David Rowen

A multicentre, randomised, double-blind, placebo controlled study of cryotherapy versus cryotherapy and podophyllotoxin cream as treatment for external anogenital warts

Objectives: To compare the efficacy and safety of combination therapy with cryotherapy and podophyllotoxin 0.15% cream versus cryotherapy alone in the treatment of anogenital warts. Methods: A randomised, double-blind, multicentre controlled trial. Patients received podophyllotoxin cream or placebo twice daily for 3 days/week for up to 4 weeks, with weekly cryotherapy continued to week 12 if required. Further treatment from week 12 to 24 was discretionary. Patients were stratified by sex and history of warts. HIV positivity, warts treated in the past 4 months, or warts with a combined area of less than 10 mm2 were exclusion criteria. Primary endpoints were clearance at weeks 4 and 12. Results: 70 patients per group were randomly assigned and started treatment; 101 first-episode warts, 91 male. No treatment-related serious adverse events were reported. Follow-up at week 12 was 85%. By intention-to-treat analysis, clearances at 4 and 12 weeks were higher in the combination group (60.0% and 60.0%, respectively) than with cryotherapy alone (45.7%, 45.7%) although not statistically significant (RR 1.31, 95% CI 0.95to 1.81). By week 24 there was no difference between the groups (68.6% and 64.3%, respectively; RR 1.07, CI 0.84 to 1.35). At week 4, wart clearance was higher in men (p = 0.001) and those with a past history of warts (p = 0.009), but these differences were not detected at week 12. There was some evidence for a higher relapse rate in the group receiving cryotherapy alone. Conclusions: Initial combination therapy with podophyllotoxin/cryotherapy was well tolerated and may have resulted in earlier clearance in some patients, compared with cryotherapy alone; however, overall differences in clearance rates were not statistically significant.

TOWARD A HUMAN PAPILLOMAVIRUS VACCINE

Much progress has been made over the past 10 years with regard to development of a vaccine active against HPV. Successful protection has been achieved in animal models using species-specific papillomaviruses; however, HPV diversity may delay the development of successful HPV vaccines, especially those designed as therapeutic vaccines for the treatment of HPV-induced carcinoma and high-grade dysplasia of the cervix. Difficulties arise with regard to assessment of efficacy of potential vaccines. The impetus for long-term studies on vaccine efficacy will initially stem from in vitro evidence of responsiveness to the vaccine. The time when a vaccine will have an impact on the prevalence of high-grade dysplasia and invasive cancer is still some way off.

An Unusual Case of Pelvic Pain: Retention of Fetal Bone after Abortion:

We present a 21-year-old woman with a short history of pelvic pain. The history was unremarkable apart from that of undergoing a surgical termination of pregnancy (TOP) some three-and-half years ago. Examination revealed a foreign body at the cervical os. Subsequent investigations revealed more foreign bodies within the cervical canal and uterine cavity, which were removed. Histologically these were found to be bones. Removal of the bone fragment initially discovered lead to an improvement of symptoms. Although the patient was treated for pelvic-inflammatory disease, no infective cause could be established. The condition of intrauterine retained fetal bones is recognized, but rare. Patients experiencing pelvic pain usually present sooner after TOP than did this patient. Although rare, it is an important condition to diagnose as it represents a treatable cause of infertility.

Increasing screening frequency in men who have sex with men: impact of guidance on risk profiling on workload and earlier diagnosis of sexually transmitted infection and HIV

Summary Increasing screening frequency in men who have sex with men (MSM) engaging in high-risk behaviours can reduce prevalence of sexually transmitted infections (STIs). This evaluation investigated the impact of applying stricter screening guidelines for MSM on service workload and earlier STI diagnoses. A validated risk assessment tool (RAT) was distributed to MSM attending a level 3 sexual health service over three months. Australian screening guidelines were applied to the data to identify MSM requiring more frequent screening and data projected to the larger MSM population. The RAT identified a 2–5-fold increase in the number of STI and HIV screenings required based on six- and three-monthly screening intervals, respectively, in the MSM cohort. When screening intervals are reduced from three-monthly to six-monthly there is a potential loss of 66.7% of earlier HIV diagnoses. The use of RATs will increase workload in sexual health services, but potentially diagnose a large proportion of disease earlier.

How normalised is HIV care in the UK? A survey of current practice and opinion.

Objectives: The prognosis for individuals infected with HIV has changed dramatically over the past 10 years, with patients living longer and requiring other specialist services. It is apparent that access of other healthcare professionals to clinical information about a patient’s HIV care differs between centres in the UK. Lack of awareness of an individual’s HIV status may compromise their clinical care. Aim: To establish current practice and identify the views of clinicians caring for patients infected with HIV. Methods: Lead consultants in all genitourinary medicine departments in the UK were invited to complete a questionnaire regarding use of combined HIV and hospital notes and ability of general practitioners and other hospital specialists to access information about individual patient’s HIV care. Clinician’s opinions on the “normalisation” of HIV management were also sought. Results: Combined notes (outpatient and inpatient) were used by 12% (16/130) of respondents. The patient’s identifying number was used to request blood tests in 86%. Of the respondents, 42% had encountered difficulties in communication that affected delivery of care for an HIV-positive patient. Conclusions: Centres using combined notes identified a higher frequency of communication with other doctors and specialties, suggesting a higher standard of care. Physicians involved in HIV care should consider combining patients’ HIV and hospital notes for improved clinical care.

Patient-initiated delay at a genitourinary medicine clinic: are there public health consequences?

Objectives: To assess the public health consequence of patients electing not to be seen within 48 hours in a genitourinary medicine (GUM) clinic. Methods: A 3-month retrospective case notes review was carried out for 310 new and re-book patients who chose to wait for more than 48 hours to be seen. Results: Altogether, 10% (310/3110) of patients opted to be seen beyond 48 h. Their median wait was 6 days including weekends and 4 days excluding weekends. Demographic details did not vary except for the male to female ratio of 1:1.7 (1:1 in patients seen within 48 h). We found that no symptomatic patients or asymptomatic contacts of those with known sexually transmitted infections (STIs) reported sex with a new partner after booking their appointment. No patient reported sex with a recently treated partner who consequently required re-treatment and none suffered a complication of a STI. In addition, there were no cases of new HIV infection in this group and the rates of STIs were similar compared with patients seen within 48 hours of contacting the unit. Conclusions: Despite 10% of patients choosing to delay attendance beyond 48 h, no adverse public health outcomes were demonstrated.

A glimmer of hope? Evaluation of time for non-genitourinary medicine physicians to diagnose HIV infection in patients presenting with HIV-related illness

Summary A study conducted in 2002–2003 at three UK south coast hospitals measuring the length of time for non-genitourinary medicine physicians to diagnose HIV when patients presented with an HIV-related illness, found a median time to diagnosis of four days with 70% of diagnoses being made within seven days. This retrospective cohort study of all patients newly diagnosed with HIV between 1 January 2010 and 31 December 2011 was conducted at the same three hospitals. Thirty-seven patients were newly diagnosed with HIV in non-genitourinary (GU) medicine inpatient and outpatient settings (24 men, 13 women), with a mean age of 43 years. The median time to diagnosis was one day (interquartile range of 0–4 days), with 81% of diagnoses made within seven days of first presentation. Late diagnosis of HIV remains a significant challenge, but delayed diagnosis in a patient admitted with an HIV-related illness is reducing in this setting.

P166 Increasing screening frequency in men who have sex with men (MSM): impact of explicit guidance on risk profiling on UK service

Background STI and HIV diagnoses are increasing among MSM. Mathematical modelling shows increasing screening frequency can reduce STI prevalence, especially targeting MSM engaging in risk behaviours. International guidelines from both the CDC and Australasian Society for HIV Medicine clearly define risk behaviours with adapted screening intervals—contrary to the UK where NICE guidance is vague. Objectives To investigate impact of applying stricter international screening guidelines for MSM, on service workload and earlier STI diagnosis in a UK level 3 service [L-3S]. Methods A validated risk questionnaire distributed to MSM attending a large provincial L-3S over a 3-month period explored their actual screening frequency, STI diagnoses and risk behaviours in the prior 12 months. Australian screening guidelines were applied to the data to identify MSM needing more frequent screening. Projections to the larger MSM population attending over 12 months were modelled, based on the demographics of the respondents. Results 126/357 completed the questionnaire, 89 were identifiable. There was no statistically significant difference between STI rates (p=0.18) and HIV diagnoses (p=0.62) between identifiable questionnaire respondents and other MSM clinic attendees. Demographic analysis showed the sample group was representative of the larger cohort. In 2011, applying Australasian Society for HIV Medicine risk profiling for the 793 MSM who attended the unit, 26% would require one additional 6-monthly attendance for HIV screening, while 6% would require two visits. Additional STI screening visits would be needed by 25% (1 visit) and 10% (2 visits). 29% of STI diagnoses were in infrequent attendees. Conclusions Stricter UK screening guidelines for MSM defining and weighting risk behaviours explicitly in line with other international guidelines, would increase L-3S MSM visits by 30% and potentially diagnose a large proportion of disease earlier. In light of the results UK guidelines may benefit from review.

P5.019 Strategies Influencing Did-Not-Attend (DNA) Rates in Sexually Transmitted Infection (STI) Clinics: A Randomised Controlled Trial (RCT) Assessing the Effectiveness of a Verbal Warning Message Given at Appointment Booking

Background Missed clinic appointments cause significant wastage of health resources worldwide. The majority of cases who DNA appointments are young and of lower socio-economic status and, conversely, are most likely to carry STIs. Several interventions aimed at reducing DNA appointments such as reminder SMS texts and letters have been studies internationally. Our UK STI department uses interventions such as monthly displays of DNA appointments, SMS reminders and removal of booking privileges to reduce DNA rates. The objective of this study was to assess whether introducing a verbal missed appointment warning at the time of booking has an effect on subsequent DNA and cancellation rates. Method 108 patients over 16 years old were recruited in this RCT to show a 25% difference between the groups. Within the first arm the patients were advised that if they did not cancel their appointments in advance and subsequently DNA’ed then they would be obliged to attend a walk-in service in the future. In the second arm the warning was removed. The DNA rates from these two arms were compared initially to each other and then to other previously studied interventions. Results Interim analysis of results shows a fall in the DNA rates with those who received a verbal warning message at the time of booking matching SMS text and letter reminders rates seen in published data. Conclusion With financial constraints affecting STI clinics worldwide, it is essential to consider low-cost methods aimed at reducing DNA rates. Whilst we have shown a warning message to be effective, it is also inexpensive and introduction of such a warning system would be beneficial in resource-limited settings.

P24 Regional experience of indications for switching patients to raltegravir and maraviroc and success after regimen change

Background In small centres there is wide variation in the accessibility of raltegravir (RAL) and maraviroc (MVC) as they are not on the formulary of several trusts. Individual PCT funding is sought on a named patient basis, a time consuming process leading to potential delays in treatment. Objectives To identify common clinical indications for treatment change to RAL or MVC. To formulate prescribing criteria on the basis of these in order to seek approval from the District Prescribing Committee and streamline treatment provision. Methods Retrospective case note review of patients started on RAL or MVC attending six HIV clinics within a regional network between 2008 and 2010 and collection of data on reasons for treatment change. Results 40 patients were reviewed, 37 of whom started RAL and 3 MVC. Multiple factors contributed to therapy change. 22 patients (55%) had resistance to other antiretrovirals or treatment failure and 20 (50%) had significant side effects or intolerance to other drug classes. Other factors included cardiovascular risk (20%), co-infections (18%) and co-morbidities (18%). 14 patients were reviewed for immunological response following treatment. Two were excluded (one unrelated death). Of the remaining 13 patients, 46% had a suppressed viral load prior to starting RAL, and 92% were suppressed after 12 months of treatment. Conclusions This study demonstrates that identifying common indications for switching to RAL and MVC within a regional network supported the process of formulating criteria to prescribe these newer drugs. This unified approach within the region led to improved and timely access to these drugs thereby improving outcomes for patients at small centres. The agreed prescribing criteria were in instances where combination therapy was not possible due to intolerability, side effects, allergies, resistance, drug interactions, co-morbidities, or HIV-2 (for RAL).