N Macdonald

Lymphogranuloma venereum in the United kingdom.

BACKGROUND Over the past 2 years, lymphogranuloma venereum (LGV), caused by L serovars of Chlamydia trachomatis, has emerged as a significant problem among men who have sex with men (MSM). We report on, to our knowledge, the largest case series of LGV to date, with detailed epidemiological and clinical characteristics of the epidemic in the United Kingdom. METHODS A national diagnostic service and surveillance system was established in October 2004. Cases were confirmed by the presence of C. trachomatis and an LGV serovar (L1, L2, or L3) from genotyping. For confirmed cases, an enhanced surveillance questionnaire was sent to the clinician. RESULTS Through February 2006, a total of 327 cases of LGV were confirmed. Cases were diagnosed across the United Kingdom, with the majority from London (71%) and Brighton (13%). Case reports were received for 282 MSM. The majority (96%) had proctitis, many with severe local and systemic symptoms. There was a high level of coinfection with human immunodeficiency virus (76%), hepatitis C (19%), and other sexually transmitted infections (39%). Nine cases of human immunodeficiency virus infection were diagnosed around the same time as LGV. Most cases were acquired within the United Kingdom, although patients with early cases were more likely to report contacts in The Netherlands. CONCLUSIONS We found a significant burden of this once-rare sexually transmitted infection among MSM in the United Kingdom. LGV may be contributing to the epidemic of human immunodeficiency virus infection by facilitating transmission. Further control efforts are required, including awareness campaigns, continued detailed surveillance, and expanded chlamydia testing among MSM.

Reductions in HIV transmission risk behaviour following diagnosis of primary HIV infection: a cohort of high-risk men who have sex with men.

Risk‐reduction counselling is a standard preventive intervention, but behaviour change is difficult to sustain over the duration of HIV infection. However, primary HIV infection (PHI) is highly infectious and plays a key role in transmission – especially through dense sexual networks – but is short term, so even transient risk reduction can mitigate its high infectivity. Targeting behaviour‐change interventions at recently infected individuals may be highly effective, particularly in higher risk groups. We explored the potential impact on HIV transmission‐risk behaviour of PHI diagnosis in men who have sex with men (MSM).

Recent trends in diagnoses of HIV and other sexually transmitted infections in England and Wales among men who have sex with men

Objectives: To examine trends in rates of diagnoses of HIV and other sexually transmitted infections (STIs) in men who have sex with men (MSM) in England and Wales between 1997 and 2002. Methods: Estimates of the MSM population living in England and Wales, London and the rest of England and Wales were applied to surveillance data, providing rates of diagnoses of HIV and STIs and age group specific rates for HIV and uncomplicated gonorrhoea. Results: Between 1997 and 2002, rates of diagnoses of HIV and acute STIs in MSM increased substantially. Rates in London were higher than elsewhere. Rises in acute STIs were similar throughout England and Wales, except for uncomplicated gonorrhoea and infectious syphilis, with greater increases outside London. Rates of gonorrhoea diagnoses doubled between 1999 and 2001 (661/100 000, 1271/100 000, p<0.001) in England and Wales followed by a slight decline to 1210/100 000 (p = 0.03) in 2002—primarily the result of a decline in diagnoses among men aged 25–34 (1340/100 000, 1128/100 000, p<0.001) and 35–44 (924/100 000, 863/100 000, p = 0.03) in London. HIV was the third most common STI diagnosed in MSM in England and Wales and the second in London, with the highest rate (1286/100 000) found among men aged 35–44 in London in 2002. Conclusions: Rates of diagnosis of HIV and other STIs have increased substantially among MSM in England and Wales. Increases show heterogeneity by infection, geography, and age over time. Rates in London were twice those seen elsewhere, with greatest changes over time. The observed changes reflect concomitant increases in high risk behaviour documented in behavioural surveillance survey programmes.

Factors associated with HIV seroconversion in gay men in England at the start of the 21st century

Objectives: To detect and quantify current risk factors for HIV seroconversion among gay men seeking repeat tests at sexual health clinics. Design: Unmatched case control study conducted in London, Brighton and Manchester, UK. Methods: 75 cases (recent HIV positive test following a negative test within the past 2 years) and 157 controls (recent HIV negative test following a previous negative test within the past 2 years) completed a computer-assisted self interview focused on sexual behaviour and lifestyle between HIV tests. Results: Cases and controls were similar in socio-demographics, years since commencing sex with men, lifetime number of HIV tests, reasons for seeking their previous HIV tests and the interval between last HIV tests (mean = 10.5 months). Risk factors between tests included unprotected receptive anal intercourse (URAI) with partners not believed to be HIV negative (adjusted odds ratio (AOR) and 95% confidence interval 4.1, 1.8 to 9.3), where increased risk was associated with concomitant use of nitrite inhalants, receiving ejaculate and increasing numbers of partners. Independent risk was also detected for unprotected insertive anal intercourse (UIAI) with more than one man (AOR 2.7, 1.3 to 5.5) and use of nitrite inhalants (AOR 2.4, 1.1 to 5.2). Conclusions: HIV serodiscordant unprotected anal intercourse remains the primary context for HIV transmission among gay men, with increased risk associated with being the receptive partner, receiving ejaculate and use of nitrite inhalants. Although the HIV transmission risk of URAI is widely acknowledged, this study highlights the risk of UIAI and that nitrite inhalants may be an important facilitator of transmission when HIV exposure occurs.

Lymphogranuloma venereum in the United Kingdom

First cases reported from enhanced surveillance Until 2003 lymphogranuloma venereum (LGV), a disease caused by the more invasive L serovars of Chlamydia trachomatis , was considered a rare disease outside resource poor countries. Since then it has emerged as a significant problem among men who have sex with men (MSM) in Europe. In 2003 an outbreak of LGV was recognised in Rotterdam in the Netherlands.1 More than 100 men have been reported in this outbreak, most of whom were HIV positive and many had concomitant sexually transmitted infections including hepatitis C infection. Although many reported unprotected anal sex as a risk factor for acquisition of LGV, fisting and the sharing of sex toys also appeared as possible routes of transmission. Almost all presented with proctitis and symptoms included rectal pain, discharge, tenesmus, and other signs of lower gastrointestinal inflammation including constipation and abdominal pain. Some reported systemic symptoms such as fever and malaise. Genital and inguinal symptoms were rare with only one patient presenting with inguinal lymphadenopathy. Since that report similar outbreaks have been …

There is such a thing as asking for trouble: taking rapid HIV testing to gay venues is fraught with challenges.

Objectives: To explore the feasibility and acceptability of offering rapid HIV testing to men who have sex with men in gay social venues. Methods: Qualitative study with in-depth interviews and focus group discussions. Interview transcripts were analysed for recurrent themes. 24 respondents participated in the study. Six gay venue owners, four gay service users and one service provider took part in in-depth interviews. Focus groups were conducted with eight members of a rapid HIV testing clinic staff and five positive gay men. Results: Respondents had strong concerns about confidentiality and privacy, and many felt that HIV testing was “too serious” an event to be undertaken in social venues. Many also voiced concerns about issues relating to post-test support and behaviour, and clinical standards. Venue owners also discussed the potential negative impact of HIV testing on social venues. Conclusion: There are currently substantial barriers to offering rapid HIV tests to men who have sex with men in social venues. Further work to enhance acceptability must consider ways of increasing the confidentiality and professionalism of testing services, designing appropriate pre-discussion and post-discussion protocols, evaluating different models of service delivery, and considering their cost-effectiveness in relation to existing services.

Risky sexual behaviour in context: qualitative results from an investigation into risk factors for seroconversion among gay men who test for HIV

Objectives: The INSIGHT case-control study confirmed that HIV serodiscordant unprotected anal intercourse (SdUAI) remains the primary risk factor for HIV infection in gay men in England. This paper uses qualitative follow-up data to examine the contexts of SdUAI and other risk factors among the case-control study participants. Methods: In-depth interviews were conducted with 26 recent HIV seroconverters and 22 non-converters. Purposive selection was used to provide diversity in demographics and sexual behaviour and to facilitate exploration of risk factors identified in the case-control study. Results: Condoms were perceived as barriers to intimacy, trust and spontaneity. The potential consequences of the loss of these were traded off against the consequences of HIV infection. Previous negative HIV tests and the adoption of risk reduction strategies diminished the perceived threat of HIV infection, supporting beliefs that HIV was something that happened to others. Depression and low self-esteem, often combined with use of alcohol or other drugs, led to further risk taking and loss of control over risk reduction strategies. Conclusions: A range of psychosocial reasons led some men to engage in UAI with serodiscordant or unknown partners, despite high levels of risk awareness. Men in their mid-life, those in serodiscordant relationships and men that had experienced bereavement or other significant, negative, life events revealed factors related to these circumstances that contributed to increases in risky UAI. A diverse portfolio of interventions is required to build confidence and control over safer sex practices that are responsive to gay men’s wider emotional needs.

Risk factors for rectal lymphogranuloma venereum in gay men: results of a multicentre case-control study in the UK

Objective To identify risk factors for rectal lymphogranuloma venereum (rLGV) in men who have sex with men (MSM). Design A case-control study at 6 UK hospitals compared MSM with rLGV (cases) with rLGV-negative controls: MSM without potential rLGV symptoms (CGa) and separately, MSM with such symptoms (CGs). Methods Between 2008 and 2010, there were 90 rLGV cases, 74 CGa and 69 CGs recruited. Lifestyles and sexual behaviours in the previous 3 months were reported using internet-based computer-assisted self-interviews. Logistic regression was used to investigate factors associated with rLGV. Results Cases were significantly more likely to be HIV-positive (89%) compared with CGa (46%) and CGs (64%). Independent behavioural risks for rLGV were: unprotected receptive anal intercourse (adjusted OR (AOR)10.7, 95% CI 3.5 to 32.8), fisting another (AOR=6.7, CI 1.8 to 25.3), sex under the influence of gamma-hydroxybutyrate (AOR=3.1, CI 1.3 to 7.4) and anonymous sexual contacts (AOR=2.7, CI 1.2 to 6.3), compared with CGa; unprotected insertive anal intercourse (AOR=4.7, CI 2.0 to 10.9) and rectal douching (AOR=2.9 CI 1.3 to 6.6), compared with CGs. An incubation period from exposure to symptoms of 30 days was indicated. Conclusions Unprotected receptive anal intercourse is a key risk factor for rectal LGV with the likelihood that rectal-to-rectal transmission is facilitated where insertive anal sex also occurs. The association between HIV and rLGV appears linked to HIV-positive men seeking unprotected sex with others with the same HIV status, sexual and drug interests. Such men should be targeted for frequent STI screening and interventions to minimise associated risks.

Diagnosis of lymphogranuloma venereum from biopsy samples

The Health Protection Agency Centre for Infections launched an alert in October 2004 to improve the awareness, diagnosis, and control of lymphogranuloma venereum (LGV), a sexually transmitted chlamydial infection, following a series of outbreaks in Western Europe.1 To date (9/3/2006), 334 cases of LGV have been diagnosed in 334 men. The case definition for a confirmed case of LGV is the presence of C trachomatis specific DNA, using two nucleic acid amplification tests (NAATs) with different primers, of serovars L1, L2, or L3, determined by genotyping (http://www.hpa.org.uk/infections/topics\_az/hiv\_and_sti/LGV/lgv.htm). All cases of LGV to date in the UK have been in men who have sex with men and typically present with proctitis and/or inguinal lymphadenopathy. Some of the men in the UK diagnosed with LGV reported long duration of symptoms presenting to gastroenterologists and having been wrongly diagnosed with inflammatory …

Clinical predictors of rectal lymphogranuloma venereum infection: results from a multicentre case–control study in the UK

Objective Since 2003, over 2000 cases of lymphogranuloma venereum (LGV) have been diagnosed in the UK in men who have sex with men (MSM). Most cases present with proctitis, but there are limited data on how to differentiate clinically between LGV and other pathology. We analysed the clinical presentations of rectal LGV in MSM to identify clinical characteristics predictive of LGV proctitis and produced a clinical prediction model. Design A prospective multicentre case–control study was conducted at six UK hospitals from 2008 to 2010. Cases of rectal LGV were compared with controls with rectal symptoms but without LGV. Methods Data from 98 LGV cases and 81 controls were collected from patients and clinicians using computer-assisted self-interviews and clinical report forms. Univariate and multivariate logistic regression was used to compare symptoms and signs. Clinical prediction models for LGV were compared using receiver operating curves. Results Tenesmus, constipation, anal discharge and weight loss were significantly more common in cases than controls. In multivariate analysis, tenesmus and constipation alone were suggestive of LGV (OR 2.98, 95% CI 0.99 to 8.98 and 2.87, 95% CI 1.01 to 8.15, respectively) and that tenesmus alone or in combination with constipation was a significant predictor of LGV (OR 6.97, 95% CI 2.71 to 17.92). The best clinical prediction was having one or more of tenesmus, constipation and exudate on proctoscopy, with a sensitivity of 77% and specificity of 65%. Conclusions This study indicates that tenesmus alone or in combination with constipation makes a diagnosis of LGV in MSM presenting with rectal symptoms more likely.