Identifying Individuals at High Risk for HIV and Sexually Transmitted Infections With an Artificial Intelligence-Based Risk Assessment Tool.

Background: We have previously developed an artificial intelligence-based risk assessment tool to identify the individual risk of HIV and sexually transmitted infections (STIs) in a sexual health clinical setting. Based on this tool, this study aims to determine the optimal risk score thresholds to identify individuals at high risk for HIV/STIs. Methods: Using 2008-2022 data from 216 252 HIV, 227 995 syphilis, 262 599 gonorrhea, and 320 355 chlamydia consultations at a sexual health center, we applied MySTIRisk machine learning models to estimate infection risk scores. Optimal cutoffs for determining high-risk individuals were determined using Youden's index. Results: The HIV risk score cutoff for high risk was 0.56, with 86.0% sensitivity (95% CI, 82.9%-88.7%) and 65.6% specificity (95% CI, 65.4%-65.8%). Thirty-five percent of participants were classified as high risk, which accounted for 86% of HIV cases. The corresponding cutoffs were 0.49 for syphilis (sensitivity, 77.6%; 95% CI, 76.2%-78.9%; specificity, 78.1%; 95% CI, 77.9%-78.3%), 0.52 for gonorrhea (sensitivity, 78.3%; 95% CI, 77.6%-78.9%; specificity, 71.9%; 95% CI, 71.7%-72.0%), and 0.47 for chlamydia (sensitivity, 68.8%; 95% CI, 68.3%-69.4%; specificity, 63.7%; 95% CI, 63.5%-63.8%). High-risk groups identified using these thresholds accounted for 78% of syphilis, 78% of gonorrhea, and 69% of chlamydia cases. The odds of positivity were significantly higher in the high-risk group than otherwise across all infections: 11.4 (95% CI, 9.3-14.8) times for HIV, 12.3 (95% CI, 11.4-13.3) for syphilis, 9.2 (95% CI, 8.8-9.6) for gonorrhea, and 3.9 (95% CI, 3.8-4.0) for chlamydia. Conclusions: Risk scores generated by the AI-based risk assessment tool MySTIRisk, together with Youden's index, are effective in determining high-risk subgroups for HIV/STIs. The thresholds can aid targeted HIV/STI screening and prevention.

Optimising HIV pre-exposure prophylaxis and testing strategies in men who have sex with men in Australia, Thailand, and China: a modelling study and cost-effectiveness analysis.

BACKGROUND: Men who have sex with men (MSM) in the Asia-Pacific region have a disproportionately high burden of HIV infection compared with the general population. Although pre-exposure prophylaxis (PrEP) for HIV is highly effective at preventing new HIV infections, the cost-effectiveness of PrEP for MSM in different countries in the Asia-Pacific region with varying PrEP coverage and HIV testing frequencies remains unstudied. We aimed to analyse the economic and health benefits of long-acting injectable cabotegravir (CAB-LA) compared with oral PrEP in high-income countries and low-income and middle-income countries within the Asia-Pacific region. METHODS: We developed a decision-analytic Markov model to evaluate the population impact and cost-effectiveness of PrEP scale-up among MSM in Australia, Thailand, and China. We assumed a static cohort of 100 000 MSM aged 18 years or older who were at risk of HIV infection, with a monthly cycle length over a 40-year time period. We evaluated hypothetical scenarios with universal PrEP coverage of 80% among 100 000 suitable MSM in each country. We modelled oral PrEP and CAB-LA for MSM with diverse HIV testing frequency strategies. We adopted the health-care system's perspective with a 3% annual discount rate. We calculated the incremental cost-effectiveness ratio (ICER), measured as additional cost per quality-adjusted life-year (QALY) gained, to compare different strategies with the status quo in each country. All costs were reported in 2021 US$. We also performed one-way, two-way, and probabilistic sensitivity analyses to assess the robustness of our findings. FINDINGS: Compared with the status quo in each country, expanding oral PrEP to 80% of suitable MSM would avert 8·1% of new HIV infections in Australia, 14·5% in Thailand, and 26·4% in China in a 40-year period. Expanding oral PrEP use with 6-monthly HIV testing for both PrEP and non-PrEP users was cost-saving for Australia. Similarly, expanding oral PrEP use remained the most cost-effective strategy in both Thailand and China, but optimal testing frequency varied, with annual testing in Thailand (ICER $4707 per QALY gained) and 3-monthly testing in China (ICER $16 926 per QALY gained) for both PrEP and non-PrEP users. We also found that replacing oral PrEP with CAB-LA for MSM could avert more new HIV infections (12·8% in Australia, 27·6% in Thailand, and 32·8% in China), but implementing CAB-LA was not cost-effective due to its high cost. The cost of CAB-LA would need to be reduced by 50-90% and be used as a complementary strategy to oral PrEP to be cost-effective in these countries. INTERPRETATION: Expanding oral PrEP use for MSM, with country-specific testing frequency, is cost-effective in Australia, Thailand, and China. Due to the high cost, CAB-LA is currently not affordable as a single-use strategy but might be offered as an additional option to oral PrEP. FUNDING: Ministry of Science and Technology of the People's Republic of China, the Australian National Health and Medical Research Council, National Key Research and Development Program of China, and National Natural Science Foundation of China.

Cost-effectiveness of artificial intelligence-assisted liquid-based cytology testing for cervical cancer screening in China.

Background: The 2021 World Health Organization (WHO) guidelines for cervical cancer screening recommend human papillomavirus (HPV) DNA or mRNA testing. Artificial intelligence (AI)-assisted liquid-based cytology (LBC) systems also have the potential to facilitate rapid scale-up of cervical cancer screening. We aimed to evaluate the cost-effectiveness of AI-assisted LBC testing, compared with the manual LBC and HPV-DNA testing, for primary cervical cancer screening in China. Methods: We developed a Markov model for a cohort of 100,000 women aged 30 years over a lifetime to simulate the natural history of cervical cancer progression. We evaluated the incremental cost-effectiveness ratios (ICER) of 18 screening strategies (a combination of the three screening methods with six screening frequencies) from a healthcare provider's perspective. The willingness-to-pay threshold (US$30,828) was chosen as three times the Chinese per-capita gross domestic product in 2019. Univariate and probabilistic sensitivity analyses were performed to examine the robustness of the results. Findings: Compared with no screening, all 18 screening strategies were cost-effective, with an ICER of $622-24,482 per quality-adjusted life-year (QALY) gained. If HPV testing after scaling up to population level screening costs $10.80 or more, screening once every 5 years using AI-assisted LBC would be the most cost-effective strategy with an ICER of $8790/QALY gained compared with the lower-cost non-dominated strategy on the cost-effectiveness frontier. Its probability of being cost-effective was higher (55.4%) than other strategies. Sensitivity analyses showed that the most cost-effective strategy would become AI-assisted LBC testing once every 3 years if the sensitivity (74.1%) and specificity (95.6%) of this method were both reduced by ≥10%. The most cost-effective strategy would become HPV-DNA testing once every 5 years if the cost of AI-assisted LBC was more expensive than manual LBC or if the HPV-DNA test cost is slightly reduced (from $10.8 to <$9.4). Interpretation: AI-assisted LBC screening once every 5 years could be more cost-effective than manually-read LBC. Using AI-assisted LBC could have comparable cost-effectiveness to HPV DNA screening, but the relative pricing of HPV DNA testing is critical in this result. Funding: National Natural Science Foundation of China, National Key R&D Program of China.

Missed opportunities for HIV testing among those who accessed sexually transmitted infection (STI) services, tested for STIs and diagnosed with STIs: a systematic review and meta-analysis.

INTRODUCTION: Of 37.7 million people living with HIV in 2020, 6.1 million still do not know their HIV status. We synthesize evidence on concurrent HIV testing among people who tested for other sexually transmitted infections (STIs). METHODS: We conducted a systematic review using five databases, HIV conferences and clinical trial registries. We included publications between 2010 and May 2021 that reported primary data on concurrent HIV/STI testing. We conducted a random-effects meta-analysis and meta-regression of the pooled proportion for concurrent HIV/STI testing. RESULTS: We identified 96 eligible studies. Among those, 49 studies had relevant data for a meta-analysis. The remaining studies provided data on the acceptability, feasibility, barriers, facilitators, economic evaluation and social harms of concurrent HIV/STI testing. The pooled proportion of people tested for HIV among those attending an STI service (n = 18 studies) was 71.0% (95% confidence intervals: 61.0-80.1, I2 = 99.9%), people tested for HIV among those who were tested for STIs (n = 15) was 61.3% (53.9-68.4, I2 = 99.9%), people tested for HIV among those who were diagnosed with an STI (n = 13) was 35.3% (27.1-43.9, I2 = 99.9%) and people tested for HIV among those presenting with STI symptoms (n = 3) was 27.1% (20.5-34.3, I2 = 92.0%). The meta-regression analysis found that heterogeneity was driven mainly by identity as a sexual and gender minority, the latest year of study, country-income level and region of the world. DISCUSSION: This review found poor concurrent HIV/STI testing among those already diagnosed with an STI (35.3%) or who had symptoms with STIs (27.1%). Additionally, concurrent HIV/STI testing among those tested for STIs varied significantly according to the testing location, country income level and region of the world. A few potential reasons for these observations include differences in national STI-related policies, lack of standard operation procedures, clinician-level factors, poor awareness and adherence to HIV indicator condition-guided HIV testing and stigma associated with HIV compared to other curable STIs. CONCLUSIONS: Not testing for HIV among people using STI services presents a significant missed opportunity, particularly among those diagnosed with an STI. Stronger integration of HIV and STI services is urgently needed to improve prevention, early diagnosis and linkage to care services.

What do young people in high-income countries want from STI testing services? A systematic review.

BACKGROUND: There are upward trends of STI rates among young people in most high-income countries. We reviewed the literature to provide a summary of information to support health services with the aim of increasing testing of STIs among young people living in high-income countries. METHODS: We conducted a systematic review (Prospero: CRD42020179720) using PubMed, Embase, PsychINFO and CINAHL. The search was performed on 10 January 2020 for studies between January 2000 and 10 January 2020. Two reviewers independently screened articles, and any discrepancies were resolved by a third reviewer. Studies were included if they were performed in high-income countries and contained data on both young people (<26 years) and STI testing preferences. Data regarding the characteristics of STI testing services that young people preferred was extracted. We categorised these characteristics using the framework of a social-ecological model. RESULTS: We identified 1440 studies, and 63 studies were included in the final review. We found 32 studies that addressed individual factors, 62 studies that addressed service factors and 17 studies that addressed societal factors. At an individual level, we identified eight attributes including the need for improved sexual health education. At a service level, 14 attributes were identified including preferences from different subgroups of young people (such as sexual and ethnic minorities) for the types of services. At a societal level, we identified two attributes including the need to address stigma associated with STIs. CONCLUSION: We provide an overview of the growing body of literature capturing the preferences of young people for STI testing services. To optimise the uptake of STI testing among young people, factors from all socioecological levels should be considered. In addition, understanding and accounting for distinct preferences from subgroups of young people could increase demand for STI testing services for those at greatest need.

Global estimates for the lifetime cost of managing HIV.

OBJECTIVE: There are an estimated 38 million people with HIV (PWH), with significant economic consequences. We aimed to collate global lifetime costs for managing HIV. DESIGN: We conducted a systematic review (PROSPERO: CRD42020184490) using five databases from 1999 to 2019. METHODS: Studies were included if they reported primary data on lifetime costs for PWH. Two reviewers independently assessed the titles and abstracts, and data were extracted from full texts: lifetime cost, year of currency, country of currency, discount rate, time horizon, perspective, method used to estimate cost and cost items included. Descriptive statistics were used to summarize the discounted lifetime costs [2019 United States dollars (USD)]. RESULTS: Of the 505 studies found, 260 full texts were examined and 75 included. Fifty (67%) studies were from high-income, 22 (29%) from middle-income and three (4%) from low-income countries. Of the 65 studies, which reported study perspective, 45 (69%) were healthcare provider and the remainder were societal. The median lifetime costs for managing HIV differed according to: country income level: $5221 [interquartile range (IQR)]: 2978-11 177) for low-income to $377 820 (IQR: 260 176-541 430) for high-income; study perspective: $189 230 (IQR: 14 794-424 069) for healthcare provider, to $508 804 (IQR: 174 781-812 418) for societal; and decision model: $190 255 (IQR: 13 588-429 772) for Markov cohort, to $283 905 (IQR: 10 558-453 779) for microsimulation models. CONCLUSION: Estimating the lifetime costs of managing HIV is useful for budgetary planning and to ensure HIV management is affordable for all. Furthermore, HIV prevention strategies need to be strengthened to avert these high costs of managing HIV.

"Moving from one environment to another, it doesn't automatically change everything". Exploring the transnational experience of Asian-born gay and bisexual men who have sex with men newly arrived in Australia.

Asian-born gay, bisexual and other men who have sex with men (gbMSM) who are newly arrived in Australia are at a higher risk of acquiring HIV than Australian-born gbMSM. We used a social constructionist framework to explore HIV knowledge and prevention strategies used by newly-arrived Asian-born gbMSM. Twenty four Asian-born gbMSM, aged 20-34 years, attending Melbourne Sexual Health Centre, who arrived in Australia in the preceding five years, participated in semi-structured, face-to-face interviews. Interviews were recorded, transcribed verbatim and analysed thematically. Participants described hiding their sexual identities in their country of origin, particularly from family members, due to fear of judgement and discrimination resulting from exposure to sexual identity and HIV related stigma in their countries of origin, although some were open to friends. Despite feeling more sexual freedom and acceptance in Australia, many were still not forthcoming with their sexual identity due to internalised feelings of stigma and shame. Exposure to stigma in their country of origin led many to report anxiety around HIV testing in Australia due to a fear of testing positive. Some described experiencing racism and lack of acceptance in the gay community in Australia, particularly on dating apps. Fear of discrimination and judgement about their sexual identity can have a significant impact on Asian-born gbMSM living in Australia, particularly in terms of social connectedness. Additionally, HIV-related stigma can contribute to anxieties around HIV testing. Our data highlights the potential discrimination Asian-born gbMSM face in Australia, which has implications for social connectedness, particularly with regard to LGBTQI communities and HIV testing practices. Future studies should determine effective strategies to reduce sexual identity and HIV-related stigma in newly-arrived Asian-born gbMSM.

Disparities in characteristics in accessing public Australian sexual health services between Medicare-eligible and Medicare-ineligible men who have sex with men.

OBJECTIVES: Accessible health services are a key element of effective human immunodeficiency virus (HIV) and sexually transmitted infection (STI) control. This study aimed to examine whether there were any differences in accessing sexual health services between Medicare-eligible and Medicare-ineligible men who have sex with men (MSM) in Melbourne, Australia. METHODS: We conducted a retrospective, cross-sectional study of MSM attending Melbourne Sexual Health Centre between 2016 and 2019. Demographic characteristics, sexual practices, HIV testing practices and STI diagnoses were compared between Medicare-eligible and Medicare-ineligible MSM. RESULTS: We included 5,085 Medicare-eligible and 2,786 Medicare-ineligible MSM. Condomless anal sex in the past 12 months was more common in Medicare-eligible compared to Medicare-ineligible MSM (74.4% vs. 64.9%; p<0.001) although the number of partners did not differ between groups. There was no difference in prior HIV testing practices between Medicare-eligible and Medicare-ineligible MSM (76.1% vs. 77.7%; p=0.122). Medicare-ineligible MSM were more likely to have anorectal chlamydia compared to Medicare-eligible MSM (10.6% vs. 8.5%; p=0.004). CONCLUSIONS: Medicare-ineligible MSM have less condomless sex but a higher rate of anorectal chlamydia, suggesting they might have limited access to STI testing or may be less willing to disclose high-risk behaviour. Implications for public health: Scaling up access to HIV and STI testings for Medicare-ineligible MSM is essential.

Domestic HPV vaccine price and economic returns for cervical cancer prevention in China: a cost-effectiveness analysis.

BACKGROUND: Coinciding with the release of the first Chinese domestic human papillomavirus (HPV) vaccine Cecolin in 2019, and the substantial advancements in cervical cancer screening technology, we aimed to evaluate the cost-effectiveness of the combined strategies of cervical cancer screening programmes and universal vaccination of girls (aged 9-14 years) with Cecolin in China. METHODS: We did a cost-effectiveness analysis in China, in which we developed a Markov model of cervical cancer to evaluate the incremental cost-effectiveness ratios of 61 intervention strategies, including a combination of various screening methods at different frequencies with and without vaccination, and also vaccination alone, from a health-care system perspective. We did univariate and probabilistic sensitivity analyses to assess the robustness of the model's findings. FINDINGS: Compared with no intervention, various combined screening and vaccination strategies would incur an additional cost of US$6 157 000-22 146 000 and result in 691-970 quality-adjusted life-years (QALYs) gained in a designated cohort of 100 000 girls aged 9-14 years over a lifetime. With a willingness-to-pay threshold of three times the Chinese per-capita gross domestic product (GDP), careHPV screening (a rapid HPV test) once every 5 years with vaccination would be the most cost-effective strategy with an incremental cost-effectiveness ratio of $21 799 per QALY compared with the lower-cost non-dominated strategy on the cost-effectiveness frontier, and the probability of it being cost-effective (44%) outperformed other strategies. Strategies that combined screening and vaccination would be more cost-effective than screening alone strategies when the vaccination cost was less than $50 for two doses, even with a lower willingness-to-pay of one times the per-capita GDP. INTERPRETATION: careHPV screening once every 5 years with vaccination is the most cost-effective strategy for cervical cancer prevention in China. A reduction in the domestic HPV vaccine price is necessary to ascertain a good economic return for the future vaccination programme. The findings provide important evidence that informs health policies for cervical cancer prevention in China. FUNDING: National Natural Science Foundation of China.

Age, ethnic and travel-related disparities in kissing and sexual practices among heterosexual men in Melbourne, Australia.

Background The kissing practices of heterosexual men are not well understood, despite the potential of kissing to be a significant risk factor for gonorrhoea transmission. This study aimed to explore kissing and sex practices among heterosexual men. METHODS: A cross-sectional survey among heterosexual men attending the Melbourne Sexual Health Centre in 2016-2017 was conducted. Men were asked to report their number of kissing-only (in the absence of sex), sex-only (in the absence of kissing) and kissing-with-sex partners in the last 3 months. The mean number of each partner type was calculated, and multivariable negative binomial regression was used to investigate associations between the number of different types of partners and demographic characteristics. RESULTS: Of the 2351 heterosexual men, men reported a mean of 2.98 kissing-only, 0.54 sex-only and 2.64 kissing-with-sex partners in the last 3 months. Younger men had a mean higher number of kissing-only partners than older men (4.52 partners among men aged ≤24 years compared with 1.75 partners among men ≥35 years, P < 0.001). Men born in Europe had the most kissing-only partners (mean: 5.16 partners) and men born in Asia had the fewest kissing-only partners (mean: 1.61 partners). Men recently arrived in Australia, including travellers from overseas, had significantly more kissing-only partners (adjusted incidence rate ratio (aIRR): 1.53; 95% CI: 1.31-1.80) than local men. CONCLUSIONS: This study provides novel data about kissing practices of heterosexual men. Studies assessing oropharyngeal gonorrhoea should include measurements of kissing until studies can clarify its contribution to transmission risk.

Access to sexual health services after the rapid roll out of the launch of pre-exposure prophylaxis for HIV in Melbourne, Australia: a retrospective cross-sectional analysis.

Background On 26 July 2016, Victoria began a large study of HIV pre-exposure prophylaxis, called PrEPX, that involved the creation of around 2600 appointments over 3 months across multiple sites in Melbourne, Australia. At this time, the Melbourne Sexual Health Centre (MSHC) appeared to have a larger demand on its services. The aim of the present study was to determine whether this apparent increase in demand was substantially different from other demand fluctuations. METHODS: Patients presenting to the MSHC from 2014 to 2016 were reviewed. Demographic characteristics, sexual risks and sexually transmitted infection diagnoses were extracted from the clinical database. RESULTS: There were 115522 walk-in presentations for care and a rise in presentations in the week following the launch of the PrEPX study, but at least six similar peaks occurred that year. The peak coinciding with the launch of PrEPX was only apparent for men who have sex with men. There was a substantial increase in the proportion of patients who could not be seen (i.e. triaged out), from 10% in the week before PrEPX to 22.2% in the second week after, but this was primarily due to staff absences. At the time of the PrEPX study, data were collected on the duration of symptoms for common conditions and found no significant (P>0.29) change in the average duration of symptoms compared with that seen before the PrEPX launch. CONCLUSIONS: The increase in the number of medical consultations required for the PrEPX study did not result in excessive demand for public sexual health services.

Patterns of sexual behaviour and sexual healthcare needs among transgender individuals in Melbourne, Australia, 2011-2014.

OBJECTIVE: Literature surrounding the healthcare needs of transgender individuals is limited in Australia. This study aimed to investigate the demographic characteristics, risk behaviours and HIV/STI positivity among male-to-female (MTF) and female-to-male (FTM) transgender individuals attending Melbourne Sexual Health Centre (MSHC), Australia, between 2011 and 2014. METHOD: A retrospective cohort analysis for 133 transgender individuals was conducted based on the first visit of individuals to MSHC during the study period. Demographic characteristics, sexual behaviours and HIV/STI positivity were examined. RESULTS: The majority of transgender individuals were single or never married (74%; n=99). Almost half of the individuals (47%; n=62) had ever engaged in sex work during their lifetime. The median number of male sexual partners (MSP) reported in the last 3 months was 1 (IQR: 1-2) and with female sexual partners (FSP) was 2 (IQR: 1-4). For those who reported having sexual partners in the previous 3 months, always using condoms with MSP was 31% (n=22), and that with FSP was 18% (n=2). HIV/STI positivity during the study period was 7% (n=8) for chlamydia, 5% (n=6) for gonorrhoea, 5% (n=5) for syphilis and 1% (n=1) for HIV. Hormone use for reassignment was reported by 63% (n=90) of individuals and reassignment surgery was reported by 27% (n=29+6=35). CONCLUSIONS: Transgender individuals in this study were found to be a diverse group, with a history of sex work being a common feature. These findings indicate that transgender individuals' sexual healthcare needs differ substantially from those in other countries, including the US and Canada. Attention to differences in MTF and FTM transgender persons must be considered in healthcare settings in Australia.

Targeted human papillomavirus vaccination for young men who have sex with men in Australia yields significant population benefits and is cost-effective.

BACKGROUND: We investigated the effectiveness and cost-effectiveness of a targeted human papillomavirus (HPV) vaccination program for young (15-26) men who have sex with men (MSM). METHODS: We developed a compartmental model to project HPV epidemic trajectories in MSM for three vaccination scenarios: a boys program, a targeted program for young MSM only and the combination of the two over 2017-2036. We assessed the gain in quality-adjusted-life-years (QALY) in 190,000 Australian MSM. RESULTS: A targeted program for young MSM only that achieved 20% coverage per year, without a boys program, will prevent 49,283 (31,253-71,500) cases of anogenital warts, 191 (88-319) person-years living with anal cancer through 2017-2036 but will only stablise anal cancer incidence. In contrast, a boys program will prevent 82,056 (52,100-117,164) cases of anogenital warts, 447 (204-725) person-years living with anal cancers through 2017-2036 and see major declines in anal cancer. This can reduce 90% low- and high-risk HPV in young MSM by 2024 and 2032, respectively, but will require vaccinating ≥84% of boys. Adding a targeted program for young MSM to an existing boys program would prevent an additional 14,912 (8479-21,803) anogenital wart and 91 (42-152) person-years living with anal cancer. In combination with a boys' program, a catch-up program for young MSM will cost an additional $AUD 6788 ($4628-11,989) per QALY gained, but delaying its implementation reduced its cost-effectiveness. CONCLUSIONS: A boys program that achieved coverage of about 84% will result in a 90% reduction in HPV. A targeted program for young MSM is cost-effective if timely implemented.

Human papillomavirus vaccination in men who have sex with men - what will be required by 2020 for the same dramatic changes seen in heterosexuals.

This paper addresses the issue of whether men who have sex with men (MSM) will share the spectacular reductions in human papillomavirus (HPV) infection and its associated neoplasia that we are currently witnessing in heterosexuals. The reproductive rate for HPV infection in heterosexuals is not well established, but 70% vaccination coverage in women has resulted in a fall of more than 90% in genital warts and HPV types 16/18 in young women and 80% fall in young men indicating that the critical vaccination threshold has been exceeded for this group. Published data on the three elements of the reproductive rate for HPV infection (i.e. transmission probability per sexual partnership, rate of partner change and duration of infectiousness) suggest they are higher in MSM than heterosexuals. This indicates that the reproductive rate for HPV will be higher in MSM and hence the critical vaccination threshold will also be higher. But while vaccinating 70% of girls protect 70% of sexual partnerships in heterosexuals, vaccinating 70% of boys protect more than 70% of partnerships in MSM. Only 9% (30% by 30%) of sexual partnerships in MSM are not protected with 70% coverage. Therefore vaccinating 70% of boys will protect 91% of sexual partnerships in MSM. However the efficacy of the HPV vaccine is much lower when sexually active MSM are vaccinated rather than boys. We argue that if MSM are to have the same benefit from the HPV vaccine that heterosexuals had, boys and not adult MSM will need to be vaccinated.

Rural-to-urban migrants are at high risk of sexually transmitted and viral hepatitis infections in China: a systematic review and meta-analysis.

BACKGROUND: Rapid economic development in urban China has led to a mass migration of surplus rural residents into urban areas for better employment opportunities. This study aims to identify prevalence levels and risks of sexually transmitted infections (STIs) and hepatitis among the rural-to-urban migrant population in China. METHODS: Chinese and English literature databases were searched for studies reporting prevalence of HIV, STIs and viral hepatitis among rural-to-urban migrants in China between 1990 and 2013. The estimates were summarised through a systematic review and meta-analysis. The risks of infection were compared between migrants and the general Chinese population. RESULTS: We identified a total of 411 eligible studies. The prevalence of HIV, syphilis, gonorrhea, genital warts and HCV among migrants were 0.23% (0.20-0.27%), 0.69% (0.57-0.84%), 2.18% (1.30-3.64%), 1.54% (0.70-3.36%) and 0.45% (0.31-3.65%), representing 4.0 (3.1-5.2), 1.9 (1.1-3.0), 13.6 (5.8-32.1), 38.5 (15.7-94.5) and 3.8 (1.9-7.3) higher odds of infection than among the general population. Construction workers, long-distance truck drivers and migrant women through marriage were migrant subgroups that were highly susceptible to STIs and hepatitis. HIV prevalence among migrant pregnant women (0.10%, 0.02-0.49%) was significantly higher than that of pregnant women in the general Chinese population (OR = 7.7, 3.4-17.4). However, no significant differences were observed in STIs and hepatitis between overall female sex workers (FSWs), men who have sex with men (MSM) and drug users (DUs), and the corresponding subgroups with a migratory background. CONCLUSIONS: Rural-to-urban migrants have a higher risk of STIs and hepatitis than the general Chinese population, but a migratory background does not increase the infection risks of STIs and hepatitis in FSWs, MSM and DUs.

Testing commercial sex workers for sexually transmitted infections in Victoria, Australia: an evaluation of the impact of reducing the frequency of testing.

BACKGROUND: The frequency of testing sex workers for sexually transmitted infections (STIs) in Victoria, Australia, was changed from monthly to quarterly on 6 October 2012. Our aim was to determine the impact of this change to the clients seen at the Melbourne Sexual Health Centre (MHSC). METHODS: Computerised medical records of all clients attending at MHSC from 7 October 2011 to 7 October 2013 were analysed. RESULTS: Comparing between the monthly and quarterly testing periods, the number of consultations at MSHC with female sex workers (FSW) halved from 6146 to 3453 (p<0.001) and the consultation time spent on FSW reduced by 40.6% (1942 h to 1153 h). More heterosexual men (p<0.001), and women (p<0.001) were seen in the quarterly testing period. The number of STIs diagnosed in the clinic increased from 2243 to 2589 from the monthly to quarterly period, respectively [15.4% increase (p<0.001)]. Up to AU$247,000 was saved on FSW testing after the shift to quarterly testing. CONCLUSIONS: The change to STIs screening frequency for sex workers from monthly to quarterly resulted in a 15% increase in STI diagnoses in the clinic and approximate a quarter of a million dollars was diverted from FSW testing to other clients. Overall the change in frequency is likely to have had a beneficial effect on STI control in Victoria.

HIV prevalence trends, risky behaviours, and governmental and community responses to the epidemic among men who have sex with men in China.

PURPOSE OF REVIEW: Numerous studies reported the rapid spread of HIV/AIDS epidemic among men who have sex with men (MSM) in China. This paper aims to investigate the overall epidemic trend and associated high-risk behaviours among Chinese MSM and to explore the governmental and community responses to the epidemic. RECENT FINDINGS: HIV prevalence among Chinese MSM increased rapidly in all Chinese regions in the past decade and disproportionally affected the Southwest China. In addition to the high-risk homosexual behaviours, overlapping bisexual, commercial, and drug use behaviours are commonly observed among Chinese MSM. The Chinese government has significantly expanded the surveillance efforts among MSM over the past decade. Community responses against HIV have been substantially strengthened with the support of international aid. However, lack of enabling legal and financial environment undermines the role of community-based organisations (CBOs) in HIV surveillance and prevention. CONCLUSION: HIV continues to spread rapidly among MSM in China. The hidden nature of MSM and the overlapping homosexual, bisexual, and commercial behaviours remain a challenge for HIV prevention among MSM. Strong collaboration between the government and CBOs and innovative intervention approaches are essential for effective HIV surveillance and prevention among MSM in China.

Ability to access community-based needle-syringe programs and injecting behaviors among drug users: a cross-sectional study in Hunan Province, China.

BACKGROUND: Needle-syringe exchange programs (NSPs) have been substantially rolled-out in China since 2002. Limited studies reported effectiveness of NSPs in a Chinese setting. This study aimed to assess the association between accessibility to NSPs and drug-use risk behaviors of IDUs by investigating primary (self-reported) data of IDUs recruited from NSP sites, community settings and mandatory detoxification centers (MDCs) in Hunan province, China. METHODS: A cross-sectional survey was conducted in Hunan province in 2010. IDU recruits participated in a face-to-face interview to provide information related to their ability to access NSPs, demographic characteristics, and injecting behaviors in the past 30 days. RESULTS: Of the total 402 participants, 35%, 14% and 51% participants indicated low, medium and high ability to access NSPs in the past 30 days, respectively. A significantly higher proportion of IDUs (77.3%) from the high-access group reported ≤2 injecting episodes per day compared with medium- (46.3%) and low-access (58.8%) groups. Only 29.0% of high-access IDUs re-used syringes before disposal in the past 30 days, significantly lower than those in the medium- (43.1%) and low-access (41.3%) groups. Reported levels of needle/syringe sharing decreased significantly as the ability to access NSPs increased (16.3%, 12.7% and 2.5% in the low, medium and high access groups, respectively). Ninety percent of IDUs recruited from MDCs had low ability to access NSPs. CONCLUSIONS: Increased NSP accessibility is associated with decreased levels of injecting frequency, repetitive use and sharing of injecting equipment among Chinese IDUs. Mandatory detention of IDUs remains as a major barrier for IDUs to access NSPs in China.