Evaluation of artificial intelligence-powered screening for sexually transmitted infections-related skin lesions using clinical images and metadata.

BACKGROUND: Sexually transmitted infections (STIs) pose a significant global public health challenge. Early diagnosis and treatment reduce STI transmission, but rely on recognising symptoms and care-seeking behaviour of the individual. Digital health software that distinguishes STI skin conditions could improve health-seeking behaviour. We developed and evaluated a deep learning model to differentiate STIs from non-STIs based on clinical images and symptoms. METHODS: We used 4913 clinical images of genital lesions and metadata from the Melbourne Sexual Health Centre collected during 2010-2023. We developed two binary classification models to distinguish STIs from non-STIs: (1) a convolutional neural network (CNN) using images only and (2) an integrated model combining both CNN and fully connected neural network (FCN) using images and metadata. We evaluated the model performance by the area under the ROC curve (AUC) and assessed metadata contributions to the Image-only model. RESULTS: Our study included 1583 STI and 3330 non-STI images. Common STI diagnoses were syphilis (34.6%), genital warts (24.5%) and herpes (19.4%), while most non-STIs (80.3%) were conditions such as dermatitis, lichen sclerosis and balanitis. In both STI and non-STI groups, the most frequently observed groups were 25-34 years (48.6% and 38.2%, respectively) and heterosexual males (60.3% and 45.9%, respectively). The Image-only model showed a reasonable performance with an AUC of 0.859 (SD 0.013). The Image + Metadata model achieved a significantly higher AUC of 0.893 (SD 0.018) compared to the Image-only model (p < 0.01). Out of 21 metadata, the integration of demographic and dermatological metadata led to the most significant improvement in model performance, increasing AUC by 6.7% compared to the baseline Image-only model. CONCLUSIONS: The Image + Metadata model outperformed the Image-only model in distinguishing STIs from other skin conditions. Using it as a screening tool in a clinical setting may require further development and evaluation with larger datasets.

Assessing the effectiveness of HIV/STI risk communication displays among Melbourne Sexual Health Centre attendees: a cross-sectional, observational and vignette-based study.

INTRODUCTION: Increasing rates of sexually transmitted infections (STIs) over the past decade underscore the need for early testing and treatment. Communicating HIV/STI risk effectively can promote individuals' intention to test, which is critical for the prevention and control of HIV/STIs. We aimed to determine which visual displays of risk would be the most likely to increase testing or use of prevention strategies. METHODS: A vignette-based cross-sectional survey was conducted with 662 clients (a median age of 30 years (IQR: 25-36), 418 male, 203 female, 41 other genders) at a sexual health clinic in Melbourne, Australia, between February and June 2023. Participants viewed five distinct hypothetical formats, presented in a randomised order, designed to display the same level of high risk for HIV/STIs: icon array, colour-coded risk metre, colour-coded risk bar, detailed text report and guideline recommendation. They reported their perceived risk, concern and intent to test for each risk display. Associations between the format of the risk display and the intention to test for HIV/STI were analysed using logistic regression. RESULTS: About 378 (57%) of participants expressed that the risk metre was the easiest to understand. The risk metre (adjusted OR (AOR)=2.44, 95% CI=1.49 to 4.01) and risk bar (AOR=2.08, CI=1.33 to 3.27) showed the greatest likelihood of testing compared with the detailed text format. The icon array was less impactful (AOR=0.73, CI=0.57 to 0.94). The risk metre also elicited the most concern but was the most preferred and understood. High-risk perception and concern levels were strongly associated with their intention to have an HIV/STI test. CONCLUSIONS: Displaying risk differently affects an individual's perceived risk of an HIV/STI and influences their intention to test.

HIV Services Uptake Among People Living with HIV in Jiangsu Province, China: A Cross-Sectional Study.

Healthcare disparities are common among people living with HIV (PLWH) in China and likely impact access to HIV services. This study aimed to assess the current status of access to HIV services among PLWH and explore the correlates of service uptake using baseline data from a prospective cohort study among PLWH in Jiangsu Province. Guided by Andersen's behavioral model, univariable and multivariable logistic regressions were conducted to identify factors associated with access to HIV services. Out of 8989 eligible PLWH included in this study, 46.4% perceived difficulty in seeing a healthcare professional for HIV treatment services in 2021-2022. PLWH aged 18-34 years (adjusted odds ratio [AOR] = 1.69, 95% CI 1.32-2.15), 35-39 years (AOR = 1.33, 95% CI 1.08-1.65), identified as a bisexual/other (AOR = 1.14, 95% CI 1.01-1.29), had a college and above education (AOR = 1.32, 95% CI 1.07-1.63), and perceived moderate (AOR = 1.70, 95% CI 1.51-1.91) and severe (AOR = 2.20, 95% CI 1.94-2.49) levels of HIV stigma were more likely to perceive difficulty in seeing healthcare professionals for HIV treatment in 2021-2022. Living in northern Jiangsu was also associated with increased odds of perceiving difficulty in seeing healthcare professionals for HIV treatment (AOR = 1.12, 95% CI 1.00-1.26). These findings underscore the need for innovative solutions to eliminate the practical barriers to HIV services utilization among PLWH who are bisexual, well-educated, and effective HIV-related stigma reduction interventions.

Ignored and undervalued in public health: a systematic review of health state utility values associated with syphilis infection.

BACKGROUND: Syphilis is a sexually transmitted infection causing significant global morbidity and mortality. To inform policymaking and economic evaluation studies for syphilis, we summarised utility and disability weights for health states associated with syphilis. METHODS: We conducted a systematic review, searching six databases for economic evaluations and primary valuation studies related to syphilis from January 2000 to February 2022. We extracted health state utility values or disability weights, including identification of how these were derived. The study was registered in the international prospective register of systematic reviews (PROSPERO, CRD42021230035). FINDINGS: Of 3401 studies screened, 22 economic evaluations, two primary studies providing condition-specific measures, and 13 burden of disease studies were included. Fifteen economic evaluations reported outcomes as disability-adjusted life years (DALYs) and seven reported quality-adjusted life years (QALYs). Fourteen of 15 economic evaluations that used DALYS based their values on the original Global Burden of Disease (GBD) study from 1990 (published in 1996). For the seven QALY-related economic evaluations, the methodology varied between studies, with some studies using assumptions and others creating utility weights or converting them from disability weights. INTERPRETATION: We found a limited evidence base for the valuation of health states for syphilis, a lack of transparency for the development of existing health state utility values, and inconsistencies in the application of these values to estimate DALYs and QALYs. Further research is required to expand the evidence base so that policymakers can access accurate and well-informed economic evaluations to allocate resources to address syphilis and implement syphilis programs that are cost-effective.

The use of suboptimal antiretroviral therapy when applying for migration to Australia: a case series.

Background Australia imposes restrictions for people living with HIV (PLHIV) applying for permanent residency (PR), including spending less than AUD51,000 on medical costs over 10years. Some PLHIV opted for suboptimal and cheaper antiretroviral therapy (ART) regimens to increase their chances of receiving PR. We collated a case series to examine PLHIV on suboptimal ART because of visa issues. Methods We identified all patients applying for a PR in Australia who obtained nevirapine, efavirenz or zidovudine between July 2022 and July 2023 from the Melbourne Sexual Health Centre. Pathology results and records detailing psychological issues relating to the patients' wishes to remain on suboptimal ART were extracted from clinical records by two researchers. Results We identified six patients with a mean age of 39years migrating from Asian and European countries. Three patients used efavirenz, and three used nevirapine. All desired to remain on cheaper, suboptimal ART to stay below visa cost thresholds, which they considered to aid favourably with their application. Four displayed stress and anxiety arising from visa rejections, appeal deadlines and the lengthy visa application process. Conclusions Despite access to more effective and safer ART, we identified patients who chose to remain on cheaper ART to improve chances of obtaining an Australian visa, potentially putting their health at risk. We found significant evidence of stress and anxiety among patients. There is a need to review and revise current migration policies and laws in Australia that discriminate against PLHIV and jeopardise public health.

A typology of HIV self-testing support systems: a scoping review.

To maximise the benefits of HIV self-testing (HIVST), it is critical to support self-testers in the testing process and ensure that they access appropriate prevention and care. To summarise systems and tools supporting HIVST (hereafter, 'support systems') and categorise them for future analysis, we synthesised the global data on HIVST support systems and proposed a typology. We searched five databases for articles reporting on one or more HIVST support systems and included 314 publications from 224 studies. Across 189 studies, there were 539 reports of systems supporting HIVST use; while across 115 studies, there were 171 reports of systems supporting result interpretation. Most commonly, these were pictorial instructions, followed by in-person demonstrations and in-person assistance while self-testing or reading self-test results. Less commonly, virtual interventions were also identified, including online video conferencing and smartphone apps. Smartphone-based automated result readers have been used in the USA, China, and South Africa. Across 173 studies, there were 987 reports of systems supporting post-test linkage to care; most commonly, these were in-person referrals/counselling, written referrals, and phone helplines. In the USA, Bluetooth beacons have been trialled to monitor self-test use and facilitate follow-up. We found that, globally, HIVST support systems use a range of methods, including static media, virtual tools, and in-person engagement. In-person and printed approaches were more common than virtual tools. Other considerations, such as linguistic and cultural appropriateness, may also be important in the development of effective HIVST programs.

Changes in the Syphilis Rapid Plasma Reagin Titer Between Diagnosis and Treatment.

BACKGROUND: We compared the rapid plasma reagin (RPR) titer on the day of initial presentation with that on the day of syphilis treatment to inform clinical practice as to whether a repeated RPR test should be recommended. METHODS: We undertook a retrospective study between 1 March 2011 and 31 December 2020 at the Melbourne Sexual Health Centre in Australia among individuals who underwent syphilis serology on the day of initial presentation and the day of treatment, if the latter were within 14 days after initial presentation. We calculated the percentage of individuals with a ≥4-fold change in RPR titer, stratified by the time between initial presentation and treatment and by syphilis stage. RESULTS: Among the 766 included syphilis cases, the median duration between initial presentation and treatment was 6 days (interquartile range, 5-7 days). Of these cases, 14.8% (n = 113) had a ≥4-fold increase or decrease during this interval. The number of cases with a ≥4-fold increase or decrease in RPR titer increased with increasing time between initial presentation and treatment, from 5.7% (n = 6) 1-3 days after initial presentation to 26.2% (n = 27) at 10-14 days (Ptrend < .001). There was no significant difference in the number of cases with a ≥4-fold increase or decrease in RPR titer between syphilis stages (P = .66). CONCLUSIONS: Our data support the recommendation of repeating the RPR titer if the day of initial presentation and the day of treatment are different, even when treatment is within a few days after initial presentation.

Incidence and Clearance of Anal Human Papillomavirus Infection in 16 164 Individuals, According to Human Immunodeficiency Virus Status, Sex, and Male Sexuality: An International Pooled Analysis of 34 Longitudinal Studies.

BACKGROUND: Understanding the natural history of anal high-risk human papillomavirus (hrHPV) infection is key for designing anal cancer prevention programs but has not been systematically characterized. METHODS: We reanalyzed data from 34 studies including 16 164 individuals in 6 risk groups defined by human immunodeficiency virus (HIV) status, sex, and male sexuality: men who have sex with men (MSM) and people with HIV (MSMWH), HIV-negative MSM, women with HIV (WWH), HIV-negative women, men who have sex with women (MSW) with HIV (MSWWH), and HIV-negative MSW. We used Markov models to estimate incidence and clearance of 13 hrHPV types and their determinants. RESULTS: Human papillomavirus (HPV) 16 had the highest incidence-clearance ratio of the hrHPV types. MSMWH had the highest hrHPV incidence (eg, 15.5% newly HPV-16 infected within 2 years), followed by HIV-negative MSM (7.5%), WWH (6.6%), HIV-negative women (2.9%), MSWWH (1.7%), and HIV-negative MSW (0.7%). Determinants of HPV-16 incidence included HIV status and number of sexual partners for MSM, women, and MSW, and anal sex behavior for MSM only. HPV-16 clearance was lower for people with HIV (PWH) and lower for prevalent than incident infection. Among MSM, increasing age was associated with lower clearance of prevalent, but not incident, HPV-16 infection. CONCLUSIONS: This robust and unifying analysis of anal hrHPV natural history is essential to designing and predicting the impact of HPV vaccination and HPV-based screening programs on anal cancer prevention, particularly in MSM and PWH. Importantly, it demonstrates the higher carcinogenic potential of longstanding anal prevalent hrHPV infection than more recent incident infection.

Expanding hepatitis C virus test uptake using self-testing among men who have sex with men in China: two parallel randomized controlled trials.

BACKGROUND: HCV self-testing (HCVST) may be an effective strategy to address low rates of HCV test uptake among men who have sex with men (MSM). We evaluated the effectiveness and cost of providing HCVST to increase HCV test uptake among MSM in China. METHODS: Two parallel, unmasked, individual-level randomized controlled trials were conducted. HIV-negative MSM and MSM living with HIV were enrolled from 22 cities in China. Men in both trials were randomly assigned (1:1) into standard-of-care (SOC) or HCVST arms. The primary outcome was the proportion of participants who tested for HCV during the trial period. Intervention effects were estimated using multiply imputed data in the main analysis. Costs were measured using a micro-costing approach. RESULTS: A total of 84 men who were HIV-negative (trial 1) and 84 men living with HIV were enrolled (trial 2). Overall, the proportion of individuals who underwent HCV testing during the trial period was higher in the HCVST arm compared to SOC in trial 1 (estimated risk difference (RD): 71.1%, 95% CI: 54.6 to 87.7%) and trial 2 (estimated RD: 62.9%, 95% CI: 45.7 to 80.1%). Over half (58.6%, 34/58) of HCV self-testers reported the self-test was their first HCV test. The cost per person tested in trial 1 was $654.52 for SOC and $49.83 for HCVST, and in trial 2 was $438.67 for SOC and $53.33 for HCVST. CONCLUSIONS: Compared to the standard of care, providing HCVST significantly increased the proportion of MSM testing for HCV in China, and was cheaper per person tested. TRIAL REGISTRATION: Chinese Clinical Trial Registry. REGISTRATION NUMBER: ChiCTR2100048379.

Disparities in healthcare access and utilization among people living with HIV in China: A scoping review and meta-analysis.

BACKGROUND: This review aims to assess the status of healthcare disparities among people living with HIV (PLWH) in China and summarize the factors that drive them. METHODS: We searched PubMed, Web of Science, Cochrane Library, Scopus, China National Knowledge Infrastructure (CNKI) and China Wanfang for studies published in English or Chinese. Studies focusing on any disparities in healthcare services among PLWH in China and published between January 2000 and July 2022 were included. RESULTS: In all, 51 articles met the inclusion criteria, with 37 studies reporting HIV-focused care, and 14 reporting non-HIV-focused care. PLWH aged ≥45 years (vs. <45 years), female (vs. male), ethnic minority (vs. Han), and cases attributed to sexual transmission (vs. injecting drug use) were more likely to receive ART. Females living with HIV have higher ART adherence than males. Notably, 20% [95% confidence interval (CI): 9-43%, I2 = 96%] of PLWH reported any illness in the previous 2 weeks without medical consultation, and 30% (95% CI: 12-74%, I2 = 90%) refused hospitalization when needed in the previous year. Barriers to HIV-focused care included inadequate HIV/ART knowledge and treatment side effects at the individual level; and social discrimination and physician-patient relationships at the community/social level. Structural barriers included medical costs and transportation issues. The most frequently reported barriers to non-HIV-focused care were financial constraints and the perceived need for medical services at individual-level factors; and discrimination from physicians, and medical distrust at the community/social level. CONCLUSION: This review suggests disparities in access and utilization of healthcare among PLWH. Financial issues and social discrimination were prominent reasons. Creating a supportive social environment and expanding insurance policies could be considered to promote healthcare equity.

Cost-effectiveness of testing for Mycoplasma genitalium among men who have sex with men in Australia.

OBJECTIVES: Mycoplasma genitalium (MG) disproportionately affects men who have sex with men (MSM). We determined the cost-effectiveness of different testing strategies for MG in MSM, taking a healthcare provider perspective. METHODS: We used inputs from a dynamic transmission model of MG among MSM living in Australia in a decision tree model to evaluate the impact of four testing scenarios on MG incidence: (1) no one tested; (2) symptomatic MSM; (3) symptomatic and high-risk asymptomatic MSM; (4) all MSM. We calculated the incremental cost-effectiveness ratios (ICERs) using a willingness-to-pay threshold of $A30 000 per quality-adjusted life year (QALY) gained. We explored the impact of adding an antimicrobial resistance (AMR) tax (ie, additional cost per antibiotic consumed) to identify the threshold, whereby any testing for MG is no longer cost-effective. RESULTS: Testing only symptomatic MSM is the most cost-effective (ICER $3677 per QALY gained) approach. Offering testing to all MSM is dominated (ie, higher costs and lower QALYs gained compared with other strategies). When the AMR tax per antibiotic given was above $150, any testing for MG was no longer cost-effective. CONCLUSION: Testing only symptomatic MSM is the most cost-effective option, even when the potential costs associated with AMR are accounted for (up to $150 additional cost per antibiotic given). For pathogens like MG, where there are anticipated future costs related to AMR, we recommend models that test the impact of incorporating an AMR tax as they can change the results and conclusions of cost-effectiveness studies.

Self-sampled specimens demonstrate comparable accuracy and consistency to clinician-sampled specimens for HPV detection among men who have sex with men in China.

OBJECTIVES: Despite a high risk of human papillomavirus (HPV) infection among men who have sex with men (MSM), few have ever tested. This study aimed to evaluate the feasibility and accuracy of HPV self-sampling among Chinese MSM, with the purpose of measuring the feasibility of self-sampling as an alternative in HPV testing scenarios. METHODS: Eligible participants were those who were assigned male at birth, aged 18 or above, had sex with men in the past year and had never gotten HPV vaccine. Participants followed the instructions to self-sample and were also clinician-sampled from the same anatomical sites (oral fluid, penis and rectum) in both approaches. All specimens were processed using multiplex PCR assay. The reference standard of an individual with a true positive for HPV is determined via PCR test, regardless of sampling methods. Sensitivity and specificity were calculated for each approach independently and kappa test was used to assess the consistency between the two approaches. RESULTS: Overall, 211 MSM were recruited at the local clinic from April to October 2020 in Zhuhai, China. The mean age was 31 years old. Only 3% of the participants sought help from healthcare providers during self-sampling. The prevalence of HPV was 49% (103 of 211). Clinician sampling detected 91 of 103 MSM infected with HPV, with a sensitivity of 88.3% (95% CI 80.2 to 93.6) and a specificity of 100.0% (95% CI 95.7 to 100.0). Self-sampling detected 81 of 103 MSM infected with HPV, with a sensitivity of 78.6% (95% CI 69.2 to 85.9) and a specificity of 100.0% (95% CI 95.7 to 100.0). The level of agreement was moderate between clinician sampling and self-sampling (k=0.67). CONCLUSIONS: Self-sampled HPV testing demonstrated comparable accuracy and consistency to clinician sampling among MSM in China. It holds the potential to complement sexual health services especially among key populations.

Sexual behaviours and sexual health among middle-aged and older adults in Britain.

OBJECTIVES: Population-representative studies of the sexual health of middle-aged and older adults are lacking in ageing societies. This study aimed to identify latent patterns of sexual behaviours and health of people aged 45-74 years. METHODS: We conducted a latent class analysis of the National Attitudes and Sexual Lifestyles Survey (Natsal-3), a nationally representative survey conducted in Britain in 2011. RESULTS: Of the 5260 respondents aged 45-74 years, 48.86% of men and 44.91% of women belonged to the Content Caseys class who reported good sexual health. The Infrequent Indigos (30.94% of men, 44.38% of women) were characterised by a lack of sexual activity, reported some dissatisfaction, and were more likely to have a disability. The Low-Functioning Lees (11.65% of men, 8.41% of women) reported some more disability and had issues with sexual functioning and higher levels of distress. The Multiple-Partnered Morgans (8.62% of men, 2.30% of women) were characterised by a greater number of sexual partners and several risk behaviours. CONCLUSIONS: The use of these four classes can aid in improved targeting of tailored sexual health services to improve sexual function, sexual satisfaction, reduce distress and risky behaviours among middle-aged and older adults. These services should be inclusive of the disabled community.

Assortative Sexual Mixing by Age, Region of Birth, and Time of Arrival in Male-Female Partnerships in Melbourne, Australia.

BACKGROUND: Patterns of sexual mixing may be influenced by demographic factors where individuals show a preference for partners with particular traits and may have different levels of risk for HIV and sexually transmitted infection transmission. We aimed to explore age differences and mixing by region of birth among male-female partnerships. METHODS: Male-female partnerships who presented to Melbourne Sexual Health Centre in Australia between 2015 and 2019 were investigated. Age and country of birth of sexual partners were collected. We calculated the age differences between partners and created tables demonstrating partnership mixing by age groups and by international region of birth. RESULTS: A total of 2112 male-female partnerships (i.e., 4224 individuals) were included. The median age was 27 years (interquartile range, 23-31 years). Between men and women in partnerships, the median age difference was 1 year. Nearly half of all individuals (49.1% [2072 of 4224]) were in a partnership with another individual in the same 5-year interval age group as their own, and a majority of individuals (58.5% [2334 of 3988]) were in a partnership with another individual from the same region of birth when compared with other regions. CONCLUSIONS: There is a strong assortative sexual mixing pattern by age and region of birth among male-female partnerships in Melbourne, Australia. These results may have applications in further research to understand sexually transmitted infection transmission among clients attending sexual health centers, particularly those born overseas.

Factors Associated With Consenting to Receive an Automated Email Summary After a Sexual Health Clinic Visit.

BACKGROUND: Electronic health records allow for inexpensive communication with patients. In March 2021, the Melbourne Sexual Health Centre implemented an automated email summary ("Sexual Health Automated Visit Email" [SHAVE]) of a client's visit. This study evaluates the proportion of attendees at a sexual health service who opted in or out of SHAVE. METHODS: This study was conducted at the Melbourne Sexual Health Centre in Australia between March 2021 and June 2022. Univariable and multivariable logistic regression analyses were used to examine the client characteristics associated with consenting to SHAVE. RESULTS: There were 18,528 clients (men, 12,700; women, 5828) included in the final analysis and 55.2% (n = 10,233) consented to receiving SHAVE. Comparing with those who did not have a new sexually transmitted infection diagnosis, clients with a new diagnosis of a sexually transmitted infection, but not HIV, had lower odds of consenting to receiving SHAVE (chlamydia: adjusted odds ratio [aOR], 0.64 [95% confidence interval {CI}, 0.57-0.72]; gonorrhea: aOR, 0.71 [95% CI, 0.62-0.82]; syphilis: aOR, 0.75 [95% CI, 0.59-0.96]). Men had lower odds of consenting when compared with women (men who have sex with women only: aOR, 0.77 [95% CI, 0.71-0.84]; men who have sex with men: aOR, 0.68 [95% CI, 0.62-0.75]). Comparing with those born in Australia or Oceania, clients born in Europe had lower odds of consenting (aOR, 0.81; 95% CI, 0.70-0.94), whereas those born in Latin America or Caribbean had higher odds of consenting (aOR, 1.25; 95% CI, 1.04-1.51). CONCLUSIONS: Email summaries may serve as a valuable strategy to improve health communication and record keeping for clients. Understanding the client characteristics associated with consenting SHAVE will allow for the implementation of strategies to better communicate with clients.

Supernatural beliefs, religious affiliations, and HIV testing among recently arrived Asian-born men who have sex with men in Australia.

HIV testing rates among recently arrived (≤5 years) Asian-born men who have sex with men (MSM) in Australia remain suboptimal. Research indicates that belief in supernatural determinants of health (supernatural beliefs) may be an important barrier to greater HIV test uptake. We examined potential associations between supernatural beliefs and HIV testing among recently arrived Asian-born MSM in Australia. In 2019, an online survey was completed by 186 self-identified MSM born in Asia, and who arrived in Australia within the past five years and were never diagnosed with HIV. Supernatural belief was measured as the extent to which one felt that health was influenced by supernatural forces. Measures of association were estimated with multiple logistic regression. Participants with supernatural beliefs were significantly less likely to have tested for HIV in the past year. The adjusted predicted probability of not testing for HIV in the past year was 44.8% among those who held supernatural beliefs (95% CI: 30.5-59.2%), but only 5.2% among those who did not hold supernatural beliefs (95% CI: 1.9-8.6%). Religious affiliation was not significantly associated with testing for HIV. Supernatural beliefs may be an important but underappreciated barrier to HIV testing among recently arrived Asian-born MSM in Australia.

Optimizing Peer Distribution of Syphilis Self-Testing Among Men Who Have Sex with Men in China: A Multi-City Pragmatic Randomized Controlled Trial.

Syphilis testing uptake is low among men who have sex with men (MSM) around the world. Syphilis self-testing (SST) may complement facility-based testing; the distribution model is yet to be explored. This study aimed to investigate the effectiveness of peer distribution of syphilis self-testing on promoting syphilis testing. We conducted a three-arm, unblinded, parallel individually randomized controlled trial among MSM in three cities in Guangdong, China. Inclusion criteria were: men who were born biologically male, aged 18 or above, have ever had sex with a man, will refer the interventions to peers, and will take the three-month follow-up survey. Enrolled indexes were randomly assigned in a 1:1:1 ratio into standard-of-care arm (SOC arm), standard SST delivery arm (S-SST arm), and a web-based referral link SST delivery arm (RL-SST arm). The primary outcome was the number of returned photograph-verified syphilis testing results per index. A total number of 300 indexes were enrolled, with 100 indexes in each arm. The number of verified syphilis tests per index conducted by alters was 0.05 in the control arm, 0.51 in the S-SST arm, and 0.31 in the RL-SST arm. The cost per alter tested was $760.60 for SOC, $83.78 for S-SST, and $93.10 for RL-SST. Minimal adverse event was reported among both indexes and alters during the study. This study showed that peer distribution of SST could improve syphilis testing uptake among MSM in China compared to facility-based testing. This approach warrants further consideration as part of expanding syphilis self-testing.

Sparking light in sexual health.

This editorial introduces the incoming co-Editors-in-Chief of the journal, and their plans to taking the journal in four directions focused on clinical impact, open science, building capacity, and improving the submission process.

Agreement of and discussion with clients about Undetectable equals Untransmissible among general practitioners in Australia: a cross-sectional survey.

BACKGROUND: The message of undetectable HIV viral load equals untransmissible (U=U) is important to reduce HIV stigma. We examined Australian general practitioner (GP)s' agreement of and discussion with clients about U=U. METHODS: We conducted an online survey through GP networks from April to October 2022. All GPs working within Australia were eligible. Univariable and multivariable logistic regression analyses were performed to identify factors associated with: (1) agreement of U=U; and (2) discussing U=U with clients. RESULTS: Of 703 surveys, 407 were included in the final analysis. Mean age was 39.7years (s.d.: 8.4). Most GPs (74.2%, n =302) agreed with U=U, but only 33.9% (n =138) had ever discussed U=U with clients. Key barriers to discussing U=U were lack of relevant client presentations (48.7%), lack of understanding about U=U (39.9%), and difficulty identifying those who would benefit from U=U (6.6%). Agreement with U=U was associated with greater odds of discussing U=U (adjusted odds ratio (AOR) 4.75, 95% confidence interval (CI): 2.33-9.68), younger age (AOR 0.96 per additional year of age, 95%CI: 0.94-0.99), and extra training in sexual health (AOR 1.96, 95%CI: 1.11-3.45). Discussing U=U was associated with younger age (AOR 0.97, 95%CI: 0.94-1.00), extra training with sexual health (AOR 1.93, 95%CI: 1.17-3.17), and negatively associated with working in a metropolitan or suburban area (AOR 0.45, 95%CI: 0.24-0.86). CONCLUSION: Most GPs agreed with U=U, but most had not discussed U=U with their clients. Concerningly, one in four GPs were neutral or disagreed with U=U, suggesting that further qualitative research to understand this finding, and implementation research to promote U=U among Australian GPs, is urgently needed.

A qualitative evaluation of a Nudgeathon event for the co-design of sexual health campaign images targeting overseas-born men who have sex with men.

BACKGROUND: Additional approaches to HIV prevention and management, such as Nudgeathons, are required to increase access to HIV pre-exposure prophylaxis (PrEP) among overseas-born men who have sex with men (MSM). METHODS: In September 2021, we conducted a 4-h online Nudgeathon, wherein four teams co-designed behaviourally informed adverts to improve PrEP access and uptake for overseas-born MSM. After the Nudgeathon, eight of 17 invited Nudgeathon attendees were interviewed about their experience. We conducted a qualitative content analysis of interview data to highlight participants' experiences of the co-design process. RESULTS: We identified three major themes: (1) what worked well; (2) group dynamics; and (3) improvement and future directions. The Nudgeathon about PrEP was a positive learning experience, with valuable contributions and overall satisfaction with the end-products. The online format was perceived as less costly than if the Nudgeathon was hosted in person, and suitable for participants from different geographical regions. In-person Nudgeathons with international attendees would require costs for flights, accommodation, function room hire and catering. Within groups, sharing personal experiences essential to co-designing concepts. However, less information on how to create nudges and more information before the Nudgeathon was preferred. CONCLUSION: Our evaluation finds that Nudgeathons are fast and efficient in developing potential solutions to complex issues related to HIV prevention.