Sexual health

Objective To examine the awareness, usage and perceptions of doxycycline post-exposure prophylaxis (doxyPEP) for sexually transmitted infection (STI) prevention among gay and bisexual men and transgender (trans) and gender diverse people in Australia. Design Cross-sectional online survey. Setting, Participants National multi-site survey in Australia from 1 July 2024 to 30 November 2024, recruiting from 13 sexual health and community clinics, 6 general practices, social media, dating applications, and university portals. Gay and bisexual men and trans and gender diverse people aged ≥18years living in Australia were included in the study. Main Outcome Measures DoxyPEP awareness, ever use, recent use (past 12months), dosage regimens, sourcing methods and planned future use. Results Among 2095 participants, half (1080/2095, 51.6%) had heard of doxyPEP. Of those aware, 323/1080 (29.9%) had ever used doxyPEP, and 306/1080 (28.3%) were recent users. DoxyPEP awareness and usage varied by HIV status and pre-exposure prophylaxis (PrEP) use (p<0.0001). Nearly two-thirds of users had taken the recommended 200mg within 72h after sex (205/323, 63.5%). Among recent users, 29/306 (9.5%) reported recent syphilis diagnoses, and 85/306 (27.8%) had ≥2 STI diagnoses in the past 12months. Of those who had ever used doxyPEP, 135/323 (41.8%) obtained prescriptions from clinicians, 17/323 (5.3%) obtained it online, and 28/323 (8.7%) purchased it in person overseas without a prescription. Of those aware of doxyPEP, 490/1080 (45.4%) planned to use doxyPEP in the next 12months, primarily to prevent chlamydia (460/490, 93.9%), gonorrhoea (422/490, 86.1%) or syphilis (386/490, 78.8%). Some intended to prevent Mycoplasma genitalium (92/490, 18.8%) or mpox (36/490, 7.4%). Among non-users, 306/756 (40.5%) worried about antibiotic resistance. Conclusions DoxyPEP use was happening quickly but often involved non-recommended regimens and unsupervised sourcing. Urgent educational interventions and improved clinical access are needed for safe implementation.

Catriona S. Bradshaw, Dash Heath-Paynter, Benjamin Riley, Daniel Grace, Fabian Y. S. Kong, Eric P. F. Chow

Restrictions on social media access for users under 16years raise a critical question about how adolescents in Australia will access sexual and reproductive health (SRH) information, especially where traditional systems often fall short. Social media has become an important source of SRH education, offering timely and relatable content that bridges gaps left by formal education and healthcare. As access to these platforms is restricted, other pathways must be strengthened. This includes investing in comprehensive in- and out-of-school sexuality education, youth-friendly primary care services and safe digital platforms designed with and for adolescents.

Olena Ivanova, Anisa R. Assifi, Danielle Mazza

Implementation of differentiated and simplified PrEP care models, tailored to the specific needs of key populations, has the potential to increase equitable access to PrEP and achieve virtual elimination of HIV transmission by 2030

Tyson Arapali · Sarah Warzywoda · Anthony K J Smith · Curtis Chan · Timothy R Broady · Erin Sullivan · Catherine MacPhail · Mohamed A Hammoud · Alexander Dowell‐Day · Benjamin R Bavinton

Good medicine is guided by the values of the patient, not those of a clinician, politician or commentator. The Cass Review, lacking expertise and compromised by implicit stigma and misinformation, does not give credible evidence-based guidance

Julia K Moore · Cate Rayner · S Rachel Skinner · Katie Wynne · Blake S Cavve · Brodie Fraser · Uma Ganti · Claire McAllister · Gideon Meyerowitz‐Katz · Tram Nguyen · Anja Ravine · Brian Ross · Darren B Russell · Liz A Saunders · Aris Siafarikas · Ken C Pang

Contrary to ongoing representations of efficacy, “therapy” that aimed to change or suppress a gender diverse child served to delay self-acceptance for two decades and caused long term harm

Jayne McFadyen · Timothy W Jones · Rowena Koek · Fintan Harte · Brendan Jansen · Megan Galbally · Warren Kealy‐Bateman · Catherine Wall · Quinnehtukqut McLamore · Anja Ravine

Lack of knowledge and skills puts clinicians at risk of causing harm to patients and for consequent avoidance of the health system by LGBQTI+ communities

Cindy Towns · Charlene Rapsey · Rhea Liang

Coordinated antenatal and sexual health care policies, clear guidelines, and broad education programs could reduce the rate

Stephanie Bond · Marcus Y Chen

Use of prophylactic doxycycline for STI prevention requires urgent implementation of comprehensive monitoring systems

Sara FE Bell · Emma L Sweeney · Fabian YS Kong · David M Whiley · Catriona S Bradshaw · Jacob A Tickner

This consensus statement on doxy-PEP provides clinicians with appropriate and accurate information on doxy-PEP

Vincent J Cornelisse · Benjamin Riley · Nicholas A Medland

Supporting children after sexual abuse is also essential for the adults they become

Nina Papalia · Benjamin L Spivak · Linda Ashford · Ahona Guha · Stefan Luebbers · James RP Ogloff · Nina Papalia · Benjamin L Spivak · Linda Ashford · Ahona Guha · Stefan Luebbers · James RP Ogloff

Clinicians should be aware of the possibility of breakthrough infection in patients with epidemiological risk factors and a characteristic vesiculopustular rash, irrespective of a history of previous vaccination

Madhara N Weerasinghe · Catriona Ooi · George Kotsiou · Vincent J Cornelisse · Arran Painter · Madhara N Weerasinghe · Catriona Ooi · George Kotsiou · Vincent J Cornelisse · Arran Painter

Shining a light on technology-facilitated sexual assault — the “why” behind the research

Janine Rowse

People who attend reproductive health or alcohol and drug services should be routinely screened for syphilis

Allison Carter · Hamish McManus · James S Ward · Tobias Vickers · Jason Asselin · Greta Baillie · Eric PF Chow · Marcus Y Chen · Christopher K Fairley · Christopher Bourne · Anna McNulty · Phillip Read · Kevin Heath · Nathan Ryder · Jenny McCloskey · Christopher Carmody · Heather McCormack · Kate Alexander · Dawn Casey · Mark Stoove · Margaret E Hellard · Basil Donovan · Rebecca J Guy

Improving the collection of neurosyphilis surveillance data and integrating neurosyphilis incidence data into syphilis reports may enhance our understanding of the epidemiology of neurosyphilis

Ei T Aung · Marcus Y Chen · Christopher K Fairley · Jason J Ong · Eric PF Chow

When chlamydia is detected, retesting and thorough contact tracing and management can help to interrupt transmission and reduce the risk of reinfection and reproductive complications

Stephanie C Munari · Jane L Goller · Margaret E Hellard · Jane S Hocking

Modification of lifestyle behaviour, management of reversible risk factors and optimisation of existing medical conditions remain pivotal

Eric Chung · Michael Lowy · Michael Gillman · Chris Love · Darren Katz · Graham Neilsen

To maximise its health benefits, self-testing for infectious diseases must be reliable, accessible, and affordable

Deborah A Williamson · Sharon R Lewin

To the Editor: We read with interest the article by Kelly and colleagues,1 In our opinion, the authors’ statement “Access to timely gender‐affirming care is associated with improved mental health outcomes and overall wellbeing” is not well supported by the two citations provided. The first citation is a systematic review by Rew and colleagues.2 A critique of this review was recently published.3 Rew et al, in response, clarified that they did not make any causal statements about puberty blockers and reported improved mental health outcomes, but believe their findings warrant more rigorous longitudinal studies.4 Kelly and colleagues’ second citation is a systematic review by Mahfouda et al.5 This review concluded there is only scarce and preliminary evidence that hormonal and surgical gender‐affirming treatments in adolescents are associated with mental health benefit and improved quality of life. The available evidence was described as having multiple methodological limitations and being at medium to high risk of bias. The authors called for further urgent research to clarify long term outcomes on psychological functioning and safety. Importantly, two recent systematic reviews by the United Kingdom’s National Institute for Health and Care Excellence found that the results of the studies investigating the benefits or adverse effects of puberty blockers and gender‐affirming hormones are of very low certainty and, as the studies themselves may not be reliable, any identified changes could be due to confounding, bias or chance.6,7 The recently published interim report of the UK’s Cass Review also noted that there are different views on the benefits versus harms of early social transition and more information about outcomes is required.8 In conclusion, the literature does not support there being a robust evidence base for the gender‐affirming social, medical and surgical interventions for children and adolescents. Rather, the literature highlights the scarce and low quality evidence and the urgent need for more high quality evidence. In any consideration of the processes of informed consent and/or court consent it would seem imperative that there is acknowledgement of the uncertain evidence base underpinning these interventions. Thus, it is of concern that Kelly and colleagues fail to do this.

Alison Clayton · Roberto D’Angelo · Patrick Clarke

It is important to provide options for obtaining both oral fluid- and blood-based HIV self-tests

Dana YL Lee · Jason J Ong · Kirsty Smith · Muhammad S Jamil · Ruthy McIver · Rebecca Wigan · Kate Maddaford · Anna McNulty · John M Kaldor · Christopher K Fairley · Benjamin Bavinton · Marcus Chen · Eric PF Chow · Andrew E Grulich · Martin Holt · Damian P Conway · Mark Stoove · Handan Wand · Rebecca J Guy

A 65-year-old man presented to the emergency department with right facial weakness and transient dysphagia

Julia Lim · Cameron Shaw

To the Editor: Wu and colleagues1 describe a case of congenital syphilis where the mother had no apparent risk factors and a single negative syphilis serology collected in early pregnancy. The father had an identifiable risk factor. In metropolitan Perth, Western Australia, infectious syphilis among women of reproductive age is rising, with an over 18‐fold increase from 2015 to 2021 (Box). During this period, most cases (229, 74.1%) were non‐Indigenous women. This growth has been accompanied by cases in pregnancy and, concerningly, neonates with congenital syphilis. The authors1 observed that identifying risk factors during pregnancy is challenging. They may be absent, difficult to ascertain, subject to change during the pregnancy, and are dependent on the pregnant woman and her sexual partners, whose risks she may not know. Identification relies on health care providers checking the risk throughout pregnancy and on whether the woman recognises, discloses or feels safe to discuss a risk factor. In Perth, syphilis diagnoses among pregnant women are occurring across cultural backgrounds. While some women have additional risks such as insecure housing or illicit drug use, this is not the norm. Consequently, and because we have likewise observed neonates with congenital syphilis born to women who screened negative early in pregnancy, routine syphilis serology at initial visit and at 28 and 36weeks (or delivery, if earlier) is now recommended for all pregnant women in metropolitan Perth as per the WA sexual health guidelines2 and local obstetric guidelines.3 This was achieved through the collaboration of clinical and public health staff under the Antenatal and Postnatal Working Group of the WA Syphilis Outbreak Response Group, where a decision was made that monitoring risk factors throughout pregnancy has limitations. Three‐test syphilis screening for all pregnant women minimises the risk of congenital syphilis occurring because of an unrecognised risk factor, ensures emerging risk factors are not missed, helps normalise testing and reduce stigma, and recognises that women remain sexually active while pregnant. Notably, screening is not a replacement for good history taking and clinical examination, but syphilis can present in subtle and unusual ways that can be overlooked. Routine syphilis testing at the first antenatal visit is advised by the Australian sexually transmissible infections guidelines.4 A test early in the third trimester is recommended depending on local guidelines.4 As syphilis rates grow in many parts of Australia,5 other jurisdictions should consider adopting additional routine syphilis screening for all pregnant women. Box – Infectious syphilis cases among women of reproductive age, 2015–2021 Data sources: The number of cases were obtained from the Western Australian Notifiable Infectious Diseases Database, Department of Health Western Australia (Jan 2022); and the rate of cases were obtained from the Australian Bureau of Statistics census‐derived population data from the Epidemiology Branch, Public and Aboriginal Health Division, Western Australia Department of Health (Dec 2021).

Hannah MacKenzie · Suzanne McEvoy · Michelle Porter

Although the methods and rhetoric have changed over time, conversion practices remain prevalent in Australia

S Whyte

To the Editor: People without Medicare coverage cannot access Pharmaceutical Benefits Scheme (PBS)‐subsidised human immunodeficiency virus (HIV) pre‐exposure prophylaxis (PrEP) or associated clinical care. Rates of HIV infection diagnosis are disproportionately higher among overseas‐born gay and bisexual men compared with Australian‐born gay and bisexual men.1 In response, in June 2020, the Alfred Hospital and the Victorian Infectious Diseases Reference Laboratory established the free PrEPMe Clinic for Medicare‐ineligible people. Data were collected using proformas after patients provided verbal consent (Alfred Health Ethics Committee approval No. 656/18). The first 100 consecutive patients were all born overseas (Box). Melbourne’s only public sexual health clinic referred 65 patients. Almost all patients were male, all patients had sex with men and reported a median of three sexual partners in 3 months at baseline; 76 patients inconsistently used condoms for anal sex. Fifty‐eight patients reported previous sexually transmissible infections (STIs); STIs were diagnosed in 12/100 patients at baseline, a rate similar to that found in Medicare‐eligible PrEP users.2 Thirty‐four patients had previously accessed HIV post‐exposure prophylaxis (PEP), and 49 patients had previously unsuccessfully attempted to obtain PrEP. The reported barriers to access mainly included costs of medical appointments and pathology, and difficulties navigating Australia’s health care system. All patients received a non‐PBS PrEP prescription. At 3‐month follow‐up, 87 patients had commenced PrEP. Local pharmacies supplied PrEP at cost price (A$40–55 per month) or free to patients with financial hardship; other patients purchased PrEP online (US$20–30 per month) or obtained free PrEP online using assistance coupons (www.pan.org.au; Box). Most patients who ordered PrEP online experienced delivery delays of 4–6 weeks, leaving them at risk of HIV infection. We report that Medicare‐ineligible gay and bisexual men and transgender women were at high risk of HIV infection, yet faced significant financial barriers to accessing PrEP. PrEP uptake has been associated with significant population‐level declines in incident HIV infection in Australia.3 Australia’s Eighth National HIV Strategy aims for virtual elimination of HIV transmissions by 2022,4 and to achieve this goal, Australia must provide universally subsidised PrEP medication and clinical services, irrespective of Medicare status.5 Medicare‐ineligible gay and bisexual men often already attend publicly funded sexual health clinics for free HIV/STI testing and treatment, as reported here. In a high income country like Australia, the additional cost of providing universally subsidised PrEP care would likely be lower than treating preventable new HIV infections, with an estimated lifetime cost of more than US$350 000 per HIV infection diagnosis.6 Box – Demographic characteristics, immunodeficiency virus (HIV) acquisition risk, and prior efforts to obtain pre‐exposure prophylaxis (PrEP) in the first 100 consecutive patients to attend the PrEPMe HIV prevention clinic at the Alfred Hospital in Melbourne, Australia* Values Total number of patients 100 Demographic characteristics Region of birth Asia 47 Latin America 31 Europe 14 Other 8 Age, years, median (IQR) 28 (26–31) Gender Cisgender male 96 Transgender female 4 Visa status Student visa 62 Working visa 34 Other 4 Referral sources Melbourne Sexual Health Centre 65 Word of mouth 16 Other† 13 Unknown 6 HIV risk at initial clinical assessment Sexual partners (3 months), median (IQR) 3 (1–5) Condom use for anal sex (3 months) Always 24 Mostly or sometimes 60 Never 13 Not applicable 1 Unknown 2 Previous STIs (ever) Yes 58 No 42 Previous STIs (ever, specific STIs) Gonorrhoea 35 Chlamydia 21 Syphilis 21 Other‡ 5 STIs diagnosed at baseline Chlamydia only 6 Other§ 6 Previous attempts at HIV risk reduction Previous use of PEP Yes 34 No 57 Unknown 9 Previous unsuccessful attempts to obtain PrEP Yes 49 No 46 Unknown 5 PrEP commencement by 3‐month follow‐up Commenced PrEP 87 Local pharmacy 65 Online 19 Online order did not arrive, then purchased at pharmacy 3 PrEP not commenced 6 Online order did not arrive 3 Other¶ 3 Lost to follow‐up 7 COVID‐19 = coronavirus disease 2019; IQR = interquartile range; PEP = post‐exposure prophylaxis; STIs = sexually transmissible infections. * Enrolment dates: 1 June 2020 to 26 October 2020. † Includes general practices, internet search, “PrEP Access Now” Facebook page, Alfred Hospital PEP program. ‡ Includes herpes simplex virus, Mycoplasma genitalium, hepatitis B virus. § Includes syphilis, hepatitis B virus, both chlamydia and gonorrhoea. ¶ Includes lost prescription, no sex due to COVID‐19.

Vincent J Cornelisse · Jude Armishaw · Mike Catton · Dean Murphy · Edwina J Wright