Ada Miltz

Poly drug use, chemsex drug use, and associations with sexual risk behaviour in HIV-negative men who have sex with men attending sexual health clinics

BACKGROUND Recreational drug use and associated harms continue to be of significant concern in men who have sex with men (MSM) particularly in the context of HIV and STI transmission. METHODS Data from 1484 HIV-negative or undiagnosed MSM included in the AURAH study, a cross-sectional, self-completed questionnaire study of 2630 individuals from 20 sexual health clinics in the United Kingdom in 2013-2014, was analysed. Two measures of recreational drug use in the previous three months were defined; (i) polydrug use (use of 3 or more recreational drugs) and (ii) chemsex drug use (use of mephedrone, crystal methamphetamine or GHB/GBL). Associations of socio-demographic, health and lifestyle factors with drug use, and associations of drug use with sexual behaviour, were investigated. RESULTS Of the 1484 MSM, 350 (23.6%) reported polydrug use and 324 (21.8%) reported chemsex drug use in the past three months. Overall 852 (57.5%) men reported condomless sex in the past three months; 430 (29.0%) had CLS with ≥2 partners, 474 (31.9%) had CLS with unknown/HIV+ partner(s); 187 (12.6%) had receptive CLS with an unknown status partner. For polydrug use, prevalence ratios (95% confidence interval) for association with CLS measures, adjusted for socio-demographic factors were: 1.38 (1.26, 1.51) for CLS; 2.11 (1.80, 2.47) for CLS with ≥2 partners; 1.89 (1.63, 2.19) for CLS with unknown/HIV+ partner(s); 1.36 (1.00, 1.83) for receptive CLS with an unknown status partner. Corresponding adjusted prevalence ratios for chemsex drug use were: 1.38 (1.26, 1.52); 2.07 (1.76, 2.43); 1.88 (1.62, 2.19); 1.49 (1.10, 2.02). Polydrug and chemsex drug use were also strongly associated with previous STI, PEP use, group sex and high number of new sexual partners. Associations remained with little attenuation after further adjustment for depressive symptoms and alcohol intake. CONCLUSION There was a high prevalence of polydrug use and chemsex drug use among HIV negative MSM attending UK sexual health clinics. Drug use was strongly associated with sexual behaviours linked to risk of acquisition of STIs and HIV.

Systematic review and meta-analysis of L1-VLP-based human papillomavirus vaccine efficacy against anogenital pre-cancer in women with evidence of prior HPV exposure.

Background It is unclear whether L1-VLP-based human papillomavirus (HPV) vaccines are efficacious in reducing the likelihood of anogenital pre-cancer in women with evidence of prior vaccine-type HPV exposure. This study aims to determine whether the combined results of the vaccine trials published to date provide evidence of efficacy compared with control (hepatitis A vaccine/placebo). Methods A systematic review and meta-analysis was conducted. Randomized-controlled trials (RCTs) were identified from MEDLINE, Embase, Web of Science, PubMed, Cochrane Central Register of Controlled Trials and references of identified studies. The bivalent vaccine containing HPV-16 and 18 VLPs from GlaxoSmithKline Biologicals (Rixenstart, Belgium), the quadrivalent vaccine containing HPV-6, 11, 16, and 18 VLPs from Merck & Co., Inc., (Whitehouse Station, NJ USA), and the HPV-16 monovalent vaccine from Merck Research Laboratories (West Point, PA USA) were evaluated. Findings Three RCT reports and two post-trial cohort studies were eligible, comprising data from 13,482 women who were included in the vaccine studies but had evidence of HPV infection at study entry. Data on efficacy was synthesized using the Mantel-Haenszel weighted fixed-effect approach, or where there was heterogeneity between studies, the DerSimonian and Laird weighted random-effect approach. The mean odds ratio (OR) and 95% confidence interval (CI) for the association between Cervarix, Gardasil and HPV-16 monovalent vaccine and HPV-associated cervical intraepithelial neoplasia grade 3 or worse was 0·90 (95% CI: 0·56, 1·44). For the association between Gardasil and HPV-associated vulval/vaginal intraepithelial neoplasia grades 2–3, the overall OR and 95% CI was 2.25 (95% CI: 0·78, 6.50). Sample size and follow-up were limited. Conclusions There was no evidence that HPV vaccines are effective in preventing vaccine-type HPV associated pre-cancer in women with evidence of prior HPV exposure. Small effects of vaccination however cannot be excluded and a longer-term benefit in preventing re-infection remains possible.

Clinically significant depressive symptoms and sexual behaviour among men who have sex with men

Background The relationship between depression and sexual behaviour among men who have sex with men (MSM) is poorly understood. Aims To investigate prevalence and correlates of depressive symptoms (Patient Health Questionnaire-9 score ≥10) and the relationship between depressive symptoms and sexual behaviour among MSM reporting recent sex. Method The Attitudes to and Understanding of Risk of Acquisition of HIV (AURAH) is a cross-sectional study of UK genitourinary medicine clinic attendees without diagnosed HIV (2013–2014). Results Among 1340 MSM, depressive symptoms (12.4%) were strongly associated with socioeconomic disadvantage and lower supportive network. Adjusted for key sociodemographic factors, depressive symptoms were associated with measures of condomless sex partners in the past 3 months (≥2 (prevalence ratio (PR) 1.42, 95% CI 1.17–1.74; P=0.001), unknown or HIV-positive status (PR 1.43, 95% CI 1.20–1.71; P<0.001)), sexually transmitted infection (STI) diagnosis (PR 1.46, 95% CI 1.19–1.79; P<0.001) and post-exposure prophylaxis use in the past year (PR 1.83, 95% CI 1.33–2.50; P<0.001). Conclusions Management of mental health may play a role in HIV and STI prevention. Declaration of interest A.N.P. has received payments for presentations made at meetings sponsored by Gilead in spring 2015. N.C.N. has received support for attendance at conferences, speaker fees and payments for attendance at advisory boards from Gilead Sciences, Viiv Healthcare, Janssen Pharmaceuticals and Bristol-Myers Squibb and a research grant from Gilead Sciences. D.A. served on the advisory board for Gilead in January 2016. M.M.G. has had sponsorship to attend conferences by Bristol-Myers Squibb, been on the BioCryst advisory board and run trials for Merck, Gilead, SSAT, BioCryst and Novartis. Copyright and usage

Changes in recreational drug use, drug use associated with chemsex, and HIV-related behaviours, among HIV-negative men who have sex with men in London and Brighton, 2013–2016

Objectives The objective of this study was to compare the prevalence of polydrug use, use of drugs associated with chemsex, specific drug use, and HIV-related behaviours, between two time periods, using two groups of HIV-negative men who have sex with men (MSM) attending the same sexual health clinics in London and Brighton, in two consecutive periods of time from 2013 to 2016. Methods Data from MSM in the cross-sectional Attitudes to and Understanding Risk of Acquisition of HIV (AURAH) study (June 2013 to September 2014) were compared with baseline data from different MSM in the prospective cohort study Attitudes to and Understanding Risk of Acquisition of HIV over Time (AURAH2) (November 2014 to April 2016). Prevalence of polydrug use, drug use associated with chemsex and specific drug use, and 10 measures of HIV-related behaviours including condomless sex, post-exposure prophylaxis (PEP) use, pre-exposure prophylaxis (PrEP) use, and HIV testing, were compared. Prevalence ratios (PRs) for the association of the study (time period) with drug use and HIV-related behaviour measures were estimated using modified Poisson regression analysis, unadjusted and adjusted for sociodemographic factors. Results In total, 991 MSM were included from AURAH and 1031 MSM from AURAH2. After adjustment for sociodemographic factors, use of drugs associated with chemsex had increased (adjusted PR (aPR) 1.30, 95% CI 1.11 to 1.53) and there were prominent increases in specific drug use; in particular, mephedrone (aPR 1.32, 95% CI 1.10 to 1.57), γ-hydroxybutyric/γ-butryolactone (aPR 1.47, 95% CI 1.15 to 1.87) and methamphetamine (aPR 1.42, 95% CI 1.01 to 2.01). Use of ketamine had decreased (aPR 0.54, 95% CI 0.38 to 0.78). Certain measures of HIV-related behaviours had also increased, most notably PEP use (aPR 1.50, 95% CI 1.21 to 1.88) and number of self-reported bacterial STI diagnoses (aPR 1.24, 95% CI 1.08 to 1.43). Conclusions There have been significant increases in drug use associated with chemsex and some measures of HIV-related behaviours among HIV-negative MSM in the last few years. Changing patterns of drug use and associated behaviours should be monitored to enable sexual health services to plan for the increasingly complex needs of some clients.

Ethnicity and sexual risk in heterosexual people attending sexual health clinics in England: a cross-sectional, self-administered questionnaire study

Objectives In the UK, people of black ethnicity experience a disproportionate burden of HIV and STI. We aimed to assess the association of ethnicity with sexual behaviour and sexual health among women and heterosexual men attending genitourinary medicine (GUM) clinics in England. Methods The Attitudes to and Understanding of Risk of Acquisition of HIV is a cross-sectional, self-administered questionnaire study of HIV negative people recruited from 20 GUM clinics in England, 2013–2014. Modified Poisson regression with robust SEs was used to calculate adjusted prevalence ratios (aPR) for the association between ethnicity and various sexual risk behaviours, adjusted for age, study region, education and relationship status. Results Questionnaires were completed by 1146 individuals, 676 women and 470 heterosexual men. Ethnicity was recorded for 1131 (98.8%) participants: 550 (48.6%) black/mixed African, 168 (14.9%) black/mixed Caribbean, 308 (27.2%) white ethnic groups, 105 (9.3%) other ethnicity. Compared with women from white ethnic groups, black/mixed African women were less likely to report condomless sex with a non-regular partner (aPR (95% CI) 0.67 (0.51 to 0.88)), black/mixed African and black/mixed Caribbean women were less likely to report two or more new partners (0.42 (0.32 to 0.55) and 0.44 (0.29 to 0.65), respectively), and black/mixed Caribbean women were more likely to report an STI diagnosis (1.56 (1.00 to 2.42)). Compared with men from white ethnic groups, black/mixed Caribbean men were more likely to report an STI diagnosis (1.91 (1.20 to 3.04)), but did not report risk behaviours more frequently. Men and women of black/mixed Caribbean ethnicity remained more likely to report STI history after adjustment for sexual risk behaviours. Discussion Risk behaviours were reported less frequently by women of black ethnicity; however, history of STI was more prevalent among black/mixed Caribbean women. In black/mixed Caribbean men, higher STI history was not explained by ethnic variation in reported risk behaviours. The association between STI and black/mixed Caribbean ethnicity remained after adjustment for risk behaviours.

Eligibility for PrEP among MSM attending GUM clinics in the UK

The National Health Service in England is currently discussing whether to fund a Pre-exposure Prophylaxis (PrEP) Programme. The number of eligible individuals expected to come forward is a key consideration. The British HIV Association/BASHH position statement supports access to PrEP for men who have sex with men (MSM) if they have a confirmed HIV-negative status, report condomless anal sex (CLS) with a man in the past 3 months and report CLS is likely to occur again in the next 3 months.1 We aimed to investigate what proportion of MSM attending genitourinary medicine (GUM) services could be eligible for PrEP in England, using data from the AURAH (Attitudes to and Understanding of Risk of Acquisition of HIV) study,2 which recruited in English GUM services (2013–2014). A total of 4380 patients were approached over the study period and …

O32 Ethnicity and sexual behaviours – the association between ethnicity and sexual risk behaviours reported by heterosexual men and women in a gum setting

Introduction In the UK people of black ethnicity experience a disproportionate burden of HIV and STI. We aimed to assess the association of ethnicity with sexual risk behaviours (SRB) and sexual health among heterosexual men and women. Methods AURAH is a cross-sectional questionnaire study of people without HIV, recruited in 20 GUM clinics in England 2013–14. We assessed the association of ethnicity with (i) condomless sex with non-regular partner(s) (CLS-NR); (ii) ≥2 new partners in the last year (2NPLY); and (iii) STI diagnosis in the past year (STI) using modified poisson regression adjusted for age, study region, education and relationship status. Results 1075 heterosexual men (n=451) and women (n=624) completed questionnaires. Ethnicity was as follows: 513 (48.4%) black/mixed African (BA), 159 (15.0%) black/mixed Caribbean (BC), 288 (27.1%) white ethnicity (WE), 101 (9.5%) other ethnicity (OE).Abstract O32 Table 1 AURAH Adjusted PR (95%CI) CLS–NR 2NPLY STI within last year Women: White  BA  BC  OE 1 0.65(0.49–0.85) 0.78(0.55–1.10) 0.66(0.39–1.13) 1 0.36(0.27–0.48)0.39(0.25–0.61)0.60(0.37–0.99) 1 0.92(0.61–1.38) 1.47(0.95–2.28) 1.23(0.68–2.23) Men: White  BA  BC  OE 1 1.05(0.83–1.32) 1.02(0.73–1.44) 0.69(0.43–1.09) 1 0.77(0.62–0.96) 0.85(0.62–1.16) 1.29(1.03–1.61) 1 1.14(0.75–1.73) 1.76(1.10–2.82) 0.59(0.24–1.43) Compared with WE women BA women were less likely to report CLS-NR, BA and BC women were less likely to report 2NPLY, and BC women were more likely to report STI. In men CLS-NR did not vary significantly by ethnicity. BA men were less likely to report 2NPLY and BC men were more likely to report STI compared with WE men. Discussion The prevalence of SRBs was lower in black ethnicity women, but history of STI was more prevalent among BC women. Similarly, higher STI history in BC men was not consistent with ethnic variation in SRB. Additional factors, e.g. sexual networks, may be important determinants of sexual health.

P3.372 Systematic Review and Meta-Analysis of L1-VLP-based Human Papillomavirus Vaccine Efficacy Against Anogenital Pre-Cancer in Women with Evidence of Prior HPV Exposure

Background It is unclear whether L1-VLP-based human papillomavirus (HPV) vaccines are efficacious in preventing anogenital pre-cancer in women with prior vaccine-type HPV exposure. Participants in the phase III efficacy trials were not excluded if infected at baseline (HPV-DNA and serology were performed in retrospect); the efficacy in this sub-group of vaccinees can be derived from published reports. Methods A systematic review and meta-analysis was conducted to compare the efficacy of L1-VLP-based HPV vaccines with control (hepatitis A or placebo). Randomized-controlled trials (including post-RCT follow-on cohort studies) were identified from MEDLINE, Embase, Web of ScienceSM, PubMed, Cochrane (and quoted references). Three vaccines were evaluated: Cervarix™ containing HPV-16/18 VLPs (GSK), Gardasil® containing HPV-6/11/16/18 VLPs (Merck), and an HPV-16 monovalent vaccine (Merck Research Laboratories). Results Three RCT reports and one post-RCT follow-on study met the eligibility criteria, comprising data from 13,339 women who were included in the vaccine studies but had evidence of HPV infection at baseline. Efficacy data were synthesised using a DerSimonian and Laird weighted random-effect model. The mean odds ratio (OR) and 95% confidence interval (CI) for the association between Cervarix™, Gardasil ® and HPV-16 monovalent vaccine and HPV-associated cervical intraepithelial neoplasia grade 3 or worse (CIN3+) was 0·90 (CI: 0·56, 1·44) and for the association between Gardasil ® and HPV-associated vulval/vaginal intraepithelial neoplasia grades 2–3 (VIN2–3/VaIN2–3) OR 1·20 (CI: 0·07, 20·40). Conclusion There was no evidence that the HPV vaccines are effective in preventing vaccine-type HPV-associated pre-cancer in women with evidence of prior HPV exposure in this analysis. However, these studies were not designed to investigate the efficacy in this group, so statistical power (sample size, follow-up period and event rate) was insufficient to detect a small effect size. Longer follow-up is also needed to detect possible prevention of re-infection.