Noel Gill

Can Remote STI/HIV Testing and eClinical Care be Compatible with Robust Public Health Surveillance?

In this paper we outline the current data capture systems for human immunodeficiency virus (HIV) and sexually transmitted infection (STI) surveillance used by Public Health England (PHE), and how these will be affected by the introduction of novel testing platforms and changing patient pathways. We outline the Chlamydia Online Clinical Care Pathway (COCCP), developed as part of the Electronic Self-Testing for Sexually Transmitted Infections (eSTI2) Consortium, which ensures that surveillance data continue to be routinely collected and transmitted to PHE. We conclude that both novel diagnostic testing platforms and established data capture systems must be adaptable to ensure continued robust public health surveillance.

O4 Hiv incidence among people who attend sexual health clinics in england in 2012: estimates using a biomarker for recent infection

Introduction In England, 80% of HIV diagnoses are in sexually transmitted infection (STI) clinics. Since 2009, Public Health England offered testing for recent HIV infection. Aim To estimate HIV incidence among STI clinic attendees in 2012. Methods The AxSYM avidity assay, modified to determine antibody avidity, was conducted on aliquots of newly diagnosed persons and results linked to the national HIV database. An incident case was defined as avidity <0.8, no antiretroviral treatment or AIDS and viral load ≥400 copies/mL at diagnosis. The number of persons tested for HIV was assessed using the Genitourinary Medicine Clinic Activity Dataset. We estimated and adjusted for a 1.9% (95% C.I. 1.0%–3.4%) false recent rate and used 202 days as the mean duration of recent infection to calculate incidence rates. Results Of 212 STI clinics in England, 150(71%) submitted specimens for recent infection testing, comprising 3,930 persons newly diagnosed; 50% were MSM. The number of HIV tests/diagnosis was 210 for all clinic attendees, 38 for MSM, 403 for all heterosexuals and 46 for black African heterosexuals. HIV incidence was 0.15% (95% C.I. 0.13–0.18%) for all attendees, 1.22% (95% C.I. 1.07–1.42%) for MSM, 1.41% (95% C.I. 1.21%-1.66%) for MSM in London, 0.03% (95% C.I. 0.02–0.04%) for heterosexuals and 0.13% (0.05–0.22%) for black African heterosexuals. Discussion/conclusion Testing for recent HIV infection combined with routinely collected clinical data provides robust and timely national estimates of HIV incidence. HIV incidence among MSM and black African heterosexuals attending STI clinics was 40 and nine times higher respectively than among all heterosexuals, and exceeds the WHO-defined elimination threshold of 0.1%.

Establishing an enteric bacteria reference laboratory in Sierra Leone

In 2012, Sierra Leone experienced its worst cholera outbreak in over 15 years affecting 12 of the countrys 13 districts. With limited diagnostic capability, particularly in bacterial culture, the cholera outbreak was initially confirmed by microbiological testing of clinical specimens outside of Sierra Leone. During 2012 - 2013, in direct response to the lack of diagnostic microbiology facilities, and to assist in investigating and monitoring the cholera outbreak, diagnostic and reference services were established in Sierra Leone at the Central Public Health Reference Laboratory focusing specifically on isolating and identifying Vibrio cholerae and other enteric bacterial pathogens. Sierra Leone is now capable of confirming cholera cases by reference laboratory testing.

Factors associated with four atypical cases of congenital syphilis in England, 2016 to 2017: an ecological analysis

Four isolated cases of congenital syphilis born to mothers who screened syphilis negative in the first trimester were identified between March 2016 and January 2017 compared with three cases between 2010 and 2015. The mothers were United Kingdom-born and had no syphilis risk factors. Cases occurred in areas with recent increases in sexually-transmitted syphilis among women and men who have sex with men, some behaviourally bisexual, which may have facilitated bridging between sexual networks.

Mixing patterns of HIV transmission among men who have sex with men in the United Kingdom

Background Near 60% of new HIV infections in the United Kingdom are estimated to occur in men who have sex with men (MSM). Patterns of mixing between different risk groups of MSM have been suggested to spread the HIV epidemics through age-disassortative partnerships and to contribute to ethnic disparities in infection rates. Understanding these mixing patterns in transmission can help to determine which groups are at a greater risk and guide prevention. Methods We analyzed combined epidemiologic data and viral sequences from MSM diagnosed with HIV as of mid-2015 at the national level. We applied a phylodynamic source attribution model to infer patterns of transmission between groups of patients by age, ethnicity and region. Results From pair probabilities of transmission between 19 847 MSM patients, we found that potential transmitters of HIV subtype B were on average 5 months older than recipients. We also found a moderate overall assortativity of transmission by ethnic group and a stronger assortativity by region. Conclusions Our findings suggest that there is only a modest net flow of transmissions from older to young MSM in subtype B epidemics and that young MSM, both for Black or White groups, are more likely to be infected by one another than expected in a sexual network with random mixing.

Molecular Epidemiology of HIV-1 Subtype B Reveals Heterogeneous Transmission Risk: Implications for Intervention and Control

Young men who have sex with men (MSM) in the United Kingdom have greater risk of infection and higher risk of transmission to other young MSM, which has implications for design of pre-exposure prophylaxis public health initiatives.

Infectious disease testing of UK-bound refugees: a population-based, cross-sectional study

BackgroundThe UK, like a number of other countries, has a refugee resettlement programme. External factors, such as higher prevalence of infectious diseases in the country of origin and circumstances of travel, are likely to increase the infectious disease risk of refugees, but published data is scarce. The International Organization for Migration carries out and collates data on standardised pre-entry health assessments (HA), including testing for infectious diseases, on all UK refugee applicants as part of the resettlement programme. From this data, we report the yield of selected infectious diseases (tuberculosis (TB), HIV, syphilis, hepatitis B and hepatitis C) and key risk factors with the aim of informing public health policy.MethodsWe examined a large cohort of refugees (n = 18,418) who underwent a comprehensive pre-entry HA between March 2013 and August 2017. We calculated yields of infectious diseases stratified by nationality and compared these with published (mostly WHO) estimates. We assessed factors associated with case positivity in univariable and multivariable logistic regression analysis.ResultsThe number of refugees included in the analysis varied by disease (range 8506–9759). Overall yields were notably high for hepatitis B (188 cases; 2.04%, 95% CI 1.77–2.35%), while yields were below 1% for active TB (9 cases; 92 per 100,000, 48–177), HIV (31 cases; 0.4%, 0.3–0.5%), syphilis (23 cases; 0.24%, 0.15–0.36%) and hepatitis C (38 cases; 0.41%, 0.30–0.57%), and varied widely by nationality. In multivariable analysis, sub-Saharan African nationality was a risk factor for several infections (HIV: OR 51.72, 20.67–129.39; syphilis: OR 4.24, 1.21–24.82; hepatitis B: OR 4.37, 2.91–6.41). Hepatitis B (OR 2.23, 1.05–4.76) and hepatitis C (OR 5.19, 1.70–15.88) were associated with history of blood transfusion. Syphilis (OR 3.27, 1.07–9.95) was associated with history of torture, whereas HIV (OR 1521.54, 342.76–6754.23) and hepatitis B (OR 7.65, 2.33–25.18) were associated with sexually transmitted infection. Syphilis was associated with HIV (OR 10.27, 1.30–81.40).ConclusionsTesting refugees in an overseas setting through a systematic HA identified patients with a range of infectious diseases. Our results reflect similar patterns found in other programmes and indicate that the yields for infectious diseases vary by region and nationality. This information may help in designing a more targeted approach to testing, which has already started in the UK programme. Further work is needed to refine how best to identify infections in refugees, taking these factors into account.

P3.153 Spatial and temporal associations between congenital syphilis cases and epidemiological characteristics of infectious syphilis in england

Introduction There has been a rapid rise in infectious syphilis (IS) diagnoses in England since 2011 but congenital syphilis (CS) is rare. In 2016, 3 CS cases were diagnosed in geographically dispersed areas of England. Unusually, their mothers had tested negative at first trimester antenatal screen (screen-negative), indicating syphilis acquisition during pregnancy. Simulation modelling using historical CS cases indicated an event probability of 3%. We investigated the spatial and temporal relationship between screen-negative CS cases and IS epidemiology in the affected areas. Methods Data from 01/2011-06/2016 were obtained from GUMCADv2, the national electronic surveillance system. England was divided into 3 syphilis epidemiological areas (SEAs): wider incident areas (WIAs; the 3 affected and immediate surrounding counties); endemic areas (with established epidemics in men who have sex with men-MSM) and non-incident non-endemic areas (NINEAs). Time-series analysis (TSA) was used to estimate IS outliers by gender, sexual orientation and SEA. Associations between IS characteristics and SEA (WIAs vs. NINEAs) were assessed using Pearson’s chi-square and Kruskal-Wallis tests. Mothers of CS cases were excluded from analyses. Results In 2011–2016, IS rates/100,000 in WIAs rose in heterosexual women (1.3–3.0) and MSM (8.9–13.9) but fell in heterosexual men (3.7–3.0). In NINEAs, rates rose in heterosexual women (1.6–1.9), MSM (5.0–10.8) and heterosexual men (2.7–3.2). On TSA, IS cases significantly exceeded expected bounds in 2016 in heterosexual women in WIAs; no exceedance was seen in NINEAs. In 2016, heterosexual women with IS were more likely to be UK-born in WIAs than in NINEAs (78% vs. 39%; p<0.001). A greater proportion of MSM were bisexual in WIAs than in NINEAs (11% vs. 8%; p<0.001). Conclusion Increased syphilis transmission in some sexual networks of MSM and a higher proportion of bisexual men in WIAs may have created more opportunities for IS acquisition in women. Efforts to raise awareness of the potential risk of acquiring syphilis during pregnancy are needed.

O01 Recent trends in HIV diagnoses and tests among men who have sex with men attending sexual health clinics in england

Introduction Men who have sex with men (MSM) remain at highest risk of HIV acquisition in England. We assessed recent national trends in HIV diagnoses and tests among MSM attending specialist sexual health clinics (SHCs) in England. Methods Numbers of HIV diagnoses and tests in MSM were obtained from GUMCADv2, the national surveillance system for sexually transmitted infections. Trends were stratified by HIV testing history (new/repeat-testers in last 2 years) and service location (London/Outside-London). Student’s t-tests were used to assess the differences in mean numbers of HIV diagnoses and tests between Q4/2014–Q3/2015 and Q4/2015–Q3/2016. Results A decline in HIV diagnoses from 515 to 427 (17%) was observed between Q4/2014–Q3/2015 and Q4/2015–Q3/2016 (p=0.05). Greatest declines were in London SHCs (276–209; 24%; p=0.04) and among new-testers (390–308; 21%; p=0.03). In London SHCs, there was a 29% diagnosis decline among new-testers (195–138; p=0.03) with no evidence of a difference in repeat-testers (81–71; p=0.33); HIV tests in repeat-testers increased 15% (9,768–11,270; p=0.02) but remained stable among new-testers (7,166–6,638; p=0.28). In Outside-London SHCs, HIV diagnoses remained stable in new- (194–170; p=0.06) and repeat-testers (44–48; p=0.52) while HIV testing increased 14% in new- (7,679–8,734; p=0.05) and 16% in repeat-testers (7,423–8,602; p=0.02). Discussion HIV diagnoses among MSM have decreased despite overall increased testing at SHCs. Stable levels of testing in new-testers as well as scale-up of repeat-testing may be contributing to diagnosis declines by earlier identification of undiagnosed infections. Further investigation of treatment and prevention initiatives among new- and repeat-testers in London SHCs is necessary.