1. Reducing syphilis among HIV-infected and –uninfected gay men in Australia David Wilson National Centre in HIV Epidemiology and Clinical Research, Sydney, Australia

2. Syphilis has been rising worldwide Syphilis predominantly affected (HIV+) gay men Health promotion activities across Australia have had little impact Australia recently developed a National Syphilis Action Plan Based on innovative interdisciplinary research mathematical modelling complemented with social research

3. Syphilis simulation model Partnership network Transmission tracking Disease progression

4. Social research Conducted an online survey to determine attitudes to specified interventions in a large (n=2306 participants) community-based sample Focus groups of gay men to assess specific beliefs about the reasons why individuals would or would not act on these interventions.

5. Example: reduction in partner numbers “you can only quantify it in hindsight” “When I go and have sex with a lot of people the big thing that is in my mind is always HIV because it’s incurable. [...] No, I would only reduce my sexual partners if there was no way of curing syphilis.” Online survey and focus group interviews addressed a large range of possible interventions

6. Reproducing the past epidemic SyphilisHIV Forecasting syphilis epidemics

7. Research underpinning recommendations: What interventions will be effective and acceptable? InterventionModellingSocial research Reduce partner acquisition rates Only effective if sustained long- term (years) Not acceptable over the long- term Increase condom use Only effective if sustained long- term (years) Not acceptable over the long- term ChemoprophylaxisShort/medium term intervention could have a moderate impact, large impact with long-term use Enthusiastic and widely acceptable Increased testingVery effective if targeted appropriately and with adequately high frequency Mass synchronised testing not acceptable, rapid testing is acceptable. Overall, increased testing is acceptable if more easily accessible/convenient. Mass treatmentOnly effective if a large % of population covered: unlikely to be effective Expect many men to be unwilling or unable to commit to activity Contact tracing/ partner notification Effective and efficientDiverse views but generally in support. Easier ways for notifying partners are required

8. Australia’s Syphilis Action Plan Priority 1: Gay men are encouraged to test for syphilis as it pertains to their level of risk. Screening for syphilis should be routine with HIV management and testing (as opt-out strategies): Sexually-active HIV-infected men should be tested for syphilis during routine check-up, usually every 3 months; Screening for syphilis should also be conducted alongside every HIV test for sexually-active gay men not previously diagnosed with HIV. In addition, as a minimum, men who have more than 20 partners per 6 months should be tested for syphilis at least twice per year. Testing sexually active gay men who have never previously been tested is also important. These interventions must be on-going, but will most likely require increased capacity. Implementation should also consider improving access to testing through different types of sites and operating hours as well as the use of rapid, home, and presumptive testing. Priority 2: Easier ways for notifying sexual partners discreetly should be created. The goal is to quantifiably observe an increase in the rate of partner notification. To decrease stigma, increased education about syphilis is required. Mechanisms for partner notification should consider patient-led, clinician-led, and centralised notification models that use a variety of means and technologies. Promoting condom use remains critical in maintaining the current high levels. Condom use and number of sexual partners are also important concepts in education for gay men in assessing their relative need for, and frequency of, testing.

9. Goal

10. Acknowledgements Richard Gray Alex Hoare Garrett Prestage Jack Bradley Ian Down Pol McCann Rebecca Guy Basil Donovan John Kaldor This study was commissioned and funded by the Commonwealth of Australia Department of Health and Ageing, NSW Health and the Victorian Department of Human Services.