Margaret Kingston

Audit of HIV testing frequency and behavioural interventions for men who have sex with men: policy and practice in sexual health clinics in England

Background National guidance recommends targeted behavioural interventions and frequent HIV testing for men who have sex with men (MSM). We reviewed current policy and practice for HIV testing and behavioural interventions (BI) in England to determine adherence to guidance. Methods 25 sexual health clinics were surveyed using a semistructured audit asking about risk ascertainment for MSM, HIV testing and behavioural intervention policies. Practice was assessed by reviewing the notes of the first 40 HIV-negative MSM aged over 16 who attended from 1 June 2010, in a subset of 15 clinics. Results 24 clinics completed the survey: 18 (75%) defined risk for MSM and 17 used unprotected anal intercourse (UAI) as an indication of high risk. 21 (88%) offered one or more structured BI. Of 598 notes reviewed, 199 (33%) MSM reported any UAI. BI, including safer sex advice, was offered to and accepted by 251/598 (42%) men. A low proportion of all MSM (52/251: 21%) accepted a structured one-to-one BI as recommended by national guidance and uptake was still low among higher risk MSM (29/107: 27%). 92% (552/598) of men had one or more HIV test over a 1-year period. Conclusions In 2010, the number of HIV tests performed met the national minimum standard but structured behavioural interventions were being offered to and accepted by only a small proportion of MSM, including those at a higher risk of infection. Reasons for not offering behavioural interventions to higher risk MSM, whether due to patient choice, a lack of staff training or resource shortage, need to be investigated and addressed.

British Association for Sexual Health and HIV: framework for guideline development and assessment.

Summary The Clinical Effectiveness Group of the British Association for Sexual Health has updated their methodology for the production of national guidelines for the management of sexually transmitted infections and related conditions. The main changes are the adoption of the GRADE system for assessing evidence and making recommendations and the introduction of a specific Conflict of Interests policy for Clinical Effectiveness Group members and guideline authors. This new methodology has been piloted during the production of the 2015 British Association for Sexual Health & HIV guideline on the management of syphilis.

Adherence to antiretroviral therapy in pregnancy

Successful interventions to prevent congenital HIV require adherence to highly active antiretroviral therapy (HAART) in pregnancy from mothers and agreement with other interventions including mode of delivery and infant testing. We sought to audit adherence support offered antenatally, adherence with HAART, recommendations for delivery and infant testing in women receiving HIV care at our unit and delivering a child in 2004 and 2005. Of the 32 women identified, an adherence discussion was conducted when commencing therapy in 87% and subsequent visits in 77%. Five women were non-adherent with HAART, one disagreed with recommendations for delivery, and attendance at initial post-natal tests was documented in 61%. In general, the British HIV Association guidelines with regard to adherence are followed. Although numbers in this cohort are small, age, ethnicity and pre-pregnancy HIV diagnosis did not seem to affect adherence, but being therapy naïve and poor adherence may predict non-attendance at infant follow-up.

Real-world persistence with antiretroviral therapy for HIV in the United Kingdom: A multicentre retrospective cohort study

Summary Objectives Persistence with an antiretroviral therapy (ART) regimen for HIV can be defined as the length of time a patient remains on therapy before stopping or switching. We aimed to describe ART persistence in treatment naïve patients starting therapy in the United Kingdom, and to describe differential persistence by treatment regimen. Methods We performed a retrospective cohort study at eight UK centres of ART-naïve adults commencing ART between 2012 and 2015. Aggregate data were extracted from local treatment databases. Time to discontinuation was compared for different third agents and NRTI backbones using incidence rates. Results 1949 patients contributed data to the analysis. Rate of third agent change was 28 per 100 person-years of follow up [95% CI 26–31] and NRTI backbone change of 15 per 100 person-years of follow up [95% CI 14–17]). Rilpivirine, as co-formulated rilpivirine/tenofovir/emtricitabine had a significantly lower discontinuation rate than all other third agents and, excluding single tablet regimens, co-formulated tenofovir/emtricitabine had a significantly lower discontinuation rate than co-formulated abacavir/lamivudine. The reasons for discontinuation were not well recorded. Conclusions Treatment discontinuation is not an uncommon event. Rilpivirine had a significantly lower discontinuation rate than other third agents and tenofovir/emtricitabine a lower rate than co-formulated abacavir/lamivudine.

The laboratory diagnosis of common genital viral infections

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A multidisciplinary, multi-agency approach to a young person's sexual health clinic

Manchester Centre for Sexual Health (MCSH) and Brook Manchester submitted a successful joint bid for genitourinary medicine (GUM) development pilot funding in 2004 to set up a dedicated young persons clinic (YPC) at MCSH and establish a nurse practitioner post developing sexual health services at Brook with support from MCSH. The YPC at MCSH commenced in April 2005. An upper age limit of 19 years was set; those under 16 years are assessed by a health advisor and senior doctor using a young persons proforma and in accordance with the Fraser Guidelines (a process agreed by the Trust child protection lead). The YPC runs from 3.30 pm to 6.30 pm as a drop-in service accepting patients up to 5.30 pm. A full sexually transmitted infection (STI) screening service is provided and contraception offered when required. The number of patients seen at the clinic has risen steadily since it opened with 1018 visits (790 of these new episodes) in the year April 2005-April 2006. The majority of patients are female (74% of attendances) and the average age is 18.6 years. STIs are frequently diagnosed with a diagnosis of chlamydial infection being made in 16% of cases and genital warts in 9%. (excerpt)

The laboratory diagnosis of gonorrhoea and syphilis infection

Following a decline in prevalence during the 1980s and early 1990s, gonorrhoea and syphilis infections are once again posing a threat to public health. In addition, the antibiotic sensitivity pattern for gonorrhoea appears to have changed with an increased prevalence of resistance. Both syphilis and gonorrhoea appear to disproportionately affect MSM and black ethnic minorities, and are concentrated in urban areas. Their diagnosis requires microbiological tests to be performed appropriately, and a rapid diagnosis can often be provided in GUM clinics using near-patient microscopy. Early diagnosis and effective, rapid treatment is crucial in limiting the morbidity for the affected individual and the public health risks resulting from the spread of infection.

2018 UK national guideline for the management of donovanosis

The objective of this guideline is to provide guidance for the diagnosis and management of donovanosis, a now rare sexually transmitted infection. This guidance is primarily for professionals working in UK Sexual Health services (although others may find it useful) and refers to the management of individuals presenting with possible symptoms of donovanosis who are over the age of 16. An updated literature review since the last Clinical Effectiveness Group (CEG) guideline produced for this condition in 2011 has shown few new developments. Most reports in the literature relate to cases of unusual presentations of the condition.

How to manage children with anogenital warts

Children found to have anogenital warts (AGW) are usually brought in the first instance to their general practitioners (GPs), who may assess and manage the children themselves or refer them onto a specialist from one of several disciplines including paediatricians, dermatologists, paediatric surgeons or genitourinary medicine (GUM) physicians. In addition, if child sexual abuse (CSA) is considered advice may be sought from a sexual assault referral centre (SARC), and if so referral to childrens social care and police would be advised. The authors have all been contacted for advice regarding the management of these children and we have noted: To streamline this process, provide a framework for safeguarding evaluation and to ensure that all children are appropriately assessed, we developed a clinical algorithm for clinicians in any field supported by an appendix on sampling for STI screening for those less familiar with this. 1. We reviewed the relevant specialty guidance on the management of STIs in children from: 1. The British Association for Sexual Health and HIV (BASHH)1 2. The physical signs of CSA publication from the Royal College of Paediatric and Child Health2 2. We canvassed the opinion of other doctors in our specialties of GUM, paediatrics and forensic medicine, including the lead authors of the BASHH guideline, by face-to-face meetings, email and telephone conversations. 3. The initial draft of the clinical algorithm evolved empirically with …

Retrospective analysis of the associations and effectiveness of performing therapeutic drug monitoring in pregnant HIV-positive women in two large centres in Manchester

There is no proven benefit for the routine use of therapeutic drug monitoring in HIV-positive pregnant women either for improving viral control or preventing mother-to-child transmission. This analysis reviewed a cohort of 171 HIV-positive pregnant women delivering between 1 January 2008 and 28 May 2013 to first establish which baseline characteristics are associated with having therapeutic drug monitoring performed, and whether therapeutic drug monitoring was associated with improved HIV control during pregnancy or mother-to-child transmission. Therapeutic drug monitoring was performed in 39% (n = 66) of patients; it was associated with baseline characteristics of poor adherence to therapy (therapeutic drug monitoring 23% versus non-therapeutic drug monitoring 10%, p = 0.025) and the use of protease inhibitors (therapeutic drug monitoring 94% versus non-therapeutic drug monitoring 77%, p = 0.005). By multivariate analysis therapeutic drug monitoring was associated with medication alterations during pregnancy (therapeutic drug monitoring 68% versus non-therapeutic drug monitoring 12%, p = < 0.001), but not associated with any difference in viral load breakthrough during pregnancy (therapeutic drug monitoring 12% versus non-therapeutic drug monitoring 7%, p = 0.456) and viral load detectable at birth (therapeutic drug monitoring 14% versus non-therapeutic drug monitoring 9%, p = 0.503). There were no instances of mother-to-child transmission. Therapeutic drug monitoring’s association with medication changes is postulated as partially causal in this cohort. There was no evidence of any association with improved control or reduced transmission of HIV to advocate routine therapeutic drug monitoring use.