Eva Jungmann

Missed opportunities for earlier HIV diagnosis within primary and secondary healthcare settings in the UK

Objective: To identify opportunities for earlier HIV diagnosis within primary and secondary care settings in the UK in Africans with newly diagnosed HIV infection. Methods: A survey of newly diagnosed HIV-positive Africans attending 15 HIV treatment centres across London was conducted between April 2004 and February 2006. The survey consisted of a confidential self-completed questionnaire linked to clinician-completed clinical records. Results: A total of 263 questionnaires were completed, representing an uptake rate of 79.5% of patients approached and 49.8% (131/263) of participants presented with advanced HIV disease (CD4 cell count < 200 cells/μl at diagnosis). In the year prior to HIV diagnosis 76.4% (181/237) had seen their GP, 38.3% (98/256) had attended outpatient services, and 15.2% (39/257) inpatient services, representing missed opportunities for earlier HIV diagnosis. Of those attending GP services the issue of HIV and/or HIV testing was raised for 17.6% (31/176) and 37.1% (78/210) had a previous negative HIV test, 32.5% of these within the UK. Medical attention was sought for wide ranging reasons, often not obviously connected to underlying HIV status. Despite the population predominantly coming from countries of high HIV prevalence personal appreciation of risk was comparatively low and knowledge of benefits of testing lacking. Conclusion: Africans are accessing health services but clinicians are failing to use these opportunities effectively for preventive and diagnostic purposes with regards to HIV infection. Comparatively low appreciation of personal risk and lack of perceived ill health within this community means clinicians need to be more proactive in addressing HIV.

How much do delayed healthcare seeking, delayed care provision, and diversion from primary care contribute to the transmission of STIs?

Objectives: To quantify the contribution of patient delay, provider delay, and diversion between services to delayed access to genitourinary medicine (GUM) clinics. To describe the factors associated with delay, and their contribution to STI transmission. Methods: Cross-sectional survey of 3184 consecutive new patients attending four GUM clinics purposively selected from across England to represent different types of population. Patients completed a short written questionnaire that collected data on sociodemographics, access, and health-seeking behaviour. Questionnaires were then linked to routinely collected individual-level demographic and diagnostic data. Results: Patient delay is a median of 7 days, and does not vary by demographic or social characteristics, or by clinic. However, attendance at a walk-in appointment was associated with a marked reduction in patient delay and provider delay. Among symptomatics, 44.8% of men and 58.0% of women continued to have sex while awaiting treatment, with 7.0% reporting sex with >1 partner; 4.2% of symptomatic patients reported sex without using condoms with new partner(s) since their symptoms had begun. Approximately 25% of all patients had already sought or received care in general practice, and these patients experienced greater provider delay. Conclusions: Walk-in services are associated with a reduction in patient and provider delay, and should be available to all populations. Patients attending primary care require clear care pathways when referred on to GUM clinics. Health promotion should encourage symptomatic patients to seek care quickly, and to avoid sexual contact before treatment.

Is first trimester exposure to the combination of antiretroviral therapy and folate antagonists a risk factor for congenital abnormalities

Objectives: To assess use of antiretroviral therapy (ART) by HIV positive pregnant women in London since 1994 and the risk of congenital abnormalities associated with multidrug exposure during the first trimester of pregnancy. Methods: Retrospective multicentre study of medical, obstetric, and paediatric notes of all mother-infant pairs, where the mother was known to be HIV infected before delivery, using a standardised proforma. Results: In this study of 195 mother-infant pairs, use of ART during any stage of pregnancy increased from 33.3% in 1994 to 92.5% in 1999 (p=0.01, trend). First trimester exposure increased from 0% in 1994 to 27.5% in 1999 (p=0.00045, trend). Congenital malformations were observed in nine infants (4.6%). Compared with infants not exposed to ART or folate antagonists during the first trimester (n=148), exposure to both ART and folate antagonists during the first trimester (n=13) was associated with an increased risk of congenital abnormalities (4% v 23.1%; OR 7.10, 95% CI 1.5, 34.2). No malformations were observed in the 34 children exposed to either ART or folate antagonists alone during the first trimester. Conclusion: An increasing number of HIV infected women conceived while on ART. Although there is no evidence of teratogenicity caused by ART if given alone during the first trimester, exposure to the combination of ART and folate antagonists was associated with a significantly higher risk of congenital abnormalities in this cohort.

What influences young women to choose between the emergency contraceptive pill and an intrauterine device? A qualitative study

Objective To explore key factors influencing young women when choosing between two methods of emergency contraception (EC). Methods We interviewed 26 young women who accessed community sexual and reproductive health services for emergency contraception after they had chosen an EC. Results Most women had an unrealistically high expectation about efficacy of the emergency contraceptive pill (ECP) and lacked knowledge of the intrauterine device (IUD) as an alternative method of EC. Previous use, easy accessibility, ease of use, and advice from peers, influenced women to choose the ECP, whereas past experience of abortion, firm motivation to avoid pregnancy, presentation after 72 hours, and considering that an IUD may provide long-term contraception as well, inclined women to choose the IUD. When participants were shown the IUD, many found it to be smaller and less frightening than they had imagined. Conclusions Women need better information and education about the IUD as a highly effective method of EC. Health professionals must provide such information at every opportunity. Showing the IUD during counselling might help correct misconceptions and would improve acceptability. Wider availability of expertise concerning EC-IUDs is essential to assist more women in making informed decisions when choosing a method for EC.

B-cell development and pneumococcal immunity in vertically acquired HIV infection.

Objectives:Many children with HIV infection now survive into adulthood. This study explored the impact of vertically acquired HIV in the era of antiretroviral therapy on the development of humoral immunity. Design:Natural and vaccine-related immunity to pneumococcus and B-cell phenotype was characterized and compared in three groups of young adults: those with vertically-acquired infection, those with horizontally acquired infection and healthy controls. Methods:Serotype-specific pneumococcal (Pnc) immunoglobulin M and G concentrations before and up to 1 year post-Pnc polysaccharide (Pneumovax) immunization were determined, and opsonophagocytic activity was analysed. B-cell subpopulations and dynamic markers of B-cell signalling, turnover and susceptibility to apoptosis were evaluated by flow cytometry. Results:HIV-infected patients showed impaired natural Pnc immunity and reduced humoral responses to immunization with Pneumovax; this was greatest in those viraemic at time of the study. Early-life viral control before the age of 10 years diminished these changes. Expanded populations of abnormally activated and immature B-cells were seen in both HIV-infected cohorts. Vertically infected patients were particularly vulnerable to reductions in marginal zone and switched memory populations. These aberrations were reduced in patients with early-life viral control. Conclusion:In children with HIV, damage to B-cell memory populations and impaired natural and vaccine immunity to pneumococcus is evident in early adult life. Sustained viral control from early childhood may help to limit this effect and optimize humoral immunity in adult life.

The need for innovative sexually transmitted infection screening initiatives for young men: evidence from genitourinary medicine clinics across England

The study objectives were to ascertain behavioural, access-related, health-seeking factors and sexually transmitted infection (STI) prevalence in young men (<25 years) attending genitourinary (GU) medicine clinics and compare them with older men (≥25 years) and young women (<25 years). Between October 2004 and March 2005, 4600 new attendees at seven sociodemographically and geographically contrasting GU medicine clinics across England completed questionnaires, which were linked to routine clinical data. Young men waited significantly less time to be seen in clinic compared with older men and young women. They were less likely to report symptoms than older men (P = 0.021) yet more likely to be diagnosed with chlamydia (P = 0.001) and gonorrhoea (P = 0.007). They were also more likely to be diagnosed with an acute STI relative to young women (P = 0.007). Our data confirm the need to make comprehensive STI screening readily available for young men and to develop effective and innovative screening strategies in different settings.

P181 Do we need to routinely re-screen heterosexual patients for HIV and Syphilis when they reattend GUM/SRH clinics? (Improving clinical practice and service delivery)

Background/introduction In the current financial climate we need to ensure that scarce resources are used efficiently. Heterosexual patients re-attending GUM/SRH services after an initial negative screen for HIV may be at low risk for acquiring new HIV and/or Syphilis and routine testing may not be cost-effective. Aim(s)/objectives Determine the incidence of HIV and Syphilis in heterosexuals re-attending GUM/SRH services after previous negative HIV testing. Establish potential savings. Methods Case note review of heterosexual patients attending a mixture of Inner London Integrated and Sexual Health clinics in 2014 and re-testing for HIV and/or Syphilis within 12 months. Data extracted includes patient demographics, tests performed and outcomes. Cost of HIV POCT £2.64, HIV serology £18.75, Syphilis screen £10.35. Results Of 31,469 patients who tested for HIV in 2014, 4,584 (14.6%) were retested within 12 months. 69% were female and 31% male. The age range was 16–81 years with 27% <25 years, 33% White British, 20% White Other, 18% Black African/Black British/Caribbean/Other Black and others from a diverse range of ethnicities. 89% tested for HIV (82% POCT, 18% Antigen/Antibody) and 88% for Syphilis. Results showed one newly diagnosed HIV infection (male seroconverter with recent high-risk activity) and no new Syphilis infections. 25 patients found with positive Syphilis Serology were all either previously treated or had a false positive result. Potential savings if we had not tested for: HIV POCT- £8,886, HIV Antigen/Antibody- £13,763, Syphilis- £42,083. Discussion/conclusion These results suggest that we need to review our current testing policy.

Response to article – T Farmer et al. Are text reminders useful to reduce DNA rates in routine GUM clinics? (Int J STD AIDS 2014; 25: 289–293)

We read with interest the recent report by Farmer et al. on using text reminders to reduce non-attendance (DNA) rates in sexual health (SH) and HIV clinic appointments. In our service, the Archway Centre, a Sexual Health Clinic in North London, UK, routine SH appointments are bookable but despite being mostly compliant with 48 h access, our DNA rate averaged 21% in 2012. We reviewed the impact of 24 h and 48 h text reminders on DNA, cancelled and rescheduled appointments. The appointment outcomes were compared in three-month periods during 2013 with respective periods in 2012 with no text reminder. Statistical significance was determined using chi-square test. In 2012, 18,413 patients attended, of which 15% booked less than 24 h in advance (DNA 5%), 44% between 24 and 48 h (DNA 22%) and 41% more than 48 h (DNA 26%) beforehand. There was non-significant variation in DNA rates by calendar month. During the period of 24 h text reminders in 2013, 85% of 4914 patients attended, booked more than 24 h in advance. DNA rates fell from 22% to 19% (p< 0.005) overall, and by 3% (p< 0.05) and 2% (p< 0.05) for females and males, respectively. During the period of 48h text reminder, 36% of 4521 patients attended, booked more than 48h in advance. In comparison to the Patrick Clements Clinic (PCC) where 85% of appointments are unbooked walk-in appointments, walk-in appointments at our centre are in addition to our majority booked appointments. This is reflected in the total number of patients analysed by Farmer et al. compared to our analysis (984 in 2009 compared to 4521 over a three-month period in 2013, respectively). Our DNA rates fell by 4% from 22% to 18% (p< 0.005) and by 4% (p< 0.05) and 5% (p< 0.05) for females and males, respectively, compared to 4% (not significant) and 10% (p< 0.02) for females and males, respectively, at the PCC. Overall, our data show 24h and 48h text reminders resulted in a statistically significant reduction inDNA rates overall and for both females and males with a higher impact of 48h reminders. Forty-eight hours texts resulted in cancellation rates falling by 1% (7% to 6%, p< 0.05) unlike 24 h texts which showed no change (6%, p1⁄4 0.2344). Gender analysis showed a statistical significance with females, with cancellation rates falling by 1% and 2% for 24 h and 48 h texts, respectively (p< 0.05). The analysis at the PCC showed the opposite. Interestingly, both text reminders resulted in more appointments being rescheduled (p< 0.05), with a statistically significant impact on females only. Further analysis to determine the timing of booking showed 15% booked less than 24 h, 44% within 24–48 h and 41% more than 48 h, in advance. Given that the majority of patients are booking less than 48 h, 24 h and 48 h reminders still significantly reduced DNA rates. Patient feedback proved acceptability: 93% found it useful, 97% felt it was appropriate and 95% wanted to continue receiving reminders. Text reminders are an acceptable, easy and costeffective strategy to increase capacity, especially given NHS targets. Given the findings of our data, we have since successfully implemented 48 h text reminders to all patients who are informed when booking their appointments, with the option to opt-out.

High rate of lymphoma among a UK cohort of adolescents with vertically acquired HIV-1 infection transitioning to adult care in the era of antiretroviral therapy.

Among an inner London UK cohort of 147 adolescents transitioning from paediatric into adult care between 2007 and 2015, a new diagnosis of lymphoma was made in five patients; incidence rate = 0.425/100 person-years (95% confidence interval = 0.424–0.426). Previously described risk factors, including low nadir CD4+ cell count and ongoing HIV-1 viraemia, appeared to be important. These data suggest that careful surveillance and a low threshold for investigating relevant symptoms continue to be essential for such patients.