Human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) is effective in reducing HIV risk in men who have sex with men (MSM). However, concerns remain that risk compensation in PrEP users may lead to decreased condom use and increased incidence of sexually transmitted infections (STIs). We assessed the impact of PrEP on sexual risk outcomes in MSM. We conducted a systematic review of open-label studies published to August 2017 that reported sexual risk outcomes in the context of daily oral PrEP use in HIV-negative MSM and transgender women. Pooled effect estimates were calculated using random-effects meta-analysis, and a qualitative review and risk of bias assessment were performed. Sixteen observational studies and 1 open-label trial met selection criteria. Eight studies with a total of 4388 participants reported STI prevalence, and 13 studies with a total of 5008 participants reported change in condom use. Pre-exposure prophylaxis use was associated with a significant increase in rectal chlamydia (odds ratio [OR], 1.59; 95% confidence interval [CI], 1.19–2.13) and an increase in any STI diagnosis (OR, 1.24; 95% CI, .99–1.54). The association of PrEP use with STI diagnoses was stronger in later studies. Most studies showed evidence of an increase in condomless sex among PrEP users. Findings highlight the importance of efforts to minimize STIs among PrEP users and their sexual partners. Monitoring of risk compensation among MSM in the context of PrEP scale-up is needed to assess the impact of PrEP on the sexual health of MSM and to inform preventive strategies.

Quiz Ref ID HIV preexposure prophylaxis (PrEP) is highly effective in reducing HIV acquisition risk among gay and bisexual men who have high medication adherence.^1-3 Following the regulatory approval of tenofovir/emtricitabine for daily use as PrEP in Australia in 2016,⁴ and prior to PrEP becoming subsidized through Australia’s Pharmaceutical Benefits Scheme in April 2018, large implementation studies in several Australian jurisdictions, most notably in Melbourne and Sydney, experienced high rates of enrollment and provided more than 15 000 gay and bisexual men with access to PrEP.^5,6 Despite the high efficacy of PrEP and emerging evidence of population-level decreases in incidence of newly acquired HIV following PrEP implementation,^6,7 concerns remain that widespread PrEP uptake may result in behavioral change that leads to increases in bacterial sexually transmitted infections (STIs).⁸

The ‘Australian Sexually Transmitted Infection (STI) Management Guidelines For Use In Primary Care’ (www.sti.guidelines.org.au) provide evidence-based, up-to-date guidance targeted at use in primary care settings. A major review of the guidelines was undertaken in 2020–22. All content was reviewed and updated by a multi-disciplinary group of clinical and non-clinical experts, and assessed for appropriateness of recommendations for key affected populations and organisational and jurisdictional suitability. The guidelines are divided into six main sections: (1) standard asymptomatic check-up; (2) sexual history; (3) contact tracing; (4) STIs and infections associated with sex; (5) STI syndromes; and (6) populations and situations. This paper highlights important aspects of the guidelines and provides the rationale for significant changes made during this major review process.

Background: This before-and-after study measured the impact of a change in testing methods from culture to nucleic acid amplification testing (NAAT) on the detection of pharyngeal and rectal gonorrhea in men who have sex with men (MSM) on a sexual health service level, including the effect on subgroups anticipated to have higher rates of gonorrhea.Methods: In March 2015, Melbourne Sexual Health Centre changed its laboratory method for gonococcal testing from culture to NAAT using the Aptima Combo 2 and Aptima GC tests. We compared the proportion of tests positive for rectal and pharyngeal gonorrhea in MSM using culture in 2014 with those using NAAT in 2015.Results: The proportion of tests positive for rectal gonorrhea by NAAT was double that obtained by culture (8% vs 3.9%; prevalence ratio [PR], 2.0; 95% confidence interval [CI], 1.8–2.4) and 5-fold for pharyngeal gonorrhea (8.3% vs 1.6%; PR, 5.2; 95% CI, 4.2–6.4). Similar increases in test positivity were observed in human immunodeficiency virus (HIV)-positive and HIV-negative men. By NAAT, test positivity for rectal gonorrhea was higher in HIV-positive compared with HIV-negative men (15.4% vs 7.3%; PR, 2.1; 95% CI, 1.7–2.6). Culture and NAAT had similar test positivity for rectal gonorrhea among men who reported contact with gonorrhea (24.9% vs 25.3%, PR 1.0, 95% CI 0.8–1.4) and men who presented with symptoms of proctitis (22.2% vs 27.9%, PR 1.3, 95% CI 0.8–2.0).Conclusions: A switch from culture to Aptima Combo 2 testing for extragenital gonorrhea in MSM increased detection and was most marked for pharyngeal infections.

Introduction: Doxycycline post‐exposure prophylaxis (doxy‐PEP) involves consuming 200 mg of doxycycline up to 72 hours after a condomless sex act to reduce the risk of bacterial sexually transmitted infections (STIs). Recent clinical trials of doxy‐PEP have demonstrated significant reductions in syphilis, chlamydia and, to a lesser degree, gonorrhoea among gay, bisexual and other men who have sex with men (GBMSM). There is a high level of interest in doxy‐PEP in the GBMSM community and, in response, the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) held a national consensus conference with the aim of creating preliminary guidance for clinicians, community, researchers and policy makers.Main recommendations: There was broad agreement that doxy‐PEP should be considered primarily for the prevention of syphilis in GBMSM who are at risk of this STI, with a secondary benefit of reductions in other bacterial STIs. At the end of the consensus process, there remained some disagreement, as some stakeholders felt strongly that doxy‐PEP should be considered only for the prevention of syphilis in GBMSM, and that the risk of increasing antimicrobial resistance outweighed any potential benefit from reductions in other bacterial STIs in the target population. The national roundtable made several other recommendations for clinicians, community, researchers and policy makers, as detailed in this article. ASHM will support the development of detailed clinical guidelines and education materials on doxy‐PEP (www.ashm.org.au/doxy‐pep).Changes in management as a result of this consensus statement: For GBMSM at high risk of syphilis, and perhaps other bacterial STIs, clinicians may consider prescribing doxy‐PEP for a limited period of time, followed by a review of ongoing need. Unlike human immunodeficiency virus (HIV) pre‐exposure prophylaxis (PrEP), doxy‐PEP may not be suitable as a population‐level intervention and should instead be used more selectively.