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.

Treponema pallidum Detection at Asymptomatic Oral, Anal, and Vaginal Sites in Adults Reporting Sexual Contact with Persons with Syphilis.

We investigated Treponema pallidum PCR positivity at mucosal sites (oral, anal, and vaginal sites) among adults who had sexual contact with a person with syphilis (syphilis contacts). All syphilis contacts had oral rinse and swab samples collected for testing. Men who have sex with men had anal swab and women had vaginal swab samples collected for testing, regardless of the presence of lesions. Of 407 persons tested, 42 (10%) had early syphilis diagnosed; of those, 19 (45%) tested positive by PCR from any anatomic site and had a positive serologic test. T. pallidum was positive from vaginal samples in 3 women, anal samples in 3 men, and oral cavity samples in 2 women and 3 men, without symptoms at those sites. Three women had no prior syphilis serologic test. T. pallidum detection at asymptomatic mucosal sites suggests early syphilis infections, particularly in cases that would conventionally be staged as latent syphilis of unknown duration.

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.

Sexual activities and condom use among heterosexual men and women engaged in mixed-gender group sex events in Melbourne, Australia.

BACKGROUND: Few studies investigate group sex among heterosexuals. The aim of this study was to provide an exploration of characteristics and practices among heterosexual men and women who engage in group sex. METHOD: We conducted a cross-sectional survey between May 2019 and March 2020 among heterosexual men and women attending a sexual health clinic in Melbourne, Australia. Participants were asked whether they had participated in group sex (sex involving more than two participants) in the past 3months, the size of the most recent event, sexual activities in which they engaged, and condom use. RESULTS: Of 3277 heterosexuals surveyed (1509 women and 1768 men), the mean age was 29.9years (s.d. 8.8) and more than half (56.0%, n =1834) were born outside Australia. One in 20 participants (5.4%) had engaged in group sex in the past 3months with the number of events ranging 1-10times. Kissing was the most common activity in group sex, and women were significantly more likely to kiss a same-sex partner than men. Overall, of 165 participants who engaged in vaginal sex, 57 (34.5%) reported always using condoms and changing condoms between consecutive partners. Of the 100 men and women who had condomless vaginal sex, 79 (79.0%) received or performed fellatio after condomless vaginal sex. CONCLUSION: About two-thirds of heterosexuals who engaged in group sex neither used condoms nor changed condoms between partners in the most recent group sex event. Safe sex messages on changing condoms between partners and between sexual activities should be reinforced for sexually transmitted infections prevention.

Exploring the Use of "Nudges" to Improve HIV and Other Sexually Transmitted Infection Testing Among Men Who Have Sex with Men.

Behavioral economics and its applied branch "nudging" can improve individual choices in various health care settings. However, there is a paucity of research using nudges to improve regular testing for HIV and other sexually transmitted infections (STIs). The study examined which reminder system and message type men who have sex with men (MSM) preferred to remind them to undergo regular 3-monthly HIV and STI testing. A cross-sectional survey study was conducted among MSM attending a sexual health clinic in Melbourne, Australia between 13 January and 5 March 2020, exploring the preferred method of reminder and framing of the message. Descriptive statistics and logistic regression were used to analyze the data. A total of 309 responses were received. The majority of the participants (90%) preferred short messaging service (SMS) as the reminder method for HIV/STI testing compared to other types (e.g., email or instant messaging). More than a third of the participants (45%) showed a preference for a neutrally framed reminder message (Your next check-up is now due. Please phone for an appointment), while one-third (35%) preferred a personalized message (Hi [first name], you are due for your next check-up. Please phone for an appointment). Younger men were more likely to favor positive framed messages than older men who favored neutrally framed messages (p < .01). SMS was the preferred reminder method for regular HIV/STI testing. Reminder messages that were neutrally framed, personalized or positive framed messages were preferred over negative or social norm messages.

A cross-sectional study of male and female kissing partners among men who have sex with men.

BACKGROUND: Kissing may be a risk factor for gonorrhoea. Past studies have focused on male kissing partners among men who have sex with men (MSM). This study aimed to examine the kissing practices of MSM who kiss male and female partners. METHODS: We conducted a cross-sectional survey at the Melbourne Sexual Health Centre (MSHC) between March and April 2019. Men attending the MSHC, aged ≥16years who reported any sexual contact with another man in the previous 12months were invited to participate in the survey. Data about the number of kissing-only (kissing without sex), kissing-with-sex, and sex-only (having sex without kissing) partners in the previous 3months were collected. Men were asked to report the number of male and female partners separately. RESULTS: There were 357 MSM included in the survey. Most men (97.2%, n =347) had kissed or had sex with another man, whereas 16.0% (n =57) had kissed or had sex with a female partner in the previous 3months. Of the 57 men, 26.3% (n =15) had only kissed a female partner without having sex. The mean number of male partners for kissing-only was 5.5 (s.d.=6.6), kissing-with-sex was 5.0 (s.d.=6.6) and sex-only was 3.9 (s.d.=4.3). The mean number of female partners for kissing-only was 4.2 (s.d.=6.9), kissing-with-sex was 3.8 (s.d.=4.9) and sex-only was 3.2 (s.d.=3.4). CONCLUSION: MSM not only kiss men in the absence of sex, but also kiss women in the absence of sex. Gonorrhoea could be transmitted between MSM and women via kissing in the absence of sex.

Trichomoniasis among men presenting to a sexual health clinic in Melbourne, Australia.

BACKGROUND: This study aimed to examine the positivity of urethral Trichomonas vaginalis in men attending an urban sexual health clinic in Melbourne, Australia. METHODS: We conducted a retrospective analysis of men who were tested for T. vaginalis using nucleic acid amplification test at the Melbourne Sexual Health Centre between August 2018 and May 2021, and calculated the positivity. RESULTS: Of the 893 men who were tested for T. vaginalis , 12 (1.3%; 95% CI 0.7-2.3) tested positive for T. vaginalis . The positivity of T. vaginalis among men who reported sexual contact with a female partner with T. vaginalis was significantly higher than men who were not contacts (18.6% [8/43] vs 0.5% [4/850], P <0.001). CONCLUSIONS: The positivity of T. vaginalis was low at our clinic. The high positivity among contacts highlights the importance of partner notification, testing and management.

Spatial and Temporal Epidemiology of Infectious Syphilis in Victoria, Australia, 2015-2018.

ABSTRACT: This analysis of notified syphilis cases in Victoria, Australia between 2015 and 2018 shows that the syphilis epidemic in Victoria has become more generalized, with increases among heterosexual men and women residing in outer Melbourne suburbs-areas that differ from those of gay men.

Exploring the attitudes of men who have sex with men on anal self-examination for early detection of primary anorectal syphilis: a qualitative study.

BACKGROUND: Studies show men who have sex with men (MSM) practising receptive anal sex are more likely to present with secondary syphilis, suggesting anorectal primary lesions are being missed. Regular anal self-examination might be able to detect anorectal syphilis lesions, hence potentially reducing transmission. This study aimed to explore the attitudes of MSM on performing anal self-examination to detect primary syphilis. METHODS: In this qualitative study, 20 MSM over 18 years of age were purposively sampled from a sexual health clinic to participate in semi-structured interviews. Interviews were recorded, transcribed verbatim and data analysed thematically. RESULTS: Four major themes and 12 sub-themes were generated from the study: (1) reasons for performing anal self-examination, (2) preferred educational resources for anal self-examination, (3) attitudes towards partner anal examination, and (4) acceptability of anal self-examination. Most participants had performed some form of anal self-examination in the past, and, just over half performed regularly for mostly health-related concerns. Most participants who infrequently or never performed anal self-examination were agreeable to perform regularly if it was recommended by health professionals with appropriate guidance. Participants preferred education on anal self-examination from health professionals and trusted online learning resources. CONCLUSION: Our study showed MSM were agreeable to anal self-examination however would like to receive education and training to gain more confidence in conducting anal self-examination as a screening tool. Further studies are required to explore the adherence and acceptability of anal self-examination for syphilis prior to studies examining efficacy. The study provides foundation for any future policy aiming at utilising anal self-examination as a screening tool for syphilis among MSM.

Clinical presentation of asymptomatic and symptomatic heterosexual men who tested positive for urethral gonorrhoea at a sexual health clinic in Melbourne, Australia.

BACKGROUND: Asymptomatic screening for gonorrhoea in heterosexual men is currently not recommended in many countries including Australia, given the prevalence is relatively low in the heterosexual population. We aimed to determine the proportion of urethral gonorrhoea cases among heterosexual men attending a sexual health clinic that was asymptomatic and symptomatic, the time since last sexual contact to the onset of symptoms and the time to clinic presentation following the onset of symptoms. METHODS: This was a cross-sectional study that included heterosexual men aged 16 years or above attending the Melbourne Sexual Health Centre (MSHC) in Australia between August 2017 and August 2018. Gonorrhoea cases were diagnosed by nucleic acid amplification testing (NAAT) and/or culture. Descriptive analyses were conducted for all gonorrhoea cases including demographic characteristics, recent sexual practices, reported urethral symptoms and duration, sexual contact with a person diagnosed with gonorrhoea, investigations performed and laboratory results. RESULTS: There were 116 confirmed cases of urethral gonorrhoea in heterosexual men over the study period of which 6.0% (95% CI: 2.7-12.1%) were asymptomatic. Typical urethral discharge was present in 80.2% (95% CI: 71.9-86.5%) of men. The mean time between last sexual contact and the onset of symptoms was 7.0 days, and between the onset of symptoms to presentation to the clinic was 5.6 days. CONCLUSIONS: A small proportion of heterosexual men with urethral gonorrhoea do not have any symptoms. Heterosexual men with urethral symptoms usually seek for healthcare within a week, prompting rapid healthcare-seeking behaviour.

International travel as risk factor for Chlamydia trachomatis infections among young heterosexuals attending a sexual health clinic in Melbourne, Australia, 2007 to 2017.

BackgroundInternational travel is considered a risk factor for acquiring Chlamydia trachomatis; however, there are little empirical data to support this.AimTo examine the prevalence and risk factors for Chlamydia trachomatis infections among heterosexual international travellers (n = 28,786) attending the Melbourne Sexual Health Centre (MSHC), Australia, compared to Australian residents (n = 20,614).MethodsWe conducted a repeated cross-sectional study and analysed sexual behaviours and chlamydia positivity among heterosexual males and females aged ≤ 30 attending MSHC for the first time between January 2007 and February 2017. 'Travellers' were defined as individuals born outside of Australia who had resided in the country < 2 years. Associations between patient characteristics and chlamydia positivity were examined.ResultsChlamydia positivity was higher among travellers (11.2%) compared with Australian residents (8.5%; p < 0.001). Male travellers had higher chlamydia positivity (12.1%) than Australian males (9.3%; p < 0.001), as did female travellers (10.4%) compared with Australian females (7.7%; p < 0.001). Travellers had a higher mean number of sexual partners than Australian residents among males (5.7 vs 4.7; p < 0.001) and females (3.6 vs 3.2; p < 0.001). Travellers from the United Kingdom, Europe, Ireland and New Zealand accounted for 29.6%, 21%, 8.5% and 5.8% of C. trachomatis infections, respectively. Chlamydia in males and females was associated with younger age (≤ 25), inconsistent condom use, a higher number of sexual partners (≥ 4 partners) and being a traveller (p < 0.001).ConclusionsWe found that international travel is an independent risk factor for chlamydia among young heterosexual travellers in Australia, who should therefore be a target group for chlamydia prevention.

Detection of human papillomavirus in urine among heterosexual men in relation to location of genital warts and circumcision status.

OBJECTIVE: Human papillomavirus (HPV) surveillance is important to monitor the effectiveness of national HPV vaccination programmes. Positivity of HPV in urine in men varies with different sampling methods. We aimed to determine the positivity for detection of HPV-6/11 in urine samples among men in relation to the position of genital warts and circumcision status. METHOD: We analysed stored chlamydia-positive urine specimens in young heterosexual men aged less than 25 years attending Melbourne Sexual Health Centre, Australia, between 2004 and 2015, for HPV genotypes. Positivity of HPV-6/11 and high-risk genotypes were stratified according to the position of genital warts and circumcision status. Positivity of HPV-6/11 was calculated using diagnosis of warts as the gold standard. Warts were classified as proximal penile warts from suprapubic area to midshaft of penis, and distal penile warts from distal shaft of penis to meatus. RESULTS: Of the 934 specimens, 253 (27.1%) men were positive for any HPV and 82 men (8.8%) had genital warts. The ORs of HPV-6/11 detection in urine were 4.63 (95% CI: 1.68 to 12.78) and 40.20 (95% CI: 19.78 to 81.70) times higher among men who had proximal penile warts and distal penile warts, respectively, compared with men who did not have genital warts. Circumcised men were less likely to have high-risk HPV (OR 0.31; 95% CI: 0.14 to 0.65) than uncircumcised men. Uncircumcised men were more likely to have distal penile warts than circumcised men (OR 8.22; 95% CI: 1.34 to 337.46). CONCLUSION: Positivity of HPV-6/11 in urine increases greatly in men with distal penile warts. Circumcised men are less likely to have distal penile warts, any HPV or high-risk HPV detected. Urine is likely to be an alternative sampling method for HPV-6/11 surveillance programme in men in countries with low circumcision rates.

Changes in HIV post-exposure prophylaxis prescriptions before and after the introduction of HIV pre-exposure prophylaxis at a sexual health clinic in Melbourne, Australia, 2011-2021.

OBJECTIVE: HIV pre-exposure prophylaxis (PrEP) became available in Victoria, Australia, in 2016. We examined non-occupational post-exposure prophylaxis (nPEP) usage among gay, bisexual and other men who have sex with men (MSM) before and after PrEP became available. METHODS: We included MSM attending Melbourne Sexual Health Centre for nPEP between 2011 and 2021. We analysed three periods: the 'pre-PrEP' (01 Jan 2011 to 25 Jul 2016), 'PrEP before COVID-19' (26 Jul 2016 to 31 Dec 2019), and 'PrEP during COVID-19' (01 Jan 2020 to 31 Dec 2021). RESULTS: There were 222,978 consultations for MSM; 8292 (3.7%) were nPEP consultations. The proportion of nPEP consultations increased from 3.3% (3093/94263) in the pre-PrEP period to 4.3% (3843/89251) in the PrEP before COVID-19 period then dropped to 3.4% (1356/39464) during the COVID-19 period. Compared to Australian-born MSM, MSM born in Central/South America (adjusted odds ratio [aOR]: 1.75; 95% confidence interval [CI]: 1.27-2.40) had the highest odds of accessing nPEP, followed by Asian-born MSM (aOR: 1.47; 95% CI: 1.27-1.71) after adjusting for PrEP availability and COVID-19. Those newly arrived in Australia in ≤4 years had higher odds (aOR: 1.14; 95% CI: 1.05-1.22) of accessing nPEP than those living in Australia for >4 years. CONCLUSION: nPEP prescriptions declined with PrEP availability. Newly arrived overseas-born MSM who are unlikely to have access to subsidised PrEP have a higher demand of nPEP. IMPLICATIONS FOR PUBLIC HEALTH: Increasing PrEP education and ensuring equal access is vital in the drive to reduce new HIV diagnoses.

Combinations of Sexual Activities During a Sex Episode with Recent Casual Male Partner Among Men Who Have Sex with Men: A Cross-Sectional Study.

We examined combinations of nine sexual activities that occurred during a sex episode with a recent male partner among men who have sex with men (MSM) who attended an urban sexual health clinic from April-2017 to September-2017. We collected the following sexual activities: tongue-kissing, penises touching, using saliva during mutual masturbation, performed rimming, received rimming, performed fellatio, received fellatio, insertive anal sex, and receptive anal sex. During a single-sex episode, the most common combinations of sexual activities involved all nine activities (10.6%, 166/1542). We assessed the agreement between any two sexual activities that occurred together during a sex episode. Agreement was highest for receiving rimming and receptive anal sex (kappa = 0.40; 95% CI: 0.35, 0.45), and performing rimming and insertive anal sex (kappa = 0.38; 95% CI: 0.33, 0.42). Agreement was lowest for insertive anal sex and receiving fellatio (kappa = -0.01; 95% CI: -0.05, 0.03), and receptive anal sex and insertive anal sex (kappa = -0.08; 95% CI: -0.13, 0.03). The sexual activities that occur between men are correlated with one another and this will influence transmission between anatomical sites.

Incidence and Risk Factors for Early Syphilis Among Men Who Have Sex With Men in Australia, 2013-2019: A Retrospective Cohort Study.

Background: We aimed to examine the incidence of syphilis in men who have sex with men (MSM) and identify subgroups of MSM at a higher risk of syphilis infection. Methods: We conducted a retrospective cohort study of MSM attending a sexual health clinic in Australia, during 2013-2019, who had at least 2 syphilis serological tests during the study period. The incidence of syphilis was expressed as per 100 person-years. A cox regression analysis was conducted to identify risk factors for syphilis. Results: A total of 24 391 individual MSM (75 086 consultations) were included. A total of 1404 new syphilis cases were diagnosed with an incidence of 3.7/100 person-years (95% confidence interval, 3.5-3.9). Syphilis incidence was higher in MSM with human immunodeficiency virus ([HIV] 9.3/100 person-years) than in MSM taking HIV pre-exposure prophylaxis (PrEP) (6.9/100 person-years) or HIV-negative MSM not taking PrEP (2.2/100 person-years). Risk factors associated with high incidence of syphilis included the following: MSM with HIV (adjusted hazard ratio [aHR] 2.7), MSM taking HIV PrEP (aHR 2.1), past history of syphilis infection (aHR 2.4), injecting drug use (aHR 2.7), condomless anal sex (aHR 1.7), >4 sexual partners in the last 12 months (aHR 1.2), and concurrent sexually transmitted infection (chlamydia and gonorrhoea) (aHR 1.6). Conclusions: The incidence of syphilis remains high among MSM, particularly in subgroups with associated risk factors for syphilis infections. These data highlight the need for biomedical and behavioral interventions to be targeted to subgroups of MSM at the highest risk of syphilis infection.

Treponema pallidum PCR screening at mucosal sites of asymptomatic men who have sex with men taking HIV pre-exposure prophylaxis.

Early detection and treatment of syphilis will reduce the infectious period and transmission. We aimed to determine whether screening men who have sex with men (MSM) taking HIV pre-exposure prophylaxis (PrEP) for syphilis using Treponema pallidum polymerase chain reaction (PCR) could detect syphilis before the appearance of syphilis antibodies in serology. MSM attending 3-monthly PrEP clinic visits in Melbourne, Australia, were screened with a PCR assay targeting the polA gene of T. pallidum from an anal swab and an oral rinse between November 2019 and March 2020. Participants were serologically screened for syphilis using chemiluminescence immunoassay. A total of 309 asymptomatic participants provided an anal swab and oral rinse sample for T. pallidum PCR screening. Two syphilis cases (0.6%) were detected: one man had a positive serology only; another man had T. pallidum detected by PCR from an anal swab and a positive serology. PCR positivity was 0.3% (n = 1) for anal swabs and 0% (n = 0) for oral rinse. In this study, T. pallidum PCR screening at routine PrEP clinic visits did not identify additional cases of early syphilis over serological screening performed at these visits. IMPORTANCE With the ongoing syphilis epidemic in men who have sex with men (MSM), we investigated the role of using Treponema pallidum polymerase chain reaction (PCR) testing at the oral cavity and anus in MSM taking pre-exposure prophylaxis for the early detection of syphilis. We evaluated whether the PCR tests from these mucosal sites can detect syphilis infection early, before the development of syphilis antibodies in serology. Our study found two syphilis cases among 309 MSM, and only one syphilis case had a positive anal PCR swab, although serology was positive. We conclude that additional PCR testing is likely to be expensive and would not be cost effective for individuals who regularly screen for syphilis. However, future studies with a larger sample size are required.

Increased syphilis testing and detection of late latent syphilis among women after switching from risk-based to opt-out testing strategy in an urban Australian sexual health clinic: a retrospective observational study.

Background: The Melbourne Sexual Health Centre (MSHC) implemented an opt-out syphilis test for women in December 2017. We aimed to examine the differences in syphilis testing uptake and confirmed syphilis cases among women after switching from risk-based to opt-out testing strategies. Methods: This was a retrospective study examining all women attending the MSHC for the first time in periods of risk-based testing (2015-2017) and opt-out testing (2018-2020). We calculated the proportion of women who tested for syphilis and the proportion of women with confirmed syphilis in each period. A chi-square test was performed to determine the differences in proportion between the risk-based testing and opt-out periods. Findings: A total of 27,481 women (i.e. 13,059 in the risk-based testing period and 14,422 in the opt-out period) were included in the final analysis, and the mean age was 26.8 years (standard deviation = 6.9). The proportion of women who were tested for syphilis at their first consultation increased from 52.8% (6890/13,059) in the risk-based testing period to 67.4% (9725/14,422) in the opt-out period (p < 0.0001). Syphilis positivity did not differ between the two periods (0.48% [33/6890] vs 0.71% [69/9725], p = 0.061) but late latent causes increased from 36.4% [12/33] to 60.9% [42/69] (p = 0.033). Interpretation: The opt-out testing strategy increased syphilis testing among women with increased detection of asymptomatic late latent syphilis. The opt-out syphilis testing strategy is beneficial in sexual health services. Health education and awareness may be required to improve syphilis testing uptake. Funding: National Health and Medical Research Council.

Non-conventional interventions to prevent gonorrhea or syphilis among men who have sex with men: A scoping review.

Objectives: We assessed nonconventional interventions that did not traditionally focus on increasing condom use and/or testing among men who have sex with men (MSM) and the evidence for these interventions. Methods: Guided by the Participants, Concept and Context (PCC) framework, we searched five online databases from inception to 9 August 2021 for original research on interventions that do not focus on increasing condom use and/or testing to prevent gonorrhea and/or syphilis in MSM. Two researchers screened titles and abstracts to assess eligibility, reviewed articles' full text and resolved discrepancies through discussion. We charted relevant study information, and the included studies were critically appraised. Results: Of 373 articles retrieved, 13 studies were included. These studies were conducted in Australia (n = 3), Belgium (n = 2), China (n = 3), the Netherlands (n = 1) and the US (n = 4). Two randomized controlled trials (RCTs) of doxycycline as pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) reduced any STI incidence (gonorrhea, syphilis, or chlamydia), but only doxycycline PEP significantly reduced syphilis incidence. Six studies of interventions that facilitated self-collection, self-examination, and self-testing, found varied evidence for gonorrhea and/or syphilis prevention. Four RCTs and one single-arm trial examined the efficacy of mouthwash, but the evidence remains inconclusive on whether mouthwash use can prevent transmission between men. Conclusion: We found evidence for doxycycline PEP in reducing syphilis incidence, evidence on the use of mouthwash to prevent gonorrhea transmission between men remains inconclusive. More evidence is needed for interventions that do not focus on increasing condom use and/or testing to prevent gonorrhea and/or syphilis.

Adherence to weekly anal self-examination among men who have sex with men for detection of anal syphilis.

Background: Men who have sex with men (MSM) practicing exclusively receptive anal sex are more likely to present with secondary than primary syphilis, implying primary anorectal lesions may be missed. If men could detect anorectal lesions by regular anal self-examination, the duration of infectiousness could be reduced. This study aimed to examine adherence to weekly anal self-examination. Method: We conducted a longitudinal feasibility study examining the adherence to weekly anal self-examinations among MSM attending a sexual health clinic in Melbourne, Australia between December 2020 and June 2021. Adherence to weekly anal self-examinations over 12 weeks was assessed from a logbook and 4-weekly surveys. Participants who identified abnormalities in their anus were recommended to seek medical review. Results: Of the 30 men who completed the study, anal self-examination was performed at least weekly for 308 of 360 person-weeks (86% of the weeks, 95% CI: 82-89). The mean adherence was 3.6 (95% CI: 3.3-3.9) examinations per 4-weeks per person in Weeks 1-4, 3.5 (95% CI: 3.1-3.8) in Weeks 5-8 and 3.3 (95% CI: 2.9-3.7) in Weeks 9-12 (P trend = 0.06). Six men (20%, 6/30) were seen for medical review after they identified abnormalities, whilst eight men (27%, 8/30) reported abnormalities, but did not seek medical review. No participants were diagnosed with syphilis during the study period. Conclusion: We conclude that men adhered well to weekly anal self-examination. Therefore, it is feasible to trial this as a routine practice among MSM. Future studies should investigate possible reductions in adherence over time and ways to increase medical review for abnormalities that men find.