key: cord-0835186-w3zezn4d
authors: Chow, Eric P F; Hocking, Jane S; Ong, Jason J; Phillips, Tiffany R; Fairey, Christopher K
title: Sexually transmitted infection diagnoses and access to a sexual health service before and after the national lockdown for COVID-19 in Melbourne, Australia
date: 2020-11-02
journal: Open Forum Infect Dis
DOI: 10.1093/ofid/ofaa536
sha: 9ae9617f1969a325d3da98cad037168e96cd7fc4
doc_id: 835186
cord_uid: w3zezn4d

BACKGROUND: We aimed to examine the impact of lockdown on sexually transmitted infection (STI) diagnoses and access to a public sexual health service in the COVID-19 pandemic in Melbourne, Australia. METHODS: The operating hours of Melbourne Sexual Health Centre (MSHC) remained the same during the lockdown. We examined the number of consultations and STI at MSHC between January and June 2020 and stratified the data into pre-lockdown (3-February to 22-March), lockdown (23-March to 10-May) and post-lockdown (11-May to 28-June) with seven weeks in each period. Incidence rate ratio (IRR) and its 95% confidence intervals (CI) were estimated using Poisson regression models. RESULTS: The total number of consultations dropped from 7,818 in pre-lockdown to 4,652 during lockdown (IRR=0.60;95%CI:0.57-0.62) but increased to 5,347 in the post-lockdown period (IRR=1.15;95%CI:1.11-1.20). There was a 68% reduction in asymptomatic screening during lockdown (IRR=0.32; 95%CI:0.30-0.35) but it gradually increased in the post-lockdown period (IRR=1.59;95%CI:1.46-1.74). STI with milder symptoms showed a marked reduction, including non-gonococcal urethritis (IRR=0.60;95%CI:0.51-0.72), and candidiasis (IRR=0.61;95%CI:0.49-0.76) during lockdown compared with pre-lockdown. STI with more marked symptoms did not change significantly, including pelvic inflammatory disease (IRR=0.95;95%CI:0.61-1.47) and infectious syphilis (IRR=1.14;95%CI:0.73-1.77). There was no significant change in STI diagnoses in post-lockdown compared to lockdown. CONCLUSIONS: The public appeared to be prioritising their attendance for sexual health services based on the urgency of their clinical conditions. This suggests that the effectiveness of clinical services in detecting, treating and preventing onward transmission of important symptomatic conditions is being mainly preserved despite large falls in absolute numbers of attendees.

Cases of coronavirus disease (COVID- 19) began gradually increasing in Australia after the first case was identified on 25-January-2020. In response the Australian government initially closed its international borders to all non-residents on 20-March and followed with different stages of restriction and lockdown. The national Stage 1 restriction was introduced on midday 23-March which included the closure of non-essential businesses, restriction on social gatherings and social distancing rules. 1 Australia moved to Stage 2 restriction from 11:59pm on 25-March with further restrictions on indoor and outdoor social gatherings limited to two persons only and also introduced mandatory quarantine for 14 days after international travel on 28-March. 1 Further, Victoria moved to Stage 3 restriction from 11:59pm on 30-March by introducing the 'Stay at home' restrictions where Victorians could only leave home for four reasons (i.e. medical needs; work or study; exercising; or shop for food and essential supplies). During the lockdown in March-April in Melbourne, there were no reductions or restrictions on public transportation. In Victoria, restrictions began to ease from 11:59pm on 12-May onwards, included allowing family and friends to visit homes.

Several studies have provided evidence demonstrating that there was a reduction in casual sex during lockdown; [2] [3] [4] [5] [6] and this is also supported by the evidence of reduction in HIV post-exposure prophylaxis during lockdown in several countries. [7] [8] [9] Hence, it is reasonably hypothesised that these changes are likely to have translated in a reduction in sexually transmitted infections (STI). However, there has been very limited research examining the impact of the COVID-19 pandemic on STIs. We aimed to examine the patterns and changes of STI diagnoses and access to sexual health services before and after lockdown during the COVID-19 pandemic in Melbourne, Australia.

This study was conducted at the Melbourne Sexual Health Centre (MSHC) between January and June 2020. MSHC is the largest public sexual health service in Victoria in Australia, which provides approximately 50,000 consultations annually between 2017 and 2019 (with an average quarterly number of consultations of 13,000 in the first quarter and 12,000 in the second, third and fourth quarter), but the total number of consultations did not vary substantially across seasons at MSHC. 10 All consultations, HIV/STI testing and treatment are free of charge for all individuals. MSHC remained open during the lockdown period. During the COVID-19 pandemic, there was no change in medical staff but up to 25% of the nursing staff were moved to COVID-19 duties elsewhere (e.g.

contact tracing for COVID-19). However, this did not change any clinic practices or processes as the clinic was quiet and underutilised during lockdown. MSHC operates a walk-in service for individuals with symptoms and for urgent matters but individuals who did not have any symptoms were required to call the clinic for an appointment for a face-to-face visit, this remained unchanged before and after the lockdown during the COVID-19 pandemic. Our on-site lab was still operating as usual during the A c c e p t e d M a n u s c r i p t 4 lockdown period, and there were no changes in the services in relation to testing and samples collection other than MSHC moved from clinician-collected to self-collected throat swabs. 11 MSHC did not offer any off-site or home testing throughout the period. Upon arrival, all clients were first screened for flu-like symptoms and had their temperature taken. Individuals were asked not to attend the clinic if they (1) were waiting for the testing result of a COVID-19 test; (2) tested positive for COVID-19; (3) were required to be self-isolated due to COVID-19; or (4) had symptoms of COVID-19. The same rules applied to all staff at MSHC. Individuals with symptoms of COVID-19 were not seen at MSHC and were sent to the hospital for COVID-19 testing. Phone consultations were only provided to stable patients living with HIV in a dedicated HIV clinic that is not part of this analysis, but not to other patients during the COVID-19 pandemic.

Consultations data were extracted from the electronic medical record at MSHC and were stratified by sex (males, females, or others). 'Others' sex was defined as individuals who self-reported their sex as intersex, transgender or other. Data included the type of consultation (e.g. asymptomatic screening vs symptomatic/urgent), reasons for attendance (e.g. reporting as a contact of infection, requesting a sex work certificate), diagnoses of STI, number of sex partners in the preceding 3 months, and the time between symptoms onset to clinic attendance. We were interested in STI diagnoses among four different client groups -(i) those presenting for an 'asymptomatic screen' defined as individuals who did not have any symptoms and attended the clinic for an on-site lab-based testing for HIV/STI, and did not require a physical examination; (ii) those presenting as 'symptomatic/urgent cases' defined as those presented with symptoms related to STI (e.g. genital discharge, genital ulcer and pelvic pain) and or those requiring urgent attention (e.g. accessing post-exposure prophylaxis); (iii) those presenting as a 'contact of infection' defined as individuals reporting contact with sexual partners with an STI (including gonorrhoea, chlamydia, syphilis and Mycoplasma genitalium); and (iv) those requesting a 'sex work certificate' defined as individuals working in the sex work industry who requiring an in-date certificate as the evidence of 3-monthly HIV/STI screening (a legal requirement for anyone doing sex work in Victoria). 12 Eight common symptomatic STI or genital infections were selected as the outcomes in this study, this includes balanitis, bacterial vaginosis, candidiasis, herpes (initial episodes or recurrent infections), infectious syphilis (primary or secondary syphilis), nongonococcal urethritis (NGU), pelvic inflammatory disease (PID) and urethral gonorrhoea. We did not look at asymptomatic conditions such as chlamydia and HIV because these conditions mainly relied on the frequency of asymptomatic screening which might be biased due to the COVID-19 pandemic or lockdown period.

The number of consultations, STI diagnoses were summed across each week and plotted by calendar week starting from the week commencing on 6-January (Monday) to the week ending on 28-June (Sunday), stratified by the sex of the individuals. MSHC closes on public holidays and therefore the A c c e p t e d M a n u s c r i p t 5 weekly number of consultations is biased if the public holiday occurs on a weekday; and hence, we adjusted the number of consultations by multiplying the weekly number by , where n is the number of working days and present both the crude number and the adjusted number of weekly consultations. 13 For 'asymptomatic screen' in males, we further stratified into either (1) men who have sex with men (MSM); or (2) males who had had sex with females only (MSW). This is because threemonthly HIV/STI screening is recommended for all sexually active MSM but not in heterosexuals.

We further stratified the study period into three seven-week periods: (1) pre-lockdown ( Poisson regression models were used for the count data for the number of consultations and STI diagnoses, and the Poisson regression coefficients were calculated. The incidence rate ratio (IRR) was calculated by exponentiating the Poisson regression coefficients and the 95% confidence intervals (CI) were also calculated. We reported the IRR in the lockdown period compared to pre-lockdown period; and in the post-lockdown compared to lockdown period. We reported the mean number of sex partners, and the regression coefficient (beta) was calculated from linear regression to determine whether there was any change (increase, decrease or no change) in the three time periods (prelockdown, during lockdown and post-lockdown). The mean time between symptoms onset to clinic attendance was also calculated. All statistical analyses were conducted using Stata (version 14, College Station, TX, USA). This study was approved by the Alfred Hospital Ethics Committee, Melbourne, Australia (301/20).

There were 21,576 clinical consultations between 6-January-2020 and 26-June-2020. There were about 1,100 consultations each week before lockdown that dropped dramatically in the weeks after the lockdown on 23-March-2020 to a low of 600 consultations per week ( Figure 1 ). The total number of consultations began to rise after three weeks of lockdown and reaching about 800 consultations each week in May-June but the weekly number of consolations was still lower compared to the level before lockdown. Compared to pre-lockdown period, there was a 40% reduction (IRR=0.60; 95%CI:0.57-0.62) in the total number of consultations during lockdown; however, there was an increase in the number of consultations in the post-lockdown period (IRR=1.15; 95%CI:1.11-1.20) but the number was still lower compared to per-lockdown (Table 1) . M a n u s c r i p t 6

There was a 68% reduction (IRR=0.32; 95%CI:0.30-0.35) in the number of consultations for asymptomatic screening during lockdown compared to pre-lockdown, with a 78% reduction (IRR=0.22; 95%CI:0.19-0.25) in females, followed by a 67% reduction (IRR 0.33; 95%CI:0.28-0.40) in heterosexual males, then a 58% reduction (IRR=0.42; 95%CI:0.38-0.48) in MSM (Table 1) .

However, there was an increase in the number of consultations for asymptomatic screening in the post-lockdown period (IRR=1.59; 95%CI:1.46-1.76) (Table 1) (Table 1) , with a nadir of 37 in the third week of lockdown but it began to rise since May and returned to the level before lockdown ( Figure 2 ). There was also a marked decline with a 91% reduction (IRR=0.09; 95%CI:0.04-0.18) in females attending the clinic for a sex work certificate during lockdown (Table 1, Figure 2 ).

There was a 41% reduction in the number of symptomatic/urgent cases (IRR=0.59; 95%CI:0.56-0.63) in the lockdown period compared to pre-lockdown although this was lower than was seen for asymptomatic screening. Symptomatic presentations with more mild symptoms showed a marked reduction, a 45% reduction (IRR=0.55; 95%CI:0.41-0.75) in balanitis in males, a 46% reduction (IRR=0.54; 95%CI:0.44-0.67) in bacterial vaginosis in females, a 40% reduction (IRR=0.60; 95%CI:0.50-0.71) in NGU in males, and a 38% reduction (IRR=0.62; 95%CI:0.49-0.77) in candidiasis in females. There was also a significant reduction in conditions with short incubation period, this included a 45% reduction in urethral gonorrhoea (IRR=0.55; 95%CI:0.39-0.77) and a 59% reduction in initial herpes (IRR=0.41; 95%CI:27-0.61). However, conditions with more marked symptoms showed a non-significant change in the lockdown period: this included PID (IRR=0.95; 95%CI:0.61-1.47) and infectious syphilis (IRR=1.14; 95%CI:0.73-1.77). There was no significant change in all STI diagnoses in post-lockdown compared with the lockdown period (Table 1, Figure 3 ).

Among those who presented with symptoms and reported the number of days of symptoms, the mean number of days between symptom onset and clinic attendance in lockdown (31. 7 

To our knowledge, this is the first study to examine the impact of the COVID-19 pandemic on STI diagnoses and access to sexual health services during lockdown in Australia and one of the few internationally. We found dramatic reductions in attendances particularly for low-risk reasons such as asymptomatic screening. There were less marked reductions for symptomatic individuals and no significant reductions among some more symptomatic and important clinical conditions such as pelvic inflammatory disease or syphilis. Interestingly, attendances for asymptomatic screening rose quickly in the post-lockdown period but no significant increases were seen for symptomatic conditions, suggesting possibly that the lockdown may have also caused a reduction in the incidence of these conditions in addition to discouraging attendances to our clinical service. The number of sexual partners almost halved among MSM during the study period with some suggestion of a recovery in the post-lockdown period, a finding that is consistent with the failure of STIs diagnoses to rise in the post-lockdown period despite marked rises in asymptomatic screening. Given the important contribution that clinical services make to STI control, it may be that a public health campaign is needed to encourage screening of those at risk, and more importantly to encourage symptomatic individuals to seek healthcare promptly.

The reduction in asymptomatic screening at the beginning of lockdown is not unexpected as attendances at all health services including cancer screening programs reported reductions in attendances. 14 However, some reduction may also be explained by changes in sexual practices during the lockdown. 4 An Australian online survey conducted in April-May 2020 has revealed that Australians reported fewer casual hook-ups during lockdown (8%) compared to 2019 (31%). 3 In August-2020, the Terrence Higgins Trust in the UK has recommended some safe sex practices during the COVID-19 pandemic, such as stop kissing, wearing a face mask during sex, changing sexual positions where there are no face-to-face contacts although it is not clear how widely these recommendations have been adopted. 15 Further studies will be required to examine whether individuals have changed their practices as per these recommendations during the COVID-19

A c c e p t e d M a n u s c r i p t 8 pandemic. Another explanation of the reduction in asymptomatic screening could be due to the fear of catching COVID-19 when visiting clinics, 2 and individuals might have delayed their regular HIV/STI screening. Our data has also shown that the number of asymptomatic screening gradually increased in the post-lockdown period, this is either because the COVID-19 epidemic in Melbourne began to be under control in May-June or individuals began to resume sex. This increase in presentations fits with a similar pattern seen among individuals reporting a contact of infections.

We also observed there was a significant reduction in the number of sex work certificates issued. This is likely to due to the closure of brothels in Victoria since March-2020 and therefore no need for sex workers to obtain certificates which are required under Victorian law to work in brothels. Some sex workers might have changed their services from in-person to virtual (e.g. webcamming and phone sex). 16 Sex workers in Victoria have low HIV/STI prevalence and hence they do not drive STI rates in Victoria. 17 18 A previous study has shown that sex workers acquire most STIs from their non-paying private partners but not from their clients. 19 Further research is needed to examine the impact COVID-

There was a marked reduction in most but not all STI diagnoses. Milder conditions (e.g. bacterial vaginosis, balanitis) had moderate reductions of about 45% but some conditions (e.g. infectious syphilis, PID) did not reduce virtually at all despite large reductions in other conditions. It is not possible to determine why this difference occurred; however, one could postulate that the seriousness or nature of the symptoms contributed to the continued attendance for some conditions. The failure to see a resurgence in all STI diagnoses may in part relate to a reduction in the incidence of some conditions, a finding that is consistent with the reduction in the number of sexual partners observed in some groups. There are several limitations to this study. First, this study was conducted in one urban sexual health clinic in Melbourne. Our findings may not be generalisable to other Australian states or countries due to the different level of COVID-19 pandemic and lockdown measures. Second, some individuals were worried about catching COVID-19 when visiting clinics and might have delayed in seeking healthcare during the COVID-19 pandemic. 2 Although the time from symptoms onset to clinic attendance did not differ before and after lockdown in our study, we were unable to stratify these data by different STI diagnoses due to small sample size as not all individuals reported the number of days with symptoms. Third, we collected the partners number three months preceding the date of attendance and therefore it might have underestimated the impact of COVID-19 and lockdown on sexual practices. In addition, we only collected the number of partners and this may not represent the frequency of sexual encounters over the period which is an important factor for STI transmission. Fourth, we were unable to compare the STI diagnoses at our clinic to the state-wide or national-wide surveillance data as most of these conditions were not notifiable in Australia.

By the end of June, the COVID-19 epidemic in most Australian states and territories was under control, except for Victoria. 22 The number of daily COVID-19 cases continued to rise since late-June in Victoria and peaked at 700 cases reported on 5-August. 23 Victoria recorded a total of 12,600 cases (66% of the cases in Australia) by the end of July. 24 --*The total number of consultations was adjusted by multiplying the weekly number by , where n is the number of working days to minimise the bias of public holiday effects. † Asymptomatic screen was defined as individuals who did not have any symptoms and attended the clinic for HIV/STI screening. ‡ Symptomatic/urgent case was defined as individuals presented with symptoms related to STI (e.g. genital discharge, genital ulcer and pelvic pain) and or those requiring urgent attention (e.g. accessing post-exposure prophylaxis). § A 'sex work certificate' was defined as individuals working in the sex work industry who require requiring an in-date certificate as the evidence of 3-monthly HIV/STI screening (a legal requirement for anyone doing sex work in Victoria). ¶ Contact of infection was defined as individuals reporting contact with sexual partners with an STI (including gonorrhoea, chlamydia, syphilis and Mycoplasma genitalium). 

We would like to thank Afrizal Afrizal at the Melbourne Sexual Health Centre for his assistance in extracting the data.

E.P.F.C. and C.K.F. conceived and designed the study. J.S.H. and J.J.O. assisted with the study design. E.P.F.C. oversaw the study, prepared the ethics application, performed data analysis and wrote the first draft of the manuscript. All authors were involved in data interpretation and revising the manuscript for important intellectual content and approved the final version.

Informed consent was not required because this was an analysis of retrospective clinical data. This study was approved by the Alfred Hospital Ethics Committee, Melbourne, Australia (301/20).

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