Holly Mitchell

Contribution of transmission in HIV-positive men who have sex with men to evolving epidemics of sexually transmitted infections in England: an analysis using multiple data sources, 2009-2013.

HIV seroadaptive behaviours may have contributed to greater sexually transmitted infection (STI) transmission in HIV-positive men who have sex with men(MSM) and to the global increase in STIs. Using multiple national surveillance data sources and population survey data, we estimated the risk of STIs in HIV-positive MSM and assessed whether transmission in HIV-positive MSM has contributed to recent STI epidemics in England. Since 2009, an increasing proportion of STIs has been diagnosed in HIV-positive MSM, and currently, the population rate of acute bacterial STIs is up to four times that of HIV-negative or undiagnosed MSM. Almost one in five of all diagnosed HIV-positive MSM in England had an acute STI diagnosed in 2013. From 2009 to 2013, the odds of being diagnosed with syphilis increased from 2.71 (95% confidence interval (CI) 2.41–3.05, p<0.001) to 4.05 (95%CI 3.70-4.45, p<0.001) in HIV-positive relative to HIV negative/undiagnosed MSM. Similar trends were seen for gonorrhoea and chlamydia. Bacterial STI re-infection rates were considerably higher in HIV-positive MSM over a five-year follow-up period, indicative of rapid transmission in more dense sexual networks.These findings strongly suggest that the sexual health of HIV-positive MSM in England is worsening, which merits augmented public health interventions and continued monitoring.

An overview of the HIV epidemic among men who have sex with men in the United Kingdom, 1999-2013

We describe epidemiological trends in HIV among men who have sex with men (MSM) in the United Kingdom (UK) to inform prevention strategies. National HIV surveillance data were analysed for trends. Multivariable analyses identified predictors of late diagnosis (<350 copies/µL) and mortality. Between 1999 and 2013, 37,560 MSM (≥15 years) were diagnosed with HIV in the UK. New diagnoses rose annually from 1,440 in 1999 to 3,250 in 2013. The majority of MSM were of white ethnicity (85%) and UK-born (68%). Median CD4 count increased steadily from 350 cells/µL to 463 cells/µL. HIV testing in England increased from 10,900 tests in 1999 to 102,600 in 2013. One-year death rates after diagnosis declined among late presenters (4.7% to 1.9%). Despite declining late diagnosis (50% to 31%), the number of men diagnosed late annually has remained high since 2004. Older age (≥50 years), and living outside London were predictors of late presentation; older age and late presentation were predictors of one-year mortality. Increases in new diagnoses reflect increased testing and ongoing transmission. Over 900 men present late each year and mortality in this group remains high and preventable. Appropriate prevention and testing strategies require strengthening to reduce HIV transmission and late diagnosis.

What are the characteristics of, and clinical outcomes in men who have sex with men prescribed HIV postexposure prophylaxis following sexual exposure (PEPSE) at sexual health clinics in England?

Objectives To explore the risk factors for, and clinical outcomes in men who have sex with men (MSM) prescribed HIV postexposure prophylaxis following sexual exposure (PEPSE) at sexual health clinics (SHCs) in England. Methods National STI surveillance data were extracted from the genitourinary medicine clinic activity dataset (GUMCADv2) for 2011–2014. Quarterly and annual trends in the number of episodes where PEPSE was prescribed were analysed by gender and sexual risk. Risk factors associated with being prescribed PEPSE among MSM attendees were explored using univariable and multivariable logistic regression. Subsequent HIV acquisition from 4 months after initiating PEPSE was assessed using multivariable Cox proportional hazards models, stratified by clinical risk profiles. Results During 2011–2014, there were 24 004 episodes where PEPSE was prescribed at SHCs, of which 69% were to MSM. The number of episodes where PEPSE was prescribed to MSM increased from 2383 in 2011 to 5944 in 2014, and from 1384 to 2226 for heterosexual men and women. 15% of MSM attendees received two or more courses of PEPSE. Compared with MSM attendees not prescribed PEPSE, MSM prescribed PEPSE were significantly more likely to have been diagnosed with a bacterial STI in the previous 12 months (adjusted OR (95% CI)—gonorrhoea: 11.6 (10.5 to 12.8); chlamydia: 5.02 (4.46 to 5.67); syphilis: 2.25 (1.73 to 2.93)), and were more likely to subsequently acquire HIV (adjusted HR (aHR) (95% CI)—single PEPSE course: 2.54 (2.19 to 2.96); two or more PEPSE courses: aHR (95% CI) 4.80 (3.69 to 6.25)). The probability of HIV diagnosis was highest in MSM prescribed PEPSE who had also been diagnosed with a bacterial STI in the previous 12 months (aHR (95% CI): 6.61 (5.19 to 8.42)). Conclusions MSM prescribed PEPSE are at high risk of subsequent HIV acquisition and our data show further risk stratification by clinical and PEPSE prescribing history is possible, which might inform clinical practice and HIV prevention initiatives in MSM.

The role of frequent HIV testing in diagnosing HIV in men who have sex with men.

In the UK, quarterly HIV testing is recommended for high‐risk men who have sex with men (MSM). In this manuscript we determined the risk of being newly diagnosed with HIV in MSM by their HIV testing history, considering both the frequency and periodicity of testing.

P176 Are sexually transmitted infections associated with child sexual exploitation in under 16 year olds attending Genitourinary Medicine clinics in the UK

Background Child sexual exploitation (CSE) is a challenging diagnosis to make, with few clinical signs or symptoms, and little evidence that markers such as sexually transmitted infections (STIs) are CSE predictors. Aim To investigate associations between STIs and CSE risk factors. Methods The genitourinary medicine clinic activity dataset (GUMCAD) was used to identify clinics with >18 STI diagnoses in 13–15 year-olds in 2012. Cases with confirmed bacterial or protozoal STIs were matched by age, gender and clinic with non-STI controls. Clinics provided details of CSE-related risk factors irrespective of STI presence through an on-line questionnaire. Associations between STI outcome and CSE-related risk factors were analysed using logistic regression. Results 18/44 (40.9%) clinics contacted provided data on 466 13–15 year-olds; 414 (88.8%) were female, and 52 (11.2%) male. 98.6% were heterosexual, and 66.7% white British. There were 18 (3.9%) 13, 108 (23.2%) 14 and 340 (80.0%) 15 year-olds. In univariate analysis an STI diagnosis was significantly associated with: ‘highly-likely’ CSE (OR 9.00, p = 0.037), >1 partner (OR 5.50, p = 0.000), >1 attendance in 2012 (OR 3.79, p = 0.0000), safeguarding referral (OR 1.94, p = 0.022), other service involvement (OR 1.72, p = 0.031) and vulnerability (OR 1.64, p = 0.026). After adjustment, STI diagnosis was significantly associated with: Health Advisor review (OR 6.78, p = 0.000), >1 partner (OR 5.82, p = 0.002), >1 attendance (OR 3.72, p = 0.000) and looked after child (OR 3.43, p = 0.039). Discussion The presence of a bacterial or protozoal STI is only weakly associated with CSE and should not be used to infer CSE in the absence of more compelling evidence.

O12 Associations between repeat attendances, sexually transmitted infections and child sexual exploitation in under 16 year olds attending genitourinary medicine clinics

Background Child sexual exploitation (CSE) diagnoses are difficult to make, often with no symptoms or signs. Previous reports suggested that sexually transmitted infections (STIs) are a CSE marker but currently there is no evidence for this. Aim To investigate associations between attendance patterns and STIs with CSE to refine clinic-based CSE risk algorithms. Methods STI diagnoses among <16 year-olds during 2012 were extracted from clinics using the genitourinary medicine clinic activity dataset (GUMCAD). Clinics with >18 STI diagnoses (all STIs) were contacted for recruitment. Cases were defined as patients with a confirmed, bacterial or protozoal STI. Controls were defined as age and gender matched asymptomatic patients at the same clinic without STIs. An online data collection tool was developed to capture additional CSE risk factors on cases and controls. A protocol was created to aid CSE definition and stratification. Results During 2012 in England, there were 12,819 attendances of young people aged 13–15 and 2337 STIs diagnosed: 1040 (44.5%) were chlamydia, 220 (9.4%) gonorrhoea and 67 (2.9%) trichomonas. Of these infections 998 (75.2%) were aged 15, 57 (4.3%) were ≤13 and 1188 (89.5%) were female. 44 clinics had >18 STIs in <16s, and 21 were recruited to the study. Discussion Considerable numbers of <16 year-olds are diagnosed with STIs in GUM clinics in England. Reporting of all these to child protection services would create considerable burdens. Additional risk information from the online tool may provide important evidence of associations between STIs and CSE in order to better use limited resources.