Claudia Estcourt

Sexually transmitted infections and risk behaviours in women who have sex with women

Objectives: To assess the prevalence of sexually transmitted infections (STIs) and blood borne viruses, risk behaviours, and demographics in women who have sex with women (WSW). Methods: Retrospective cross sectional study using a multivariate model. Demographic, behavioural, and morbidity data were analysed from standardised medical records of patients attending a public STI and HIV service in Sydney between March 1991 and December 1998. All women with any history of sex with a woman were compared with women who denied ever having sex with another woman (controls). Results: 1408 WSW and 1423 controls were included in the study. Bacterial vaginosis (BV) was significantly more common among WSW (OR 1.7, p<0.001). Abnormalities on cervical cytology were equally prevalent in both groups, except for the higher cytological BV detection rate in WSW (OR 5.3, p=0.003). Genital herpes and genital warts were common in both groups, although warts were significantly less common in WSW (OR 0.7, p=0.001). Prevalence of gonorrhoea and chlamydia were low and there were no differences between the groups. The prevalence of hepatitis C was significantly greater in WSW (OR 7.7, p<0.001), consistent with the more frequent history of injecting drug use in this group (OR 8.0, p<0.001). WSW were more likely to report previous sexual contact with a homo/bisexual man (OR 3.4, p<0.001), or with an injecting drug user (OR 4.2, p<0.001). Only 7% of the WSW reported never having had sexual contact with a male. Conclusion: We demonstrated a higher prevalence of BV, hepatitis C, and HIV risk behaviours in WSW compared with controls. A similar prevalence of cervical cytology abnormalities was found in both groups. Measures are required to improve our understanding of STI/HIV transmission dynamics in WSW, to facilitate better health service provision and targeted education initiatives.

HIV, sexually transmitted infections, and risk behaviours in male commercial sex workers in Sydney.

Objectives: To assess prevalence of HIV and sexually transmitted infections (STIs), risk behaviours, and demographics in male commercial sex workers (CSWs)/prostitutes in Sydney. Methods: Retrospective, cross sectional study with two comparison groups. Demographic, behavioural, and morbidity data were analysed from standardised medical records of patients attending a public STI and HIV service in Sydney between January 1991 and March 1998. Two comparison groups were used: female CSWs and non-CSW working homosexual men who attended over the same time. Results: 94 male CSWs, 1671 female CSWs, and 3541 non-CSW working homosexual men were included. The prevalence of HIV in male CSWs tested (6.5%) was significantly greater than in female CSWs (0.4%, p=0.0001), but less than in non-CSW homosexual men (23.9%, p<0.0001). Genital warts occurred significantly more frequently in male CSWs than in comparison groups. Prevalence of other STIs was similar in all groups. Male CSWs saw significantly fewer clients per week than female CSWs and male and female CSWs used condoms with almost all clients. Male CSWs reported significantly more non-work sexual partners than female CSWs and non-CSW homosexual men and were significantly more likely to have unprotected penetrative sex with their non-work partners than non-CSW homosexual men. Injecting drug use was significantly more frequent in male CSWs than in both comparison groups. Conclusions: Although male CSWs use condoms with clients, they are more likely to practise unsafe sex with non-work partners (especially women) and inject drugs than female CSWs and non-CSW homosexual men. Some men with HIV are working within the commercial sex industry. Targeted health education to encourage safer drug use and safer sex outside work is needed.

Can we improve partner notification rates through expedited partner therapy in the UK? Findings from an exploratory trial of Accelerated Partner Therapy (APT)

Objectives To develop two new models of expedited partner therapy for the UK, and evaluate them for feasibility, acceptability and preliminary outcome estimates to inform the design of a randomised controlled trial (RCT). Methods Two models of expedited partner therapy (APTHotline and APTPharmacy), known as ‘Accelerated Partner Therapy’ (APT) were developed. A non-randomised comparative study was conducted of the two APT models and routine partner notification (PN), in which the index patient chose the PN option for his/her partner(s) in two contrasting clinics. Results The proportion of contactable partners treated when routine PN was chosen was 42/117 (36%) and was significantly higher if either APT option was chosen: APTHotline 80/135 (59%), p=0.003; APTPharmacy 29/44 (66%) p=0.001. However, partner treatment was often achieved through other routes. Although 40–60% of partners in APT groups returned urine samples for sexually transmitted infection (STI) testing, almost none accessed HIV and syphilis testing. APT options appear to facilitate faster treatment of sex partners than routine PN. Preferences and recruitment rates varied between sites, related to staff satisfaction with existing routine PN; approach to consent; and possibly, characteristics of local populations. Conclusions Both methods of APT were feasible and acceptable to many patients and led to higher rates of partner treatment than routine PN. Preferences and recruitment rates varied greatly between settings, suggesting that organisational and cultural factors may have an important impact on the feasibility of an RCT and on outcomes. Mindful of these factors, it is proposed that APT should now be evaluated in a cluster RCT.

Where do young men want to access STI screening? A stratified random probability sample survey of young men in Great Britain.

Objectives Rates of sexually transmitted infections (STIs) in UK young people remain high in men and women. However, the National Chlamydia Screening Programme has had limited success in reaching men. The authors explored the acceptability of various medical, recreational and sports venues as settings to access self-collected testing kits for STIs and HIV among men in the general population and those who participate in sport. Methods A stratified random probability survey of 411 (weighted n=632) men in Great Britain aged 18–35 years using computer-assisted personal and self-interviews. Results Young men engaged well with healthcare with 93.5% registered with, and 75.3% having seen, a general practitioner in the last year. 28.7% and 19.8% had previously screened for STIs and HIV, respectively. Willingness to access self-collected tests for STIs (85.1%) and HIV (86.9%) was high. The most acceptable pick-up points for testing kits were general practice 79.9%, GUM 66.8% and pharmacy 65.4%. There was a low acceptability of sport venues as pick-up points in men as a whole (11.7%), but this was greater among those who participated in sport (53.9%). Conclusions Healthcare settings were the most acceptable places for accessing STI and HIV self-testing kits. Although young men frequently access general practice, currently little STI screening occurs in this setting. There is considerable potential to screen large numbers of men and find high rates of infection through screening in general practice. While non-clinical settings are acceptable to a minority of men, more research is needed to understand how these venues could be used most effectively.

An evaluation of the performance of OraQuick® ADVANCE Rapid HIV-1/2 Test in a high-risk population attending genitourinary medicine clinics in East London, UK:

To date, no data have been published on the use of OraQuick® ADVANCE Rapid HIV-1/2 Test (OraQuick) in the UK. We report preliminary findings of an ongoing evaluation of OraQuick in UK genitourinary (GU) medicine clinics. A total of 820 samples from patients in high-risk groups for HIV were tested with OraQuick and results were compared with standard HIV antibody testing. HIV prevalence (enzyme immunoassay [EIA]) was 5.73%, sensitivity of OraQuick was 93.64% (95% CI 82.46–98.66%), specificity 99.87% (99.28–100%), positive predictive value 97.78% (88.27–99.94%) and negative predictive value 99.61% (98.87–99.92%). This includes three false-negatives considered to be due to observer error and now rectified by further training. This has increased test sensitivity to 100%. Our observed test performance of OraQuick compares well with EIA and with other rapid tests. We believe that simple, non-invasive antibody detection tests such as OraQuick can increase HIV testing and diagnosis in UK GU medicine and community settings.

The relative clinical effectiveness and cost-effectiveness of three contrasting approaches to partner notification for curable sexually transmitted infections: a cluster randomised trial in primary care

BACKGROUND Partner notification is the process of providing support for, informing and treating sexual partners of individuals who have been diagnosed with sexually transmitted infections (STIs). It is traditionally undertaken by specialist sexual health services, and may involve informing a partner on a patients behalf, with consent. With an increasing proportion of STIs diagnosed in general practice and other community settings, there is a growing need to understand the best way to provide partner notification for people diagnosed with a STI in this setting using a web-based referral system. OBJECTIVE We aimed to compare three different approaches to partner notification for people diagnosed with chlamydia within general practice. DESIGN Cluster randomised controlled trial. SETTING General practices in England and, within these, patients tested for and diagnosed with genital chlamydia or other bacterial STIs in that setting using a web-based referral system. INTERVENTIONS Three different approaches to partner notification: patient referral alone, or the additional offer of either provider referral or contract referral. MAIN OUTCOME MEASURES (1) Number of main partners per index patient treated for chlamydia and/or gonorrhoea/non-specific urethritis/pelvic inflammatory disease; and (2) proportion of index patients testing negative for the relevant STI at 3 months. RESULTS As testing rates for chlamydia were far lower than expected, we were unable to scale up the trial, which was concluded at pilot stage. We are not able to answer the original research question. We present the results of the work undertaken to improve recruitment to similar studies requiring opportunistic recruitment of young people in general practice. We were unable to standardise provider and contract referral separately; however, we also present results of qualitative work aimed at optimising these interventions. CONCLUSIONS External recruitment may be required to facilitate the recruitment of young people to research in general practice, especially in sensitive areas, because of specific barriers experienced by general practice staff. Costs need to be taken into account together with feasibility considerations. Partner notification interventions for bacterial STIs may not be clearly separable into the three categories of patient, provider and contract referral. Future research is needed to operationalise the approaches of provider and contract partner notification if future trials are to provide generalisable information. TRIAL REGISTRATION Current Controlled Trials ISRCTN24160819. FUNDING This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 5. See the NIHR Journals Library website for further project information.

The Men's Safer Sex (MenSS) trial: protocol for a pilot randomised controlled trial of an interactive digital intervention to increase condom use in men

Introduction Sexually transmitted infections (STI) are a major public health problem. Condoms provide effective protection but there are many barriers to use. Face-to-face health promotion interventions are resource-intensive and show mixed results. Interactive digital interventions may provide a suitable alternative, allowing private access to personally tailored behaviour change support. We have developed an interactive digital intervention (the Mens Safer Sex (MenSS) website) which aims to increase condom use in men. We describe the protocol for a pilot trial to assess the feasibility of a full-scale randomised controlled trial of the MenSS website in addition to usual sexual health clinical care. Methods and analysis Participants: Men aged 16 or over who report female sexual partners and recent unprotected sex or suspected acute STI. Participants (N=166) will be enrolled using a tablet computer in clinic waiting rooms. All trial procedures will be online, that is, eligibility checks; study consent; trial registration; automated random allocation; and data submission. At baseline and at 3, 6 and 12 months, an online questionnaire will assess condom use, self-reported STI diagnoses, and mediators of condom use (eg, knowledge, intention). Reminders will be by email and mobile phone. The primary outcome is condom use, measured at 3 months. STI rates will be recorded from sexual health clinic medical records at 12 months. The feasibility of a cost-effectiveness analysis will be assessed, to calculate incremental cost per STI prevented (Chlamydia or Gonorrhoea), from the NHS perspective. Ethics and dissemination Ethical approval: City and East NHS Research Ethics Committee (reference number 13 LO 1801). Findings will be made available through publication in peer-reviewed journals, and to participants and members of the public via Twitter and from the University College London eHealth Unit website. Raw data will be made available on request. Trial registration number Current Controlled Trials. ISRCTN18649610. Registered 15 October 2013 http://www.controlled-trials.com/ISRCTN18649610.

Preparedness for use of the rapid result HIV self-test by gay men and other men who have sex with men (MSM): a mixed methods exploratory study among MSM and those involved in HIV prevention and care

The aim of the study was to explore preparedness for the HIV self‐test among men who have sex with men (MSM) and those involved in HIV prevention and care.

Assessment of risk for pelvic inflammatory disease in an urban sexual health population

Objectives: To determine the sexual and demographic risk factors for the acquisition of presumptive pelvic inflammatory disease (PID). Methods: A retrospective, case-control study in women, who attended the Sydney Sexual Health Centre (SSHC), between April 1991 and December 1997. Logistic regression analysis was used to adjust for confounding variables. Results: 741 women with PID and an equal number of controls were included. Cases were significantly younger than controls (p<0.001). 42% of cases were born in north or South East Asia, compared with 12% of the controls (p<0.001). The adjusted odds ratio for being born in north or South East Asia was 2.8 (95% CI 1.70–4.46), for not speaking English at home was 1.6 (95% CI 1.02–2.55), for having had previous PID was 5.9 (95% CI 3.59–9.73), and for being employed in the commercial sex industry and being born in north or South East Asia was 2.8 (95% CI 1.22–6.22). Women aged 15–19 were at considerable risk of developing PID (OR 5.3 (95% CI 2.76–10.11)). Women with previous human papillomavirus infection were significantly less likely to develop PID (OR 0.6 (95% CI 0.42–0.79)). The use of IUCDs (OR 4.5 (95% CI 2.14–9.39)), condoms (OR 1.4 (95% CI 1.03–1.87)), and not using contraception (OR 1.8 (95% CI 1.20–2.76)) was each associated with an increased risk. Conclusions: Several measures may help to reduce the burden of PID. Women should be encouraged to delay the onset of sexual activity and IUCDs should not be used in young women. Sexual health services for women whose home language is not English, and for commercial sex workers born in north or South East Asia should be improved.

The eSexual Health Clinic system for management, prevention, and control of sexually transmitted infections: exploratory studies in people testing for Chlamydia trachomatis

BACKGROUND Self-directed and internet-based care are key elements of eHealth agendas. We developed a complex online clinical and public health intervention, the eSexual Health Clinic (eSHC), in which patients with genital chlamydia are diagnosed and medically managed via an automated online clinical consultation, leading to antibiotic collection from a pharmacy. Partner notification, health promotion, and capture of surveillance data are integral aspects of the eSHC. We aimed to assess the safety and feasibility of the eSHC as an alternative to routine care in non-randomised, exploratory proof-of-concept studies. METHODS Participants were untreated patients with chlamydia from genitourinary medicine clinics, untreated patients with chlamydia from six areas in England in the National Chlamydia Screening Programmes (NCSP) online postal testing service, or patients without chlamydia tested in the same six NCSP areas. All participants were aged 16 years or older. The primary outcome was the proportion of patients with chlamydia who consented to the online chlamydia pathway who then received appropriate clinical management either exclusively through online treatment or via a combination of online management and face-to-face care. We captured adverse treatment outcomes. FINDINGS Between July 21, 2014, and March 13, 2015, 2340 people used the eSHC. Of 197 eligible patients from genitourinary medicine clinics, 161 accessed results online. Of the 116 who consented to be included in the study, 112 (97%, 95% CI 91-99) received treatment, and 74 of those were treated exclusively online. Of the 146 eligible NCSP patients, 134 accessed their results online, and 105 consented to be included. 93 (89%, 95% CI 81-94) received treatment, and 60 were treated exclusively online. In both groups, median time to collection of treatment was within 1 day of receiving their diagnosis. 1776 (89%) of 1936 NCSP patients without chlamydia accessed results online. No adverse events were recorded. INTERPRETATION The eSHC is safe and feasible for management of patients with chlamydia, with preliminary evidence of similar treatment outcomes to those in traditional services. This innovative model could help to address growing clinical and public health needs. A definitive trial is needed to assess the efficacy, cost-effectiveness, and public health impact of this intervention. FUNDING UK Clinical Research Collaboration.