Jyoti Dhar

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.

A Randomized Comparative Trial of Continued Abacavir/Lamivudine plus Efavirenz or Replacement with Efavirenz/Emtricitabine/Tenofovir DF in Hypercholesterolemic HIV-1 Infected Individuals

Background Drug choice and metabolic changes with antiretroviral therapy contribute to cardiovascular risk in persons with HIV-1 infection. Methods A randomized, 12 week, open-label, comparative study of the impact on lipids of continuation of abacavir/lamivudine (ABC/3TC) plus efavirenz (EFV) or replacement with the single tablet regimen of EFV/emtricitabine/tenofovir DF (EFV/FTC/TDF) in hypercholesterolaemic subjects on successful antiretroviral therapy, with a 12-week extension with all subjects on EFV/FTC/TDF. Results 157 subjects received study drug, 79 switched to EFV/FTC/TDF and 78 subjects continued ABC/3TC+EFV. At Week 12, 73 subjects on ABC/3TC+EFV switched to EFV/FTC/TDF. The switch was well tolerated and no subject experienced viral rebound. Median baseline fasting total cholesterol was 6.32mmol/L. 12 weeks following switch, the difference in the means (LSM) between treatment groups (EFV/FTC/TDF minus ABC/3TC+EFV) in total cholesterol change from baseline was -0.74mmol/l (95% CI −1.00, −0.47, p < 0.001). The median change from baseline in total cholesterol following switch in the EFV/FTC/TDF arm was -0.86mmol/l (p < 0.001) compared with +0.01mmol/l (p = 0.45) in the continuation arm at Week 12. Significant (p < 0.001) differences between treatment groups following switch were seen for all lipid fractions from baseline to Week 12: LDL cholesterol (−0.47 mmol/L [−0.70, −0.25]), HDL cholesterol (−0.15 mmol/L [−0.21, −0.08]), triglycerides (−0.43 mmol/L [-0.75, -0.11]), and non HDL cholesterol (−0.56 mmol/L [−0.80, −0.31]). In the extension phase, similar declines in total cholesterol were observed with a median change from Week 12 to Week 24 of −0.73mmol/L (p < 0.001). Conclusions Switching from ABC/3TC+EFV to EFV/FTC/TDF in persons with hypercholesterolemia maintains virological control and significantly improves key lipid parameters. Trial Registration ClinicalTrials.gov NCT00615810

How and why do South Asians attend GUM clinics? Evidence from contrasting GUM clinics across England.

Background Improving access to sexual healthcare is a priority in the UK, especially for ethnic minorities. Though South Asians in the UK report low levels of sexual ill health, few data exist regarding their use of genitourinary medicine (GUM) services. Objectives To describe reasons for attendance at GUM clinics among individuals of South Asian origin relative to patients of other ethnicities. Methods 4600 new attendees (5% South Asian; n=226) at seven sociodemographically and geographically contrasting GUM clinics across England completed a questionnaire between October 2004 and March 2005, which were linked to routine clinical data. Results South Asians were more likely than other groups to be signposted to the GUM clinic by another health service—for example, in women 14% versus 8% respectively (p=0.005) reported doing so from a family planning clinic. These women also reported that they would be less likely to go to the clinic if their symptoms resolved spontaneously compared with other women (51% vs 31%, p=0.024). However, relative to other clinic attendees, no differences in the proportions of South Asians who had acute STI(s) diagnosed at clinic were noted. Furthermore, South Asian men were more likely to report as their reason for attendance that they wanted an HIV test (23.4% vs 14.8%, p=0.005). Conclusion Despite having similar STI care needs to attendees from other ethnic groups, South Asians, especially women, may be reluctant to seek care from GUM clinics, especially if their symptoms resolve. Sexual health services need to develop locally-delivered and culturally-appropriate initiatives to improve care pathways.

O32 Ethnicity and sexual behaviours – the association between ethnicity and sexual risk behaviours reported by heterosexual men and women in a gum setting

Introduction In the UK people of black ethnicity experience a disproportionate burden of HIV and STI. We aimed to assess the association of ethnicity with sexual risk behaviours (SRB) and sexual health among heterosexual men and women. Methods AURAH is a cross-sectional questionnaire study of people without HIV, recruited in 20 GUM clinics in England 2013–14. We assessed the association of ethnicity with (i) condomless sex with non-regular partner(s) (CLS-NR); (ii) ≥2 new partners in the last year (2NPLY); and (iii) STI diagnosis in the past year (STI) using modified poisson regression adjusted for age, study region, education and relationship status. Results 1075 heterosexual men (n=451) and women (n=624) completed questionnaires. Ethnicity was as follows: 513 (48.4%) black/mixed African (BA), 159 (15.0%) black/mixed Caribbean (BC), 288 (27.1%) white ethnicity (WE), 101 (9.5%) other ethnicity (OE).Abstract O32 Table 1 AURAH Adjusted PR (95%CI) CLS–NR 2NPLY STI within last year Women: White  BA  BC  OE 1 0.65(0.49–0.85) 0.78(0.55–1.10) 0.66(0.39–1.13) 1 0.36(0.27–0.48)0.39(0.25–0.61)0.60(0.37–0.99) 1 0.92(0.61–1.38) 1.47(0.95–2.28) 1.23(0.68–2.23) Men: White  BA  BC  OE 1 1.05(0.83–1.32) 1.02(0.73–1.44) 0.69(0.43–1.09) 1 0.77(0.62–0.96) 0.85(0.62–1.16) 1.29(1.03–1.61) 1 1.14(0.75–1.73) 1.76(1.10–2.82) 0.59(0.24–1.43) Compared with WE women BA women were less likely to report CLS-NR, BA and BC women were less likely to report 2NPLY, and BC women were more likely to report STI. In men CLS-NR did not vary significantly by ethnicity. BA men were less likely to report 2NPLY and BC men were more likely to report STI compared with WE men. Discussion The prevalence of SRBs was lower in black ethnicity women, but history of STI was more prevalent among BC women. Similarly, higher STI history in BC men was not consistent with ethnic variation in SRB. Additional factors, e.g. sexual networks, may be important determinants of sexual health.

Switching from Kivexa + efavirenz to Atripla reduces total cholesterol in hypercholesterolemic subjects: final results of a 24-week, randomized study

7‐11 November 2010, Tenth International Congress on Drug Therapy in HIV Infection, Glasgow, UK