Medical Education - Research Publications
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ItemNumber of ocular syphilis cases creeps to record high(WILEY, 2018-01)
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ItemIncident HIV infection has fallen rapidly in men who have sex with men in Melbourne, Australia (2013-2017) but not in the newly-arrived Asian-born(BMC, 2018-08-20)BACKGROUND: We examined differences in incident HIV infection between newly-arrived Asian-born and other men who have sex with men (MSM) after the introduction of universal HIV treatment guidelines in 2015 and pre-exposure prophylaxis in 2016. METHODS: Clinical, demographic, laboratory and behavioural data on MSM presenting for HIV testing at the Melbourne Sexual Health Centre from July 2013 to June 2017 were extracted. We compared the proportion of newly-arrived (four years or less in Australia), Asian-born and other MSM tested each year who were diagnosed with incident HIV infection (negative test within one year or diagnosis with indeterminate or negative Western Blot). RESULTS: We analysed 35,743 testing episodes in 12,180 MSM, including 2781 testing episodes in 1047 newly-arrived Asian-born MSM. The proportion of other MSM tested each year who were diagnosed with incident HIV infection fell from 0.83% in 2014 to 0.38% in 2017 (p = .001), but did not fall in newly-arrived Asian-born MSM (from 1.18% in 2014 to 1.56% in 2017, p = .76). In the multivariate logistic regression, in 2016/2017 but not in 2014/2015, being newly-arrived Asian-born was associated with an increased odds of diagnosis of incident HIV infection (aOR 3.29, 95%CI 1.82-5.94, p < .001). CONCLUSIONS: The epidemiology of HIV in Melbourne Australia has changed dramatically. While there has been an overall reduction amongst MSM, the incidence of HIV in newly-arrived Asian-born MSM remains high. Failing to address these new inequalities leaves individuals at risk and may offset the population benefit of biomedical HIV prevention.
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ItemMycoplasma genitalium Infection in Adults Reporting Sexual Contact with Infected Partners, Australia, 2008-2016(CENTERS DISEASE CONTROL, 2017-11)Data on the likelihood of Mycoplasma genitalium infection in sexual contacts, particularly for men who have sex with men (MSM), are needed to form an evidence base for guidelines. We conducted a cross-sectional analysis of patients attending a sexual health clinic in Melbourne, Victoria, Australia, during 2008-2016. We calculated the proportion of contacts with M. genitalium infection and determined factors associated with infection. Among those patients reporting sexual contact with an M. genitalium-infected person, 48.2% of women, 31.0% of heterosexual men, and 41.7% of MSM were infected. Among heterosexual contacts, women were twice as likely to be infected; among MSM, rectal infection was more common than urethral infection; and among persons within heterosexual partnerships, concordance of infection was high. High positivity among female and MSM contacts and high concordance in heterosexual partnerships provide some justification for presumptive treatment; however, clinicians should consider antimicrobial drug resistance and toxicity of quinolones.
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ItemPreferences for HIV testing services among young people in Nigeria(BMC, 2019-12-27)BACKGROUND: Despite high HIV incidence rates among young people in Nigeria, less than 24% of this population have ever tested for HIV. These low HIV testing rates suggest that current testing services may not align with their testing preferences. To address this gap, the objective of this study was to assess preferences for HIV testing options among young people in Nigeria. METHODS: We conducted a cross-sectional study using survey to assess preferences for HIV testing options among 113 youth aged 14-24 years residing in Nigeria. The survey included a series of hypothetical HIV testing options, comprised of six characteristics centered around HIV testing service (i.e. location of testing, test administrator, mode of pre-test, mode of post-test counseling, type of HIV test, and cost of HIV test). For each characteristic, participants were asked to select one of the options that they prefer or indicate none of the above. A descriptive analysis of the preferences made by participants was conducted, summarizing proportions of participants who selected different options for HIV testing. RESULTS: The mean age of study participants was 19.5 years old (SD = 2.7). Most youth (73, 64.6%) had at least a secondary school degree. There was pronounced heterogeneity in HIV testing preferences among young people. Although most youth preferred free HIV testing, 14 (16.7%) reported preferring paying a small amount compared to free testing. More youth preferred blood-based HIV self-testing 39(48.8%) compared to facility-based HIV testing and oral HIV self-testing. CONCLUSIONS: Our finding suggest that young people have a range of HIV testing preferences in Nigeria. This suggests that a "one-size-fits-all" approach to delivering services to youth may be challenging in this context. HIV testing services can be optimized to reach young people if a variety options are provided to meet their unique preferences.
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ItemPrepared for PrEP: preferences for HIV pre-exposure prophylaxis among Chinese men who have sex with men in an online national survey(BMC, 2019-12-16)BACKGROUND: Pre-exposure prophylaxis (PrEP) is not widely available in China. Previous studies reported low awareness and inconclusive findings on the acceptability of PrEP among Chinese men who have sex with men (MSM). METHODS: We conducted a secondary analysis of an online national survey comparing preferences for oral and long-acting injectable PrEP among MSM and identifying correlates of preferences. The study did not collect detailed information about partner types that may influence negotiated safety and PrEP uptake. RESULTS: Nine-hundred and seventy-nine men from the larger sample of 1045 men responded to the PrEP survey questions. Most men (81.9%) had never heard of PrEP, but reported interest in using PrEP. More participants chose injectable PrEP (36.3%) as their preferred formulation than oral PrEP (24.6%). Men who had at least two HIV tests (adjusted OR = 1.36, 95%CI 1.04, 1.78) more commonly preferred injectable PrEP. CONCLUSION: Our findings may help inform PrEP messaging in areas where PrEP has yet to be scaled up.
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ItemIdentifying MSM-competent physicians in China: a national online cross-sectional survey among physicians who see male HIV/STI patients(BMC, 2018-12-13)BACKGROUND: Men who have sex with men (MSM) are at high risk of human immunodeficiency virus (HIV) infection and sexually transmitted infection (STI) in China. Inadequate clinical services and poor clinical competency among physicians are major barriers to improving the sexual health of MSM. This study aims to understand physician clinical competency in providing MSM health services in China. METHODS: We conducted an online cross-sectional survey among Chinese physicians who have seen male patients for STI complaints in the past year. We obtained information on individual demographics, clinical practice, attitudes toward MSM, and interest in contributing to MSM clinical services. We defined an MSM-competent physician as one who asked male patients about sexual orientation, sexual practices, and recommended HIV/ STI testing during a clinic visit. We conducted multivariable logistic regression to identify factors associated with MSM competency. RESULTS: In total, 501 physicians completed the survey. The most common subspecialties were dermatovenereology (33.1%), urology (30.1%), and general medicine (14.4%). Roughly half (n = 267, 53.3%) reported seeing MSM in the past 12 months. Among physicians who saw MSM in the past 12 months, 60.3% (n = 161) met criteria as MSM-competent physicians, and most (n = 234, 87.6%) MSM-competent physicians reported positive or neutral attitudes towards MSM. Over 60% of all physicians were willing to participate in activities for improving MSM services, such as training and being on a list of physicians willing to serve MSM. MSM-competent physicians showed no sociodemographic differences compared with non MSM-competent physicians. MSM-competent physicians were more willing to have their medical institution named on a public clinic list capable of serving MSM (aOR: 1.70, 95%CI: 1.01-2.86) and being on a public physician list capable of serving MSM (aOR: 1.77, 95%CI: 1.03-3.03). CONCLUSIONS: MSM-competent physicians included a broad range of individuals that practiced in diverse clinical settings. Most physicians were interested in improving and expanding MSM clinical services, despite having neutral attitudes toward same-sex behavior. Future interventions should focus on developing MSM clinical competency and expanding services that meet the needs of MSM.
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ItemUsing discrete choice experiments to inform the design of complex interventions(BMC, 2019-03-04)BACKGROUND: Complex health interventions must incorporate user preferences to maximize their potential effectiveness. Discrete choice experiments (DCEs) quantify the strength of user preferences and identify preference heterogeneity across users. We present the process of using a DCE to supplement conventional qualitative formative research in the design of a demand creation intervention for voluntary medical male circumcision (VMMC) to prevent HIV in Tanzania. METHODS: The VMMC intervention was designed within a 3-month formative phase. In-depth interviews (n = 30) and participatory group discussions (n = 20) sought to identify broad setting-specific barriers to and facilitators of VMMC among adult men. Qualitative results informed the DCE development, identifying the role of female partners, service providers' attitudes and social stigma. A DCE among 325 men in Njombe and Tabora, Tanzania, subsequently measured preferences for modifiable VMMC service characteristics. The final VMMC demand creation intervention design drew jointly on the qualitative and DCE findings. RESULTS: While the qualitative research informed the community mobilization intervention, the DCE guided the specific VMMC service configuration. The significant positive utilities (u) for availability of partner counselling (u = 0.43, p < 0.01) and age-separated waiting areas (u = 0.21, p < 0.05) led to the provision of community information booths for partners and provision of age-separated waiting areas. The strong disutility of female healthcare providers (u = - 0.24, p < 0.01) led to re-training all providers on client-friendliness. CONCLUSION: This is, to our knowledge, the first study documenting how user preferences from DCEs can directly inform the design of a complex intervention. The use of DCEs as formative research may help increase user uptake and adherence to complex interventions.
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ItemNo Place Like Home? Disentangling Preferences for HIV Testing Locations and Services Among Men Who Have Sex with Men in China(SPRINGER/PLENUM PUBLISHERS, 2019-04)In China, some health departments and gay community-based organizations have begun to offer home-based HIV testing kits in order to augment test uptake among men who have sex with men (MSM). However, HIV test preferences and motivations for home-testing among MSM in China are not well understood. The HIV testing preferences of 803 MSM throughout China were evaluated using single-item assessment and a discrete choice experiment (DCE). In both the single-item assessment and DCE, participants expressed strong preference for free and anonymous testing by health professionals. Both approaches also indicated that naïve testers most prefer home testing. However, among previous testers, the single-item assessment indicated that "home" was the most preferred testing location (vs. hospital or clinic), while the DCE indicated that "home" was the least preferred testing location after controlling for anonymity. HIV home-testing may have limited appeal to previously tested Chinese MSM if anonymity is not maintained.
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ItemDriving force of condomless sex after online intervention among Chinese men who have sex with men(BMC, 2019-07-22)BACKGROUND: Condom use remains consistently low among Chinese men who have sex with men (MSM). This study aims to identify factors associated with condom use after online video intervention. METHODS: This is a secondary data analysis of data collected from an online non-inferiority trial comparing the effectiveness of two condom use promotion video interventions among Chinese MSM. Participants from the two groups were combined since the effectiveness of two video interventions were shown to be non-inferior. Univariable and multivariable logistic regression were used to identify factors associated with condomless sex after the intervention during the follow-up interval. RESULTS: Overall, 1173 participants were recruited at baseline and 791 (67.4%) completed the three-month follow-up survey. 57.3% (453/791) of the participants reported condomless sex after intervention in the three-month follow-up interval. MSM who have had sex under the influence of alcohol in the last 3 months (Odds Ratio(OR) = 1.90; 95% CI: 1.22, 2.97; Adjusted OR(AOR) = 1.79; 95% CI: 1.13, 2.83) and ever have had sex tourism (OR = 2.75; 95% CI: 1.34, 5.63; AOR = 2.40; 95% CI: 1.15, 5.07) at baseline were more likely to have condomless sex after intervention in the three-month follow-up period. MSM who had a higher level of community engagement in sexual health (OR = 0.54; 95% CI: 0.35, 0.82; AOR = 0.49; 95% CI: 0.32, 0.75 with substantial engagement) and who viewed additional condom promotion videos during the follow-up period by themselves (OR = 0.67; 95% CI = 0.50, 0.89; AOR = 0.67; 95% CI: 0.50, 0.91). were less likely to have condomless sex during the follow-up period. CONCLUSION: The intervention appeared to be effective among MSM who reported viewing additional condom promotion videos by themselves and more community engagement after the intervention. In MSM who reported risky sexual behaviors at baseline, the intervention appeared less effective. Tailored intervention videos that target particular subgroups, active in-person community engagement, and optimized intervention frequency should be considered in future sexual health interventions.
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ItemEconomic cost analysis of door-to-door community-based distribution of HIV self-test kits in Malawi, Zambia and Zimbabwe(JOHN WILEY & SONS LTD, 2019-03)INTRODUCTION: HIV self-testing (HIVST) is recommended by the World Health Organization in addition to other testing modalities to increase uptake of HIV testing, particularly among harder-to-reach populations. This study provides the first empirical evidence of the costs of door-to-door community-based HIVST distribution in Malawi, Zambia and Zimbabwe. METHODS: HIVST kits were distributed door-to-door in 71 sites across Malawi, Zambia and Zimbabwe from June 2016 to May 2017. Programme expenditures, supplemented by on-site observation and monitoring and evaluation data were used to estimate total economic and unit costs of HIVST distribution, by input and site. Inputs were categorized into start-up, capital and recurrent costs. Sensitivity and scenario analyses were performed to assess the impact of key parameters on unit costs. RESULTS: In total, 152,671, 103,589 and 93,459 HIVST kits were distributed in Malawi, Zambia and Zimbabwe over 12, 11 and 10 months respectively. Across these countries, 43% to 51% of HIVST kits were distributed to men. The average cost per HIVST kit distributed was US$8.15, US$16.42 and US$13.84 in Malawi, Zambia and Zimbabwe, respectively, with pronounced intersite variation within countries driven largely by site-level fixed costs. Site-level recurrent costs were 70% to 92% of full costs and 20% to 62% higher than routine HIV testing services (HTS) costs. Personnel costs contributed from 26% to 52% of total costs across countries reflecting differences in remuneration approaches and country GDP. CONCLUSIONS: These early door-to-door community HIVST distribution programmes show large potential, both for reaching untested populations and for substantial economies of scale as HIVST programmes scale-up and mature. From a societal perspective, the costs of HIVST appear similar to conventional HTS, with the higher providers' costs substantially offsetting user costs. Future approaches to minimizing cost and/or maximize testing coverage could include unpaid door-to-door community-led distribution to reach end-users and integrating HIVST into routine clinical services via direct or secondary distribution strategies with lower fixed costs.