and December 2021 were recruited. Participants received near-to-patient-testing (NPT-group) for the three STIs using the GeneXpert® System (Cepheid), and concurrent routine-testing by transcription-mediated-amplification (TMA; Aptima, Hologic). Antibiotic-use among NGU or proctitis cases in the NPT-group was compared to clinic-controls undergoing routine-testing only. The proportion in the NPT-group who notified partners <24 hrs of their STI-specific result was calculated.

Findings

Among 904 consults by 808 NPT-participants, ≥1 STI was detected in 63/252 (25.0%) with NGU, 22/51 (43.1%) with proctitis, and 167/527 (31.7%) STI-contacts. MG was detected among 35/157 (22.3%) MG-TOC consults. Among NGU and proctitis cases, fewer in the NPT-group received empiric treatment compared to clinic-controls (29.4% [95% CI: 24.3-34.9%] vs 83.8% [95% CI: 79.2-87.8%], p < 0.001), resulting in more NPT-group cases appropriately treated (STI-specific drug/no drug appropriately; 80.9% [95% CI: 76.0-85.1%] vs 33.0% [95% CI: 27.7-38.6%], p < 0.001) and fewer mistreated (incorrect drug/treated but pathogen-negative; 17.8% [13.7-22.6%] vs 61.4% [55.6-66.9%], p < 0.001). Of 167/264 in the NPT-group with an STI who responded regarding partner-notification, 95.2% notified all/some partners; 85.9% notified them <24 hrs of the STI-specific result.

Interpretation

Near-to-patient-testing significantly improved antibiotic use and a high proportion of individuals rapidly notified partners of STI-specific results, highlighting the broad benefits of timely diagnostic strategies for STIs in clinical decision making and partner notification.

Funding

ARC ITRP Hub-grant; NHMRC.

Impact of COVID-19 on access to and delivery of sexual and reproductive healthcare services in countries with universal healthcare systems: A systematic review

OBJECTIVES

The COVID-19 pandemic has caused unforeseen impacts on sexual and reproductive healthcare (SRH) services worldwide, and the nature and prevalence of these changes have not been extensively synthesized. We sought to synthesise reported outcomes on the impact of COVID-19 on SRH access and delivery in comparable countries with universal healthcare systems.

METHODS

Following PRISMA guidelines, we searched MEDLINE, Embase, PsycInfo, and CINAHL from January 1st, 2020 to June 6th, 2023. Original research was eligible for inclusion if the study reported on COVID-19 and SRH access and/or delivery. Twenty-eight OECD countries with comparable economies and universal healthcare systems were included. We extracted study characteristics, participant characteristics, study design, and outcome variables. The methodological quality of each article was assessed using the Quality Assessment with Diverse Studies (QuADS) tool. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed for reporting the results. This study was registered on PROSPERO (#CRD42021245596).

SYNTHESIS

Eighty-two studies met inclusion criteria. Findings were qualitatively synthesised into the domains of: antepartum care, intrapartum care, postpartum care, assisted reproductive technologies, abortion access, gynaecological care, sexual health services, and HIV care. Research was concentrated in relatively few countries. Access and delivery were negatively impacted by a variety of factors, including service disruptions, unclear communication regarding policy decisions, decreased timeliness of care, and fear of COVID-19 exposure. Across outpatient services, providers favoured models of care that avoided in-person appointments. Hospitals prioritized models of care that reduced time and number of people in hospital and aerosol-generating environments.

CONCLUSIONS

Overall, studies demonstrated reduced access and delivery across most domains of SRH services during COVID-19. Variations in service restrictions and accommodations were heterogeneous within countries and between institutions. Future work should examine long-term impacts of COVID-19, underserved populations, and underrepresented countries.

Effect of COVID-19 pandemic restrictions on chlamydia and gonorrhoea notifications and testing in Queensland, Australia: an interrupted time series analysis

OBJECTIVE

To investigate trends in testing and notifications of chlamydia and gonorrhoea during the COVID-19 pandemic in Queensland, Australia.

METHODS

Statewide disease notification and testing data between 1 January 2015 and 31 December 2021 were modelled using interrupted time series. A segmented regression model estimated the pre-pandemic trend and observed effect of the COVID-19 pandemic response on weekly chlamydia notifications, monthly gonorrhoea notifications and monthly testing figures. The intervention time point was 29 March 2020, when key COVID-19 public health restrictions were introduced.

RESULTS

There were 158 064 chlamydia and 33 404 gonorrhoea notifications and 2 107 057 combined chlamydia and gonorrhoea tests across the 72-month study period. All three studied outcomes were increasing prior to the COVID-19 pandemic. Immediate declines were observed for all studied outcomes. Directly after COVID-19 restrictions were introduced, declines were observed for all chlamydia notifications (mean decrease 48.4 notifications/week, 95% CI -77.1 to -19.6), gonorrhoea notifications among males (mean decrease 39.1 notifications/month, 95% CI -73.9 to -4.3) and combined testing (mean decrease 4262 tests/month, 95% CI -6646 to -1877). The immediate decline was more pronounced among males for both conditions. By the end of the study period, only monthly gonorrhoea notifications showed a continuing decline (mean decrease 3.3 notifications/month, p<0.001).

CONCLUSION

There is a difference between the immediate and sustained impact of the COVID-19 pandemic on reported chlamydia and gonorrhoea notifications and testing in Queensland, Australia. This prompts considerations for disease surveillance and management in future pandemics. Possible explanations for our findings are an interruption or change to healthcare services during the pandemic, reduced or changed sexual practices or changed disease transmission patterns due to international travel restrictions. As pandemic priorities shift, STIs remain an important public health priority to be addressed.

A Neglected Narrative in the COVID-19 Pandemic: Epidemiological and Clinical Impacts of the COVID-19 Outbreak on Syphilis

The COVID-19 pandemic has profoundly changed our lives. While healthcare resources were redistributed and mobilized to focus on dealing with the COVID-19 crisis, there have been unmet medical needs of patients with other diseases such as syphilis, weaving an integral but neglected component of the pandemic story. In different countries, the epidemiology of newly reported syphilis underwent diverse changes during the COVID-19 pandemic. Asymptomatic cases experienced the largest decline in number. From the perspective of transmission, on one hand, the implementation of lockdown measures led to a higher degree of abstinence and sex distancing in many countries, thereby reducing the transmission of syphilis. On the other hand, vertical transmission was reported to have increased significantly during COVID-19. Meanwhile, the volume of STI clinic capacity declined, and STI staff were redeployed to facilitate the contact tracing of COVID-19. As a result, many STI centers converted traditional in-person clinical services to telemedicine and self-testing. However, syphilis testing and clinical treatment cannot fully adapt to this conversion. In syphilis diagnosis, COVID-19 infection and vaccination were reported to cause false positivity in syphilis serological tests. Diverse cutaneous manifestations of COVID-19 could resemble the skin lesions in syphilis patients, requiring differential diagnosis from clinicians. As for the post-pandemic years, consequent to service interruptions and diagnosis delays, a surge in the number of confirmed cases of syphilis is expected. The COVID-19 pandemic has also been a meaningful lesson for the control and prevention of infectious diseases. The experience in combating COVID-19 has underscored the importance of maintaining a robust and well-supported medical system for the provision of sexual health services and better healthcare equality even during eras of crisis, not least for syphilis patients.

Immediate and Ongoing Impact of COVID-19 on Chlamydia Treatment in Australia

BACKGROUND

The COVID-19 pandemic has impacted the sexual health and well-being of individuals, directly through risk of contracting COVID-19, and indirectly through government lockdowns. Government restrictions were especially strict and long-lasting in Australia, they also varied by state, offering an interesting opportunity to study the impacts of varying restrictions. This study compares the impact of the COVID-19 pandemic and resulting restrictions on chlamydia treatment prescriptions during 2020, through to July 2021 between different states and demographic groups in Australia.

METHODS

The rate of prescriptions per 100,000 population filled each month from January 2017 to July 2021 from Australia's Pharmaceutical Benefits Scheme for Azithromycin with a restricted indication to treat Chlamydia trachomatis was used to measure chlamydia treatment. The impact of COVID-19 lockdowns was modeled using an interrupted time-series Poisson regression model.

RESULTS

The data included 520,025 prescriptions to treat chlamydia, averaging 37.5 prescriptions per month per 100,000 population. Prescriptions declined 26% in April to May 2020 when initial COVID-19 lockdowns began in Australia; prescriptions increased in the following months but remained on average 21% below prepandemic (2017-2019) levels through to July 2021. Prescriptions declined the most in 1 Australian state, Victoria, both in the initial lockdown and the following period; generally, states with more COVID-19 cases saw bigger reductions in prescriptions.

CONCLUSIONS

This is the first study to examine how treatment for chlamydia in Australia was impacted by the COVID-19 pandemic and restrictions not only in the immediate-term, but also ongoing up to July 2021, providing important information for planning for sexual health services in future pandemics.

Weight Change When Initiating, Switching to, and Discontinuing Integrase Strand Transfer Inhibitors in People Living with HIV

Further investigations into the relationship between integrase strand transfer inhibitors (INSTIs) and weight gain are required, especially whether ceasing INSTI results in weight loss. We evaluated weight changes associated with different antiretroviral (ARV) regimens. A retrospective longitudinal cohort study was conducted using data extracted from the electronic clinical database at the Melbourne Sexual Health Centre, Australia, from 2011 to 2021. The association between weight change per time unit and ARV use in people living with HIV (PLWH) and the factors associated with weight changes when using INSTIs were estimated using a generalized estimated equation model. We included 1540 PLWH contributing 7476 consultations and 4548 person-years of data. ARV-naive PLWH initiating INSTIs gained an average of 2.55 kg/year (95% confidence interval 0.56 to 4.54; p = 0.012), while those using protease inhibitors and non-nucleoside reverse transcriptase inhibitors had no significant weight change. When switching off INSTIs, there was no significant weight change (p = 0.055). These weight changes were adjusted for age, gender, time on ARVs, and/or use of tenofovir alafenamide (TAF). Weight gain was the main reason PLWH ceased INSTIs. In addition, risk factors for weight gain in INSTI users were age younger than 60 years, male gender, and concomitant use of TAF. Weight gain was found among PLWH using INSTIs. After INSTI discontinuation, PLWH's weight stopped rising, but no weight loss was observed. Careful weight measurement after initiating INSTIs and early initiation of strategies to avoid weight gain will be important to prevent permanent weight gain and the associated morbidity.

Web-Based Harm Reduction Intervention for Chemsex in Men Who Have Sex With Men: Randomized Controlled Trial

BACKGROUND

Men who have sex with men (MSM) who practice chemsex have a higher likelihood of engaging in risky sexual behaviors and higher rates of HIV infection and other sexually transmitted infections (STIs) than those who do not.

OBJECTIVE

This trial aimed to evaluate the effectiveness of a web-based intervention in reducing the sexual harms of chemsex among MSM.

METHODS

The study was a 2-arm, assessor-blinded, randomized, parallel-group trial with a 3-month follow-up period. The study was conducted in the year 2021 in Hong Kong. Underpinned by the theory of planned behaviors and a harm reduction approach, the intervention consisted of interactive components and knowledge-based information about chemsex. Participants in the control group received brief information and content about sexual violence. The primary outcome was self-efficacy in refusing risky sexual behaviors and chemsex, as measured by the Condom Self-Efficacy Scale (CSES), Self-Efficacy for Sexual Safety (SESS) instrument, and Drug Avoidance Self-Efficacy Scale (DASES). The secondary outcomes included intentions to have chemsex, actual engagement in chemsex, HIV and other STI testing, and condom use in the last 3 months. All outcomes were self-reported. An online structured questionnaire was used to collect data.

RESULTS

In total, 316 MSM enrolled in the study. The intervention group demonstrated a significantly larger improvement in condom-use self-efficacy (as measured by CSES scores; time-by-group interaction: β=4.52, 95% CI 2.03-7.02; P<.001), self-efficacy for sexual safety (as measured by SESS scores; time-by-group interaction: β=2.11, 95% CI 0.66-3.56; P=.004), and drug avoidance self-efficacy (as measured by DASES scores; time-by-group interaction: β=6.98, 95% CI 1.75-12.22; P=.009). Regarding the secondary outcomes, participants in the intervention group demonstrated a significantly larger reduction in the likelihood of having engaged in chemsex in the last 3 months (time-by-group interaction: odds ratio [OR]=0.23, 95% CI 0.10-0.53; P=.001) and likelihood of having had the intention to engage in chemsex in the last 3 months (time-by-group interaction: OR=0.37, 95% CI 0.18-0.78; P=.009). Participants in the intervention group also showed a significantly larger increase in the likelihood of having undergone HIV testing in the last 3 months (time-by-group interaction: OR=3.08, 95% CI 1.72-5.54; P<.001).

CONCLUSIONS

This study suggests that a web-based intervention with a harm reduction approach can enhance the self-efficacy of MSM in refusing risky sexual behaviors and chemsex and improve the uptake of HIV testing. We also provide initial evidence that such interventions can reduce both the intention of MSM to engage in chemsex and their actual engagement in chemsex.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN20134522; https://www.isrctn.com/ISRCTN20134522.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s12889-021-10742-8.

Adjusting Behavioural Surveillance and Assessing Disparities in the Impact of COVID-19 on Gay and Bisexual Men's HIV-Related Behaviour in Australia

COVID-19 has disrupted sexual behaviour and access to health systems. We adapted regular HIV behavioural surveillance of gay and bisexual men (GBM) in Australia in response to COVID-19, assessed the impact on the profile of the sample, the participants' HIV-related behaviour, and whether COVID-19 may have accentuated existing disparities in the Australian HIV epidemic. Data collected from five states during July 2017-June 2021 were included (N = 31,460). The emphasis on online recruitment after COVID-19 led to smaller sample sizes, greater geographic reach, and a higher proportion of bisexual-identifying participants. Most participants (88.1%) reported physical distancing and 52.1% had fewer sex partners due to COVID-19. In the COVID-19-affected rounds (July 2020-June 2021), the number of male partners, recent HIV testing and pre-exposure prophylaxis (PrEP) use all fell, and HIV risk among the smaller group of participants who reported casual sex increased. COVID-related changes were generally more pronounced among GBM aged under 25 years, participants from suburbs with fewer gay residents, and bisexual men. These groups should be prioritised when encouraging GBM to reengage with HIV testing services and effective prevention methods, like condoms and PrEP.

Access to HIV Antiretroviral Therapy among People Living with HIV in Melbourne during the COVID-19 Pandemic

The social measures taken to control the COVID-19 pandemic can potentially disrupt the management of HIV. The objective of this study was to examine the impact of the Australian COVID-19 lockdown restrictions on access to antiretroviral therapy (ART) for people living with HIV in Melbourne. Using data from the Melbourne Sexual Health Centre (MSHC), we assessed the changes in rates of ART postal delivery, controlled viral load, and ART dispensing from 2018 to 2020. The percentage of ART delivered by postage from the MSHC pharmacy was calculated weekly. The percentage of people living with HIV with a controlled viral load (≤200 copies/mL) was calculated monthly. We calculated a yearly Medication Possession Ratio (MPR). The average percentage of HIV ART dispensed through postage for the years 2018, 2019, and 2020 was 3.7% (371/10,023), 3.6% (380/10,685), and 14% (1478/10,765), respectively (P_trend < 0.0001). Of the 3115 people living with HIV, the average MPR for 2018, 2019, and 2020 was 1.05, 1.06, and 1.14, respectively (P_trend = 0.28). The average percentage of people with an HIV viral load of <200 copies/mL for the years 2018, 2019, and 2020 was 97.6% (2271/2327), 98.0% (2390/2438), and 99.2% (2048/2064), respectively (P_trend < 0.0001). This study found that the proportion of controlled viral load and access to ART of people living with HIV in Melbourne was largely unaffected by the COVID-19 lockdown restrictions. This suggests that some of the services provided by the MSHC during the pandemic, such as HIV ART postal delivery, may assist long-term HIV management.

Oral, Vaginal and Anal Sexual Practices among Heterosexual Males and Females Attending a Sexual Health Clinic: A Cross-Sectional Survey in Melbourne, Australia

Sex practices among heterosexuals are not well studied. We aimed to explore sexual practices among heterosexuals attending a sexual health clinic. This cross-sectional survey was conducted at Melbourne Sexual Health Centre between March and April 2019. Data were collected on kissing, oral sex (fellatio or cunnilingus), vaginal sex, anal sex and rimming in the previous 3 months. Univariable and multivariable logistic regression analyses were performed to examine the associations between engaging in anal sex and other sex practices. There were 709 participants (333 men; 376 women) who were eligible and completed the survey (response rate was 24.6%). In the past 3 months, most participants had had vaginal sex (n = 677; 95.5%), with a mean of 3.0 (standard deviation (SD): 3.9) vaginal sex partners, and half reported engaging in condomless vaginal sex in the past 3 months (n = 358; 50.1%). A total of 135 (19.0%) participants had had anal sex, with a mean of 1.3 (SD: 1.0) anal sex partners, with 63.5% (n = 94) engaging in any condomless anal sex in the past 3 months. Most participants (n = 637, 89.8%) had received oral sex in the past 3 months; this proportion did not differ by age group or gender. Women (n = 351, 93.4%) were more likely to perform oral sex than men (n = 275; 82.6% men) (p < 0.001) and to have received rimming (26.6% women vs. 12.6% men; p < 0.001). Men were more likely to have performed rimming (25.5% men vs. 9.3% women; p < 0.001). After adjusting for age, number of partners and sexual practice, anal sex was associated with being ≥35 years (adjusted odds ratio (aOR): 2.3; 95% CI: 1.2–4.2), receiving rimming (aOR: 3.8; 95% CI: 2.4–6.0) and performing rimming (aOR: 2.8; 95% CI: 1.8–4.6). Rimming and anal sex are practiced by one-fifth or more of heterosexuals. Older heterosexuals were more likely to engage in anal sex and to perform rimming. Future research should consider the benefits of testing extragenital sites where appropriate.

Comparing HIV Post-Exposure Prophylaxis, Testing, and New Diagnoses in Two Australian Cities with Different Lockdown Measures during the COVID-19 Pandemic

Australia introduced a national lockdown on 22 March 2020 in response to the COVID-19 pandemic. Melbourne, but not Sydney, had a second COVID-19 lockdown between July and October 2020. We compared the number of HIV post-exposure prophylaxis (PEP) prescriptions, HIV tests, and new HIV diagnoses during these lockdown periods. The three outcomes in 2020 were compared to 2019 using incidence rate ratio. There was a 37% and 46% reduction in PEP prescriptions in Melbourne and Sydney, respectively, with a larger reduction during lockdown (68% and 57% reductions in Melbourne's first and second lockdown, 60% reduction in Sydney's lockdown). There was a 41% and 32% reduction in HIV tests in Melbourne and Sydney, respectively, with a larger reduction during lockdown (57% and 61% reductions in Melbourne's first and second lockdowns, 58% reduction in Sydney's lockdown). There was a 44% and 47% reduction in new HIV diagnoses in Melbourne and Sydney, respectively, but no significant reductions during lockdown. The reduction in PEP prescriptions, HIV tests, and new HIV diagnoses during the lockdown periods could be due to the reduction in the number of sexual partners during that period. It could also result in more HIV transmission due to substantial reductions in HIV prevention measures during COVID-19 lockdowns.