Ann Sullivan

Rectal chlamydia - a reservoir of undiagnosed infection in men who have sex with men.

Objective: To determine the prevalence of rectal chlamydia infection in a cohort of men who have sex with men (MSM) and the proportion of infection that would be missed without routine screening. Methods: MSM presenting to four HIV/GUM outpatient clinics at the Chelsea & Westminster Hospital NHS Foundation Trust between 1 November 2005 and 29 September 2006 were offered testing for rectal chlamydia infection in addition to their routine screen for sexually transmitted infections (STIs). Chlamydia trachomatis (CT) tests were performed using the Beckton-Dickinson Probe-Tec Strand Displacement Assay. Positive samples were re-tested at the Sexually Transmitted Bacteria Reference Laboratory, to confirm the result and identify lymphogranuloma venereum (LGV)-associated serovars. Results: A total of 3076 men were screened. We found an 8.2% prevalence of infection with CT (LGV and non-LGV serovars) in the rectum and 5.4% in the urethra. The HIV and rectal chlamydia co-infection rate was 38.1%. The majority of rectal infections (69.2%, (171/247)) were asymptomatic and would have been missed if routine screening had not been undertaken. Of the samples re-tested, 94.2% (227/242) rectal and 91.8% (79/86) urethral specimens were confirmed CT positive and 36 cases of LGV were identified. Conclusion: Our data show a high rate of rectal chlamydia infection, in the majority of cases it was asymptomatic. We recommend routine screening for rectal chlamydia in men at risk, as this may represent an important reservoir for the onward transmission of infection.

HIV Replication Alters the Composition of Extrinsic Pathway Coagulation Factors and Increases Thrombin Generation

Background HIV infection leads to activation of coagulation, which may increase the risk for atherosclerosis and venous thromboembolic disease. We hypothesized that HIV replication increases coagulation potentially through alterations in extrinsic pathway factors. Methods and Results Extrinsic pathway factors were measured among a subset of HIV participants from the Strategies for Management of Anti‐Retroviral Therapy (SMART) trial. Thrombin generation was estimated using validated computational modeling based on factor composition. We characterized the effect of antiretroviral therapy (ART) treatment versus the untreated state (HIV replication) via 3 separate analyses: (1) a cross‐sectional comparison of those on and off ART (n=717); (2) a randomized comparison of deferring versus starting ART (n=217); and (3) a randomized comparison of stopping versus continuing ART (n=500). Compared with viral suppression, HIV replication consistently showed short‐term increases in some procoagulants (eg, 15% to 23% higher FVIII; P<0.001) and decreases in key anticoagulants (eg, 5% to 9% lower antithrombin [AT] and 6% to 10% lower protein C; P<0.01). The net effect of HIV replication was to increase coagulation potential (eg, 24% to 48% greater thrombin generation from computational models; P<0.01 for all). The pattern of changes from HIV replication was reversed with ART treatment and consistent across all 3 independent comparisons. Conclusions HIV replication leads to complex changes in extrinsic pathway factors, with the net effect of increasing coagulation potential to a degree that may be clinically relevant. The key influence of changes in FVIII and AT suggests that HIV‐related coagulation abnormalities may involve changes in hepatocyte function in the context of systemic inflammation. Clinical Trial Registration URL: ClinicalTrials.gov. Unique identifier: NCT00027352.

United Kingdom National Guideline on the Management of Trichomonas vaginalis 2014

The main objective is to assist practitioners in managing men and women diagnosed with Trichomonas vaginalis (TV) infection. This guideline offers recommendations on the diagnostic tests, treatment regimens and health promotion principles needed for the effective management of TV, covering the management of the initial presentation, as well as how to prevent transmission and future infection.

Unselected hepatitis C screening of men who have sex with men attending sexual health clinics

Sexual transmission of hepatitis C (HCV) between HIV positive men who have sex with men (MSM) is increasingly being reported. There is limited and conflicting data as to whether HIV negative MSM are at increased risk of infection. Local directorate guidelines recommended HCV testing only in MSM having a sexual transmitted infection (STI) screen who disclosed risk factors. In 2007 we introduced unselected screening into routine practice within our sexual health clinics. This report reviews the results of this change in our practice. Over 6 months, 3365 MSM attended for STI screening. Of 2309 MSM who agreed to be screened for HCV (69%) the prevalence of HCV was 0.65% (95% CI 0.36-1.1). This is similar to the prevalence of HCV in the general population within England. We conclude that unselected screening of MSM for HCV within our sexual health services is not currently justified.

British Association for Sexual Health and HIV: framework for guideline development and assessment.

Summary The Clinical Effectiveness Group of the British Association for Sexual Health has updated their methodology for the production of national guidelines for the management of sexually transmitted infections and related conditions. The main changes are the adoption of the GRADE system for assessing evidence and making recommendations and the introduction of a specific Conflict of Interests policy for Clinical Effectiveness Group members and guideline authors. This new methodology has been piloted during the production of the 2015 British Association for Sexual Health & HIV guideline on the management of syphilis.

A retrospective study of neutropenia in HIV disease.

In aiming to define the characteristics of HIV-infected subjects developing neutropenia and describe the causes, features and effects of neutropenia we undertook a retrospective study in a dedicated HIV unit in London, UK. Two hundred and forty-four patients with documented neutropenia, defined as absolute neutrophil count (ANC) < 1000/mm 3, during a 12-month period were studied. First neutropenia occurred at a median CD4 count of 30 cells/mm 3. Low CD4 count was associated with longer episodes of neutropenia with a more profound nadir. Two thirds of episodes lasted less than 2 weeks. ANC nadir was < 500 cells/mm 3 in 45% of episodes. Infections were most frequent in patients with profound but brief neutropenic episodes. Neutropenia was generally mild, short-lived and associated with late-stage disease. However, profound neutropenia did develop suddenly in some patients with no prior history of neutropenia (in 13% first neutropenic ANC recorded was 500 cells/mm 3), and at CD4 count> 200 cells/mm 3. Most patients were receiving multiple myelosuppressive therapies. Infection was associated with brief, profound neutropenia.

Getting it right; walk-in service versus booked and emergency appointments.

HIV epidemic among injecting drug users in Central Bangladesh. Int J STD AIDS 2004;15:280–2 12 Pio A, Luelmo F, Kumaresan J, Spinaci S. National tuberculosis programme review: experience over the period 1990–95. Bull World Health Organ 1997;75:569–81 13 Salimullah M, Tahera Y, Siddiqui MA, et al. Prevalence of human immunodeficiency virus infection among tuberculosis cases in some clinics in Dhaka, Bangladesh. Trans R Soc Trop Med Hyg 2000;94:276 14 Yirrell DL, Pickering H, Palmarini G, et al. Molecular epidemiological analysis of HIV in sexual networks in Uganda. AIDS 1998;12:285–90

Demand for and availability of specialist chemsex services in the UK: A cross-sectional survey of sexual health clinics

BACKGROUND/INTRODUCTION Chemsex amongst men who have sex with men (MSM) is well documented in major cities within the United Kingdom (UK), but few data from less urban areas exist. We undertook a survey of sexual health clinic (SHC) healthcare workers (HCWs) to explore demand for and availability of chemsex services to understand training needs and inform service planning. METHODS An online survey was distributed to HCWs in all SHCs across the UK. For English clinics, we explored associations between responses and geo-demographic region using national surveillance data and population statistics. RESULTS Responses were received from 56% (150/270) of SHCs in the UK (89% (133/150) from English clinics). 80% (103/129) of UK clinics reported chemsex consultations and in 50% (65/129) these occurred at least monthly, with no significant difference found when analysed by the geo-demographic characteristics of England (p=0.38). Respondents from most clinics (99% (117/118)) wanted chemsex training, 81 %(103/129) felt there was a local clinical need for a chemsex service and 33% (14/43) had chemsex care-pathways for referrals in place. DISCUSSION/CONCLUSION Patients reporting chemsex regularly present to SHCs throughout the UK including rural areas. Given the potential negative health outcomes associated with chemsex, there is a need for local, high quality, appropriate services and training to minimise harm.

The Context of Sexual Risk Behaviour Among Men Who Have Sex with Men Seeking PrEP, and the Impact of PrEP on Sexual Behaviour

There are still important gaps in our understanding of how people will incorporate PrEP into their existing HIV prevention strategies. In this paper, we explore how PrEP use impacted existing sexual risk behaviours and risk reduction strategies using qualitative data from the PROUD study. From February 2014 to January 2016, we conducted 41 in-depth interviews with gay, bisexual and other men who have sex with men (GBMSM) enrolled in the PROUD PrEP study at sexual health clinics in England. The interviews were conducted in English and were audio-recorded. The recordings were transcribed, coded and analysed using framework analysis. In the interviews, we explored participants’ sexual behaviour before joining the study and among those using or who had used PrEP, changes to sexual behaviour after starting PrEP. Participants described the risk behaviour and management strategies before using PrEP, which included irregular condom use, sero-sorting, and strategic positioning. Participants described their sexual risk taking before initiating PrEP in the context of the sexualised use of drugs, geographical spaces linked with higher risk sexual norms, and digitised sexual networking, as well as problematic psychological factors that exacerbated risk taking. The findings highlight that in the main, individuals who were already having frequent condomless sex, added PrEP to the existing range of risk management strategies, influencing the boundaries of the ‘rules’ for some but not all. While approximately half the participants reduced other risk reduction strategies after starting PrEP, the other half did not alter their behaviours. PrEP provided an additional HIV prevention option to a cohort of GBMSM at high risk of HIV due to inconsistent use of other prevention options. In summary, PrEP provides a critical and necessary additional HIV prevention option that individuals can add to existing strategies in order to enhance protection, at least from HIV. As a daily pill, PrEP offers protection in the context of the sex cultures associated with sexualised drug use, digitised sexual applications and shifting social norms around sexual fulfilment and risk taking. PrEP can offer short or longer-term options for individuals as their sexual desires change over their life course offering protection from HIV during periods of heightened risk. PrEP should not be perceived or positioned in opposition to the existing HIV prevention toolkit, but rather as additive and as a tool that can and is having a substantial impact on HIV.

O03 Impact of prep on sexual behaviour? significantly lower rate of rectal ct in non-prep users in the deferred phase of proud disappeared when everyone had access to prep

Introduction PROUD is uniquely placed to compare rates of STIs between PrEP users and non-PrEP users, and to provide longitudinal data in PrEP users between Nov12–Nov16. We describe reported STIs in the year prior to enrolment, and rates during the deferred and post-deferred phases of PROUD when all participants had access to PrEP. Methods Data were extracted from baseline self-completed questionnaires. Staff were asked to capture STI screens and diagnoses from quarterly study and interim routine clinic visits. We compared incidence rates of selected STIs for those with immediate (IMM) access to deferred (DEF) access during the deferred and post-deferred phase. Results 517 participants completed the STI baseline questions, reporting a median (IQR) of 3 (2–4) screens in the 12m prior to enrolment; 172 (89 IMM, 83 DEF) reported a rectal infection. Rectal STI rates were similar by phase and arm with the exception of lower rates of rectal CT in the DEF arm during the deferred phase (p-value=0.024):Abstract O03 Table 1 Rectal infections in PrEP Deferred Phase Post-deferred Phase Rate (N/pyrs) IMM DEF IMM DEF Rectal GC 35.3 (81/229) 33.7 (67/203) 31.4 (129/411) 32.7 (116/355) Rectal CT 33.6 (77/229) 21.2 (43/203) 33.1 (136/411) 29.9 (106/355) Discussion The ongoing high rates of rectal infections show that participants remaining in follow-up continued to need PrEP. The significantly reduced incidence of rectal CT in those allocated to deferred PrEP was not observed in the post-deferred phase when everyone had access to PrEP. This may be chance or may reflect an influence of PrEP on sexual practices.