Barry Evans

The late diagnosis and consequent short-term mortality of HIV-infected heterosexuals (England and Wales, 2000-2004).

Objectives:To describe the proportion of HIV-infected heterosexual individuals diagnosed late and estimate how much mortality could have been prevented by earlier diagnosis. Design:A population-based study using surveillance reports from England and Wales. Methods:Calculation of proportions diagnosed late (CD4 cell count < 200 cells/μl) and short-term mortality (death within a year of diagnosis). Results:A total of 16 375 heterosexual individuals were diagnosed with HIV (2000–2004): 10 503 with CD4 cell counts available at that time; 42% (4425) were diagnosed late. Late diagnosis increased with age (P < 0.01). One fifth of women diagnosed antenatally were diagnosed late compared with 42% of other women and 49% of men; 70% of all heterosexuals diagnosed were black Africans, born and infected in Africa. Of those, at least 40% were recent arrivals to the UK, and twice as many were diagnosed late as black-African heterosexuals infected in the UK. Short-term mortality was 3.2% (491/15 523); 6.1% among those diagnosed late and 0.7% among others (P < 0.01). Short-term mortality was lower among black-African compared with white heterosexuals (3.1 versus 4.5%; P < 0.01) because of diagnosis at a younger age. Earlier diagnosis would have reduced short-term mortality by 56% (249 fewer deaths) and all mortality by 32% between 2000 and 2004. Conclusion:Groups at high risk of late diagnosis should be targeted for health promotion activities, opportunistic screening, and removal of any barriers to testing. HIV testing in a variety of settings would reduce missed diagnoses and costs. New patient checks in primary care may provide the earliest opportunity to diagnose HIV infection among recent arrivals to the UK.

Sexually transmitted infections in western europe among HIV-positive men who have sex with men

Background: Since 1996, there has been a resurgence in sexually transmitted infections (STIs) among men who have sex with men (MSM) in Western Europe. This has coincided with a significant decrease in HIV-associated mortality following the introduction of highly active antiretroviral therapies (HAART) and a corresponding increase in the number of MSM living with HIV. Levels of unprotected anal intercourse have also increased. In this article, we use STI surveillance data from a number of Western European countries to better understand the contribution of HIV-positive MSM to the recent increase in STIs. Methods: Published literature, surveillance reports, and ad hoc publications relating to HIV prevalence trends and STIs among HIV-positive MSM in Western Europe were reviewed. Results: Post-HAART, HIV prevalence among community samples of MSM ranged from 5% to 18%. HIV prevalence among MSM diagnosed with an STI was substantially higher. On average, HIV prevalence among MSM diagnosed with syphilis in 11 countries was 42% (range 14%–59%). Most HIV-positive MSM with syphilis were aware of their HIV status. In England and Wales, 32% of MSM with gonorrhea were HIV-positive in 2004. Outbreaks of lymphogranuloma venereum have been documented in 9 countries; HIV-positive MSM accounted for 75% of cases on average (range 0%–92%). Cases of sexually transmitted hepatitis C have been predominantly identified among HIV-positive MSM in Rotterdam, Paris, Amsterdam, and the United Kingdom. Conclusions: In Western Europe, STIs have been disproportionately diagnosed among HIV-positive MSM post-HAART. Improved survival coupled with serosorting among HIV-positive MSM appears to explain the high prevalence of HIV among MSM with STIs. STI transmission among HIV-positive men will have contributed substantially to increasing STI trends seen among MSM in Western Europe, since 1996. These findings highlight the need for routine STI testing among HIV-positive MSM as well as safer sex messages highlighting the implications of STI coinfection.

UK Guideline for the use of post-exposure prophylaxis for HIV following sexual exposure

We present the updated British Association for Sexual Health and HIV (BASHH) guidelines for post-exposure prophylaxis (PEPSE) to HIV. This document includes a review of the current data to support the use of PEPSE, considers how to calculate the risks of infection after a potential exposure, and provides recommendations on when PEPSE would and would not be considered. We review which agents to use for PEPSE including the potential for drug-drug interactions and make recommendations for monitoring individuals receiving PEPSE. Other areas included are the possible impact on sexual behaviour, cost-effectiveness and issues relating to service provision. Throughout the document, consideration is given to the place of PEPSE within the broader context of HIV prevention strategies and sexual health.

No time to wait: how many HIV-infected homosexual men are diagnosed late and consequently die? (England and Wales, 1993-2002).

Objectives:To present national trends of the estimated number and proportion of late HIV diagnoses and short-term mortality following diagnosis among men who have had sex with men (MSM). To determine separately risk factors for late diagnosis and short-term mortality. Methods:Analysis of national HIV/AIDS case reports of new diagnoses linked to CD4 cell counts from the CD4 Surveillance Scheme. Inverse probability weighting adjusted for individuals with no CD4 cell count at diagnosis. Outcomes were late diagnosis (CD4 cell count <200 × 106 cells/l at diagnosis) and short-term mortality (death within 1 year of diagnosis). Results:Of 14 158 new diagnoses, 31% were estimated as late diagnoses. Despite a decreasing trend (P trend <0.01) an estimated 430 (25%) MSM were still diagnosed late in 2001. Late diagnosis disproportionately affected individuals diagnosed outside London, of non-white ethnicity, and of older age. There were 710 (5.0% of 14 158) deaths within a year of HIV diagnosis. Estimated short-term mortality was 14% for MSM diagnosed late and 1% for other MSM (adjusted odds ratio, 10.8; 95% confidence interval, 7.7–15.9). Short-term mortality declined concurrently with availability of highly active antiretroviral therapy and was independently associated with age and diagnosis outside London but not ethnicity. Conclusions:The continued late diagnosis of one in four MSM means these individuals lose the option to start therapy early, miss opportunities to prevent further transmission and are approximately 10 times more likely to die within a year of diagnosis. Early diagnosis of all MSM in 2001 could have reduced short-term mortality by 84% and all mortality in that year by 22%.

Emerging trends in the epidemiology of invasive mycoses in England and wales (1990-9)

Invasive fungal infections are becoming an increasing public health problem owing to the growth in numbers of susceptible individuals. Despite this, the profile of mycoses remains low and there is no surveillance system specific to fungal infections currently existing in England and Wales. We analysed laboratory reports of deep-seated mycoses made to the Communicable Disease Surveillance Centre between 1990 and 1999 from England and Wales. A substantial rise in candidosis was seen during this period (6.76-13.70 reports per million population/year), particularly in the older age groups. Rates of cryptococcosis in males fluctuated over the decade but fell overall (1.05-0.66 per million population/year), whereas rates of female cases gradually rose up until 1998 (0.04-0.41 per million population/year). Reports of Pneumocystis carinii in men reduced substantially between 1990 and 1999 (2.77-0.42 per million population/year) but showed little change in women. Reports of aspergillosis fluctuated up until 1996, after which reports of male and female cases rose substantially (from 0.08 for both in 1996 to 1.92 and 1.69 per million population/year in 1999 for males and females respectively), largely accounted for by changes in reporting practice from one laboratory. Rates of invasive mycoses were generally higher in males than females, with overall male-to-female rate ratios of 1.32 (95% CI 1.25-1.40) for candidosis, 1.30 (95% CI 1.05-1.60) for aspergillosis, 3.99 (95% CI 2.93-5.53) for cryptococcosis and 4.36 (95% CI 3.47-5.53) for Pneumocystis carinii. The higher male than female rates of reports is likely to be a partial reflection of HIV epidemiology in England and Wales, although this does not fully explain the ratio in infants and older age groups. Lack of information on underlying predisposition prevents further identification of risk groups affected. Whilst substantial under-reporting of Pneumocystis carinii and Cryptococcus species was apparent, considerable numbers of superficial mycoses were misreported indicating a need for clarification of reporting guidelines. Efforts to enhance comprehensive laboratory reporting should be undertaken to maximize the utility of this approach for surveillance of deep-seated fungal infections.

Assessing the impact of national anti-HIV sexual health campaigns: trends in the transmission of HIV and other sexually transmitted infections in England.

Objective: To assess the impact of the sexual component of AIDS and HIV campaigns on transmission of HIV and other sexually transmitted infections (STIs). Design: Comparison of time series data. Setting: England, 1971–1999. Outcome measures: HIV transmission and diagnoses among men who have sex with men (MSMs), rates of attendances and specific STI diagnoses (per 100 000 total population) at genitourinary medicine (GUM) clinics. Results: Awareness of AIDS and campaigns in 1983–4 among homosexual men coincided with substantial declines in transmission of HIV and diagnoses of syphilis among MSMs. During general population campaigns in 1986-7 new GUM clinic attendances requiring treatment fell by 117/105 in men and 42/105 in women. Rates for gonorrhoea fell by 81/105 and 43/105 and genital herpes by 6/105 and 4/105, respectively. Previous rises in genital wart rates were interrupted, while rates of attendances not requiring treatment (the “worried well”) increased by 47/105 and 58/105 for men and women, respectively. Since 1987 diagnoses of HIV among MSMs have not declined, averaging 1300–1400 annually. Following a period of unchanging rates there have been substantial increases in GUM attendances requiring treatment, notably for gonorrhoea, syphilis, and viral STIs since 1995. Conclusions: Self help initiatives and awareness among homosexual men in 1983–4 contributed significantly to a fall in HIV transmission among MSMs, and the general campaigns of 1986–7 were associated with similar effects on all STI transmission. Both effects seem to have occurred through changing sexual behaviour, and probably contributed to the UKs low national HIV prevalence. Bacterial STI incidence has increased significantly since 1995 and there is no evidence that recent prevention initiatives have reduced HIV transmission among MSMs, hence sexual health initiatives need to be comprehensively reinvigorated in England.

Recent trends in diagnoses of HIV and other sexually transmitted infections in England and Wales among men who have sex with men

Objectives: To examine trends in rates of diagnoses of HIV and other sexually transmitted infections (STIs) in men who have sex with men (MSM) in England and Wales between 1997 and 2002. Methods: Estimates of the MSM population living in England and Wales, London and the rest of England and Wales were applied to surveillance data, providing rates of diagnoses of HIV and STIs and age group specific rates for HIV and uncomplicated gonorrhoea. Results: Between 1997 and 2002, rates of diagnoses of HIV and acute STIs in MSM increased substantially. Rates in London were higher than elsewhere. Rises in acute STIs were similar throughout England and Wales, except for uncomplicated gonorrhoea and infectious syphilis, with greater increases outside London. Rates of gonorrhoea diagnoses doubled between 1999 and 2001 (661/100 000, 1271/100 000, p<0.001) in England and Wales followed by a slight decline to 1210/100 000 (p = 0.03) in 2002—primarily the result of a decline in diagnoses among men aged 25–34 (1340/100 000, 1128/100 000, p<0.001) and 35–44 (924/100 000, 863/100 000, p = 0.03) in London. HIV was the third most common STI diagnosed in MSM in England and Wales and the second in London, with the highest rate (1286/100 000) found among men aged 35–44 in London in 2002. Conclusions: Rates of diagnosis of HIV and other STIs have increased substantially among MSM in England and Wales. Increases show heterogeneity by infection, geography, and age over time. Rates in London were twice those seen elsewhere, with greatest changes over time. The observed changes reflect concomitant increases in high risk behaviour documented in behavioural surveillance survey programmes.

Recent trends in HIV and other STIs in the United Kingdom: data to the end of 2002

Sexual health in the United Kingdom has deteriorated in recent years with further increases in HIV and other sexually transmitted infections (STIs) reported in 2002. This paper describes results from the available surveillance data in the United Kingdom from the Health Protection Agency and its national collaborators. The data sources range from voluntary reports of HIV/AIDS from clinicians, CD4 cell count monitoring, a national census of individuals living with HIV, and the Unlinked Anonymous Programme, to statutory reports of STIs from genitourinary medicine (GUM) clinics and enhanced STI surveillance systems. In 2002, an estimated 49 500 adults aged over 15 years were living with HIV in the United Kingdom, of whom 31% were unaware of their infection. Diagnoses of new HIV infections have doubled from 1997 to 2002, mainly driven by heterosexuals who acquired their infection abroad. HIV transmission also continues within the United Kingdom, particularly among homo/bisexual men who, in 2002, accounted for 80% of all newly diagnosed HIV infections acquired in the United Kingdom. New diagnoses of syphilis have increased eightfold, and diagnoses of chlamydia and gonorrhoea have doubled from 1997 to 2002 overall; STI rates disproportionately affect homo/bisexual men and young people. Effective surveillance is essential in the provision of timely information on the changing epidemiology of HIV and other STIs; this information is necessary for the targeting of prevention efforts and through providing baseline information against which progress towards targets can be monitored.

The risk of cancer in HIV-infected people in southeast England: a cohort study.

This study used data from the Communicable Disease Surveillance Centres national HIV database and the Thames Cancer Registry to assess the risk of cancer in HIV-infected people in southeast England. Among 26 080 HIV-infected men with 158 660 person-years follow-up, 1851 cancers, and among 7110 HIV-infected women (31 098 person-years), 171 cancers were identified. The standardised incidence ratio (SIR) for all non-AIDS-defining cancers was significantly increased in HIV-infected men (2.8, 95% confidence interval (CI) 2.6–3.1) but was nonsignificant in HIV-infected women (1.1, 95% CI 0.8–1.6). Most of the cancers observed were in men (n=1559) and women (n=127) with AIDS, and among them, the SIR for all non-AIDS-defining cancers was significantly increased in men (8.2, 95% CI 7.2–9.2) and women (2.8, 95% CI 1.6–4.6). The SIR for all non-AIDS-defining cancers was only just significantly increased in men with HIV-infection but not AIDS (1.2, 95% CI 1.0–1.5) and was nonsignificant in such women (0.8, 95% CI 0.5–1.2).

Factors associated with HIV seroconversion in gay men in England at the start of the 21st century

Objectives: To detect and quantify current risk factors for HIV seroconversion among gay men seeking repeat tests at sexual health clinics. Design: Unmatched case control study conducted in London, Brighton and Manchester, UK. Methods: 75 cases (recent HIV positive test following a negative test within the past 2 years) and 157 controls (recent HIV negative test following a previous negative test within the past 2 years) completed a computer-assisted self interview focused on sexual behaviour and lifestyle between HIV tests. Results: Cases and controls were similar in socio-demographics, years since commencing sex with men, lifetime number of HIV tests, reasons for seeking their previous HIV tests and the interval between last HIV tests (mean = 10.5 months). Risk factors between tests included unprotected receptive anal intercourse (URAI) with partners not believed to be HIV negative (adjusted odds ratio (AOR) and 95% confidence interval 4.1, 1.8 to 9.3), where increased risk was associated with concomitant use of nitrite inhalants, receiving ejaculate and increasing numbers of partners. Independent risk was also detected for unprotected insertive anal intercourse (UIAI) with more than one man (AOR 2.7, 1.3 to 5.5) and use of nitrite inhalants (AOR 2.4, 1.1 to 5.2). Conclusions: HIV serodiscordant unprotected anal intercourse remains the primary context for HIV transmission among gay men, with increased risk associated with being the receptive partner, receiving ejaculate and use of nitrite inhalants. Although the HIV transmission risk of URAI is widely acknowledged, this study highlights the risk of UIAI and that nitrite inhalants may be an important facilitator of transmission when HIV exposure occurs.