Population rates of HIV, gonorrhoea and syphilis diagnoses by sexual orientation in New Zealand.

INTRODUCTION: Globally, gay and bisexual men (GBM) are over-represented in HIV, syphilis and gonorrhoea cases. However, surveillance systems rarely provide meaningful measures of inequity, such as population-specific rates, due to a lack of sexual orientation denominators. HIV, gonorrhoea and syphilis are legally notifiable diseases in New Zealand (NZ); we calculate rates by sexual orientation for the first time. METHODS: We analysed 2019 national surveillance data on HIV, syphilis and gonorrhoea notifications disaggregated by sexual orientation. Unique health records identified duplicate notifications and reinfections. Missing data were imputed from known cases. We used the NZ Health Survey 2014/2015 to estimate population sizes by sexual orientation, measured in two ways (current sexual identity, sexual contact in the previous 12 months with men, women or both). We calculated notification rates per 100 000 for each sexual orientation subgroup and rate ratios. RESULTS: In 2019, GBM accounted for 76.3%, 65.7% and 39.4% of HIV, syphilis and gonorrhoea notifications, respectively. Population rates per 100 000 for HIV were 158.3 (gay/bisexual men) and 0.5 (heterosexuals); for syphilis, population rates per 100 000 were 1231.1 (gay/bisexual men), 5.0 (lesbian/bisexual women) and 7.6 (heterosexuals); for gonorrhoea (imputed), population rates per 100 000 were 6843.2 (gay/bisexual men), 225.1 (lesbian/bisexual women) and 120.9 (heterosexuals). The rate ratios for GBM compared with heterosexuals were: 348.3 (HIV); 162.7 (syphilis); and 56.6 (gonorrhoea). Inequities remained in sensitivity analysis (substituting sexual identity with sexual behaviour in the previous 12 months). CONCLUSION: GBM in NZ experience profound inequities in HIV, syphilis and gonorrhoea. Rate ratios by sexual orientation provide useful 'at-a-glance' measures of inequity in disease incidence.

Self-reported STIs and sexual health checks in a cross-sectional study of gay and bisexual men in New Zealand.

OBJECTIVES: To determine the incidence of self-reported sexually transmitted infections (STIs) and sexual health checks in community and internet samples of New Zealand gay, bisexual and other men who have sex with men (MSM) and factors associated with these. METHODS: We analysed anonymous self-completed data from 3138 MSM who participated in the location-based Gay Auckland Periodic Sex Survey (GAPSS) and the internet-based Gay Online Sex Survey (GOSS) undertaken in February 2011. RESULTS: Overall 8.2% of the participants reported at least one STI in the previous 12 months, which did not differ significantly by demographic factors or HIV status. While having anal sex and more partners were associated with more STI, after adjustment for the number of partners, the type of partner (regular or casual) was not. Medium and low condom users reported STIs more than high condom users, regardless of partner type. Overall 40% had a sexual health check-up without an STI diagnosed in the past year, with similar numbers attending general practice and sexual health clinics. Having a check-up was lower among Pacific and Asian men, those identifying as bisexual and recruited online. While those with more partners, having anal intercourse and diagnosed with HIV were more likely to go for a check-up, those using condoms less often were not. CONCLUSIONS: STIs are commonly reported in this community sample of MSM but will underestimate the true incidence due to asymptomatic infection. Screening for STIs outside sexual health clinics should be normalised for MSM and made accessible, safe and relevant.

Pertussis epidemiology in adults: Retrospective analysis of pertussis incidence and association with comorbidities among adult populations in Aotearoa New Zealand, using national administrative datasets.

BACKGROUND: In New Zealand, approximately half reported pertussis cases are adult. Studies indicate underestimated pertussis burden in this population and probable reservoir for childhood pertussis. Pertussis is linked to chronic obstructive pulmonary disease (COPD) development and increased risk with pre-existing COPD. While acellular pertussis vaccines are available for adults, data on pertussis disease burden in adults and association with COPD remain limited. AIM: To estimate pertussis incidence in New Zealand adult health service user (HSU) population aged ≥ 18 between 2008-2019 and inform adult pertussis vaccination strategies by assessing disease burden and risk factors in different adult populations. METHODS: Retrospective observational cohort study using an HSU cohort, formed by linking administrative health data using unique National Health Index identifier. For primary analysis, annual incidence rates were calculated using pertussis hospitalisations and notifications. In secondary analysis, Cox proportional hazards survival analyses explored association between pertussis in adults and chronic comorbidities. RESULTS: The cohort had 2,907,258 participants in 2008 and grew to 3,513,327 by 2019, with 11,139 pertussis cases reported. Highest annual incidence rate of 84.77 per 100,000 PYRS in 2012, notably affecting females, those aged 30-49 years, and European or Maori ethnicity. Adjusting for sociodemographic variables found no significant risk of prior pertussis notification leading to comorbidity diagnosis (Adjusted-HR: 0.972). However, individuals with prior comorbidity diagnosis had 16 % greater risk of receiving pertussis notification or diagnosis (Adjusted-HR: 1.162). CONCLUSIONS: Study found significant pertussis burden among the HSU adult cohort and highlighted higher risk of pertussis for those with recent comorbidity diagnoses. Vaccination for pertussis should be recommended for individuals with comorbidities to reduce infection risk and disease severity. GPs must have capability to test for pertussis, given it is notifiable disease with implications for individuals, their families, and broader population. High-quality disease surveillance is crucial for informing policy decisions.

Implementing HIV pre-exposure prophylaxis (PrEP): let's not get caught with our pants down.

HIV pre-exposure prophylaxis (PrEP) is a daily pill that prevents HIV acquisition. In March 2018, New Zealand became one of the first countries in the world to publicly fund PrEP for individuals at high risk. PrEP promises significantly improved HIV control but is unfamiliar to most health practitioners here, compromising its potential. In this article we review the rationale for PrEP and identify barriers to rapid implementation. The latter include: consumer and health practitioner awareness; acceptability; scale-up targets; prescribing and pharmacy bottlenecks; service capacity to manage follow-up; primary care training; monitoring systems for uptake and quality; equity; eligibility; risk compensation and policy. Many of these areas are ripe for research and innovation. By addressing these obstacles we can realise the potential of PrEP and move closer to ending HIV in Aotearoa/New Zealand.

What do African new settlers in New Zealand 'know' about HIV? y.

AIM: To demonstrate the differences between objective and operational knowledges of HIV transmission and care in Black African migrants, and how these differences may be managed in a clinical interview. METHOD: This two phase national New Zealand study first estimated the resident Black African migrant population and HIV seroprevalence. The second phase collected surveys (n=703); focus groups (n=131 people) amplified the survey data. Community advisory groups comprising community leaders and people living with HIV were consulted throughout the study. RESULTS: Black African migrants reported good levels of basic knowledge of HIV on the survey, but demonstrated a range of culturally constructed beliefs and operational knowledge in focus groups. CONCLUSION: Study findings suggest that objective knowledge assessment is not sufficient, and that a contextual approach to understanding what people 'know' is essential, not only for HIV, but for the delivery of all health care education and interventions to Black African new settlers. Routine HIV education and testing, together with staff education, may increase acceptance of these interventions.

Stigma, lack of knowledge and prevalence maintain HIV risk among Black Africans in New Zealand.

OBJECTIVE: The AfricaNZ Health project aimed explore HIV risks in Black African communities in NZ with a view to informing HIV infection prevention and health promotion programs. METHODS: AfricaNZ Health was completed in two phases. The first developed desk estimates of the resident Black African population in New Zealand, and Africans living with HIV. The second comprised two arms: an anonymous survey administered at African community events and a series of focus groups around the country. RESULTS: High levels of knowledge and positive attitudes about HIV were more often found in older than younger age groups. Condom use was higher in the younger group than in older age groups. Traditional attitudes still inform some beliefs about HIV. Stigma about HIV and anyone at risk for HIV remains very high among Africans. Western sexual identity constructs are not meaningful. CONCLUSIONS: A culturally informed strategy for risk and stigma reduction is urgently needed. IMPLICATIONS: The existing prevention and care infrastructure, informed by MSM experiences, must address increased risk to Black African new settlers, but this is not a reason to discriminate or further stigmatise an already vulnerable population.

Infrequent condom use with casual partners among New Zealand gay and bisexual men.

AIMS: To identify predictors of non-condom use among gay and bisexual men (GBM) in New Zealand with casual male partners. METHODS: We analysed anonymous self-completed data from GBM who participated in the communitybased Gay Auckland Periodic Sex Survey (GAPSS) and Internet-based Gay Online Sex Survey (GOSS), undertaken in 2014. Infrequent condom use was defined as not using condoms "always" or "almost always" during anal intercourse in the prior six months. RESULTS: Of the 1,912 GBM reporting anal intercourse with a casual partner, 27.2% reported infrequent condom use. Being recruited from Internet dating sites, Pacific ethnicity, having over 20 recent male partners, infrequent condom use with a current regular partner, or being HIV-positive were independently predictive of infrequent condom use. Conversely, being older, having a tertiary degree, using a condom at first anal intercourse, being exclusively receptive with a casual partner/s, and seeing condoms promoted through multiple channels predicted frequent condom use. Attitudes to condoms and safe sex were strongly predictive of actual condom use. CONCLUSIONS: Social marketing should target the modifiable predictors of condom use, such as attitudes to safe sex. Interventions also need to engage successfully with GBM reporting non-modifiable traits such as HIV-positive GBM.

Respondent-driven sampling among gay and bisexual men: experiences from a New Zealand pilot study.

BACKGROUND: Respondent-driven sampling (RDS) is a method of approximating random sampling of populations that are difficult to locate and engage in research such as gay, bisexual and other men who have sex with men (GBM). However, its effectiveness among established urban gay communities in high-income countries is largely unexplored outside North America. We conducted a pilot study of RDS among urban GBM in Auckland, New Zealand to assess its local applicability for sexual health research. FINDINGS: Pre-fieldwork formative assessment explored RDS suitability among local GBM. Highly-networked initial participants ("seeds") and subsequent participants completed a questionnaire, took a rectal swab for chlamydia and gonorrhoea testing, and were asked to recruit up to three eligible peers over the subsequent 2 weeks using study coupons. Compensation was given for participating and for each peer enrolled. Feedback on the pilot was obtained through questionnaire items, participant follow-up, and a focus group. Nine seeds commenced recruitment, directly enrolling 10 participants (Wave One), who in turn enrolled a further three (Wave Two). Two of the 22 participants (9 %) had undiagnosed rectal chlamydia. The coupon redemption rate (23 %) was lower than the expected rate (33 %) for this population. Participants were motivated by altruism above financial incentives; however, time, transport and reluctance recruiting peers were perceived as barriers to enrolment. DISCUSSION: Slow recruitment in our pilot study suggests that RDS might not be an effective or efficient method of sampling gay men in all high-income urban settings. However those who participated in the pilot were willing to provide anal swabs and information on their sexual behaviour, and also on the size of their GBM social network which is necessary to weight data in RDS. Refinements and adaptations such as reducing the transaction costs of taking part (e.g. offering online participation) could improve responses but these have their own drawbacks (higher set-up costs, difficulty collecting biological specimens).

General practitioner awareness of sexual orientation among a community and internet sample of gay and bisexual men in New Zealand.

INTRODUCTION: General practitioners (GPs) can improve HIV and sexually transmitted infection (STI) screening, vaccination and wellbeing among gay, bisexual and other men who have sex with men (GBM) if they are aware of a patient's sexual orientation. AIM: To estimate GP awareness of their GBM patients' sexual orientation and examine whether HIV and STI screening was associated with this. METHODS: We analysed anonymous, self-completed data from 3168 GBM who participated in the community-based Gay Auckland Periodic Sex Survey (GAPSS) and Internet-based Gay men's Online Sex Survey (GOSS) in 2014. Participants were asked if their usual GP was aware of their sexual orientation or that they had sex with men. RESULTS: Half (50.5%) believed their usual GP was aware of their sexual orientation/behaviour, 17.0% were unsure, and 32.6% believed he/she was unaware. In multivariate analysis, GP awareness was significantly lower if the respondent was younger, Asian or an 'Other' ethnicity, bisexual-identified, had never had anal intercourse or had first done so very recently or later in life, and had fewer recent male sexual partners. GBM whose GP was aware of their sexual orientation were more likely to have ever had an HIV test (91.5% vs 57.9%; p<0.001), specific STI tests (91.7% vs 68.9%; p<0.001), and were twice as likely to have had an STI diagnosed. DISCUSSION: Lack of sexual orientation disclosure is resulting in missed opportunities to reduce health inequalities for GBM. More proactive, inclusive and safe environments surrounding the care of sexual orientation minorities are needed in general practice to encourage disclosure.