Azithromycin or Doxycycline for Asymptomatic Rectal Chlamydia trachomatis.

BACKGROUND: Rectal chlamydia is a common bacterial sexually transmissible infection among men who have sex with men. Data from randomized, controlled trials are needed to guide treatment. METHODS: In this double-blind trial conducted at five sexual health clinics in Australia, we randomly assigned men who have sex with men and who had asymptomatic rectal chlamydia to receive doxycycline (100 mg twice daily for 7 days) or azithromycin (1-g single dose). Asymptomatic chlamydia was selected as the trial focus because more than 85% of men with rectal chlamydia infection are asymptomatic, and clinical guidelines recommend a longer treatment course for symptomatic infection. The primary outcome was a negative nucleic acid amplification test for rectal chlamydia (microbiologic cure) at 4 weeks. RESULTS: From August 2016 through August 2019, we enrolled 625 men (314 in the doxycycline group and 311 in the azithromycin group). Primary outcome data were available for 290 men (92.4%) in the doxycycline group and 297 (95.5%) in the azithromycin group. In the modified intention-to-treat population, a microbiologic cure occurred in 281 of 290 men (96.9%; 95% confidence interval [CI], 94.9 to 98.9) in the doxycycline group and in 227 of 297 (76.4%; 95% CI, 73.8 to 79.1) in the azithromycin group, for an adjusted risk difference of 19.9 percentage points (95% CI, 14.6 to 25.3; P<0.001). Adverse events that included nausea, diarrhea, and vomiting were reported in 98 men (33.8%) in the doxycycline group and in 134 (45.1%) in the azithromycin group (risk difference, -11.3 percentage points; 95% CI, -19.5 to -3.2). CONCLUSIONS: A 7-day course of doxycycline was superior to single-dose azithromycin in the treatment of rectal chlamydia infection among men who have sex with men. (Funded by the National Health and Medical Research Council; RTS Australian New Zealand Clinical Trials Registry number, ACTRN12614001125617.).

'It's Not Really a Part of Standard Practice': Institutional Silencing of Sexuality Within Australian Mental Health Settings.

Research seeking to understand and improve sexuality-related practice in mental health settings has paid little attention to the institutional context in which clinicians' practice is embedded. Through a social constructionist lens, we used thematic analysis to examine how 22 Australian mental health clinicians implicated the wider institutional context when discussing and making sense of sexuality-related silence within their work. Interviews were part of a study exploring participants' perceptions of sexuality and sexual health in their work more generally. Broader silences that shaped and reinforced participants' perceptions and practice choices were situated in professional education; workplace cultures; and the tools, procedures and policies that directed clinical practice. We argue that sexuality-related silence in mental health settings is located in the institutional context in which clinicians learn and work, and discuss how orienting to this broader context will benefit research and interventions to improve sexuality-related practice across health settings.

Factors Associated With Early Resumption of Condomless Anal Sex Among Men Who Have Sex With Men After Rectal Chlamydia Treatment.

BACKGROUND: The resumption of sexual activity shortly after commencing treatment for sexually transmitted infections (STIs) is poorly described despite contributing to onward transmission. With azithromycin remaining an option for rectal Chlamydia trachomatis, resuming sex too early after treatment may contribute to antimicrobial resistance because of exposure of newly acquired STIs to subinhibitory concentrations. METHODS: Clinical and sexual behavioral data were collected from men participating in a trial assessing treatment efficacy for rectal chlamydia. Data were collected at recruitment and weekly for 3 weeks after commencing treatment. Outcome measures were resumption of any sexual activity or condomless receptive anal sex within 1, 2, or 3 weeks after commencing treatment. Generalized linear regression was used to calculate adjusted risk ratios (aRR) to identify associated factors. RESULTS: Almost 1 in 10 men (9.5%; 95% confidence interval [CI], 7.2-12.1) resumed condomless receptive anal sex within 1 week of commencing treatment. This was associated with current preexposure prophylaxis use (aRR, 3.4; 95% CI, 2.5-4.8]) and having 9 or more sexual partners in the last 3 months (aRR, 3.2; 95% CI, 1.6-5.0). Most men (75.0%; 95% CI, 71.3-78.5) resumed any sexual activity within 3 weeks; this was associated with a greater number of sexual partners (4-8 partners; aRR, 1.2; 95% CI, 1.1-1.5; ≥9 partners; aRR, 1.5; 95% CI, 1.3-1.7). CONCLUSIONS: Resuming condomless receptive anal sex early after treatment may facilitate onward transmission and promote antimicrobial resistance for STIs. Although azithromycin remains a treatment option, this analysis highlights the need for new health promotion messages regarding early resumption of sex and continued surveillance for antimicrobial resistance.

Looking at the positives: proactive management of STIs in people with HIV.

Patients who are HIV-positive and co-infected with other sexually transmitted infections (STIs) are at risk of increased morbidity and mortality. This is of clinical significance. There has been a dramatic increase in the incidence of STIs, particularly syphilis, gonorrhoea, Mycoplasma genitalium and hepatitis C virus (HCV) in HIV-positive patients. The reasons for this are multifactorial, but contributing factors may include effective treatment for HIV, increased STI testing, use of HIV pre-exposure prophylaxis and use of social media to meet sexual partners. The rate of syphilis-HIV co-infection is increasing, with a corresponding increase in its incidence in the wider community. HIV-positive patients infected with syphilis are more likely to have neurological invasion, causing syndromes of neurosyphilis and ocular syphilis. HIV infection accelerates HCV disease progression in co-infected patients, and liver disease is a leading cause of non-AIDS-related mortality among patients who are HIV-positive. Since several direct-acting antivirals have become subsidised in Australia, there has been an increase in treatment uptake and a decrease in HCV viraemia in HIV-positive patients. The incidence of other sexually transmitted bacterial infections such as Neisseria gonorrhoeae and M. genitalium is increasing in HIV patients, causing urethritis, proctitis and other syndromes. Increasing antimicrobial resistance has also become a major concern, making treatment of these infections challenging. Increased appropriate testing and vigilant management of these STIs with data acquisition on antimicrobial sensitivities and antimicrobial stewardship are essential to prevent ongoing epidemics and emergence of resistance. Although efforts to prevent, treat and reduce epidemics of STIs in patients living with HIV are underway, further advances are needed to reduce the significant morbidity associated with co-infection in this patient setting.

Clinical reasoning - a guide to improving teaching and practice.

BACKGROUND: The process of clinical reasoning is undertaken by all clinicians, often automatically, and is the cognitive process that underlies diagnosis and management of a patient's presenting problem. The teaching of clinical reasoning can pose a challenge to the clinical teacher. OBJECTIVE: This article reviews the process of clinical reasoning and provides the teacher with a framework to teach clinical reasoning to students and junior doctors. DISCUSSION: By considering clinical reasoning as a skill to be learnt rather than a concept to be understood, a framework for teaching this skill can be developed. The learner initially observes a consultation by the teaching clinician, followed by the teacher explaining the reasoning processes used including hypothesising, hypothesis testing, re-analysis and differential diagnosis. The student then comments on the reasoning of the teacher in a subsequent consultation, followed by feedback from the teacher on the student's reasoning in a third consultation.

'It's just a peripheral issue': A qualitative analysis of mental health clinicians' accounts of (not) addressing sexuality in their work.

Sexuality, relationships, and intimacy are integral parts of many peoples' lives, not negated by mental distress and illness. Yet typically, these needs are not addressed adequately in mental health settings. In-depth interviews were conducted with mental health clinicians with an aim of exploring their perceptions and understandings of sexuality and sexual concerns within mental health settings. Participants were 22 mental health nurses, psychologists, and psychiatrists working with people across a range of settings in four Australian cities. Sexuality or aspects of this were often not addressed in clinical practice, and this was common across participants' accounts. A critical thematic analysis was conducted to explore how participants made sense of or explained this silence in relation to sexuality. Two key themes were 'Sexuality is hard to talk about' and 'Sexuality is a "peripheral issue"'. In positioning sexuality as a peripheral issue, participants drew on three key explanations (sub-themes): that sexuality rarely 'comes up', that it is not pragmatic to address sexuality, and that addressing sexuality is not part of participants' roles or skill sets. A third theme captured the contrasting perception that 'Sexuality could be better addressed' in mental health settings. This analysis indicates that, beyond anticipated embarrassment, mental health clinicians from three disciplines account for omissions of sexuality from clinical practice in similar ways. Moreover, these accounts serve to peripheralize sexuality in mental health settings. We consider these results within the context of espoused holistic and recovery-oriented principles in mental health settings.

The outcomes and acceptability of near-peer teaching among medical students in clinical skills.

OBJECTIVE: To determine the outcomes and acceptability of final-year students tutoring in Clinical Skills to Years 1-2 students in a 4-week Medical Education elective. METHODS: A paper-based survey with 14 questions requiring responses on a Likert-like scale and 2 questions with free-text responses was used to investigate Year 6 student-tutor (n=45) and Years 1-2 tutee (n=348) perceptions of near-peer teaching in Clinical Skills. The independent t-test compared mean responses from student-tutors and tutees, and thematic analysis of free-text responses was conducted. RESULTS: Tutee perceptions were significantly higher than student-tutor self-perceptions in small-group teaching and facilitation skills (p=0.000), teaching history-taking skills (p=0.046) and teaching physical examination skills (p=0.000). Perceptions in aspects of 'Confidence in tutoring' were not significantly different for student-tutors and tutees, with both having lowest perceptions for identifying and providing remediation for underperforming tutees. Student-tutors rated all areas of personal and professional development highly. Main themes emerging from analysis of student comments were the benefits to student-tutors, benefits to tutees and areas needing improvement, with outcomes of this near-peer teaching relating well to cognitive and social theories in the literature. CONCLUSIONS: Both student tutors and their tutees perceived near-peer teaching in Clinical Skills to be acceptable and beneficial with particular implications for Medical Education.

Sexually transmissible infections and characteristics of men aged 60 years and over attending a public sexually transmitted diseases (STD) clinic in South Australia.

UNLABELLED: Background With society ageing, sexually transmissible infections (STIs) in the older population are of interest from an economic, health-related and social burden perspective. Few studies on STIs in men older than 60 years of age exist. METHODS: A retrospective study was performed looking at characteristics of, and STIs in, 29106 men (of which 689 were older than 60 years of age), at first presentation, visiting the only South Australian public sexually transmitted diseases (STD) clinic over a 13-year period. RESULTS: Older men [men who have sex with men (MSM) and men who have sex with women (MSW)] were less likely than younger men to have been tested for HIV. CONCLUSION: There is a need for increased HIV testing in older men.