Peter Kirwan

Insidious risk of severe mycobacterium chimaera infection in cardiac surgery patients

Background. An urgent UK investigation was launched to assess risk of invasive Mycobacterium chimaera infection in cardiothoracic surgery and a possible association with cardiopulmonary bypass heater-cooler units following alerts in Switzerland and The Netherlands. Methods. Parallel investigations were pursued: (1) identification of cardiopulmonary bypass–associated M. chimaera infection through national laboratory and hospital admissions data linkage; (2) cohort study to assess patient risk; (3) microbiological and aerobiological investigations of heater-coolers in situ and under controlled laboratory conditions; and (4) whole-genome sequencing of clinical and environmental isolates. Results. Eighteen probable cases of cardiopulmonary bypass–associated M. chimaera infection were identified; all except one occurred in adults. Patients had undergone valve replacement in 11 hospitals between 2007 and 2015, a median of 19 months prior to onset (range, 3 months to 5 years). Risk to patients increased after 2010 from <0.2 to 1.65 per 10000 person-years in 2013, a 9-fold rise for infections within 2 years of surgery (rate ratio, 9.08 [95% CI, 1.81–87.76]). Endocarditis was the most common presentation (n = 11). To date, 9 patients have died. Investigations identified aerosol release through breaches in heater-cooler tanks. Mycobacterium chimaera and other pathogens were recovered from water and air samples. Phylogenetic analysis found close clustering of strains from probable cases. Conclusions. We identified low but escalating risk of severe M. chimaera infection associated with heater-coolers with cases in a quarter of cardiothoracic centers. Our investigations strengthen etiological evidence for the role of heater-coolers in transmission and raise the possibility of an ongoing, international point-source outbreak. Active management of heater-coolers and heightened clinical awareness are imperative given the consequences of infection.

Fall in new HIV diagnoses among men who have sex with men (MSM) at selected London sexual health clinics since early 2015: testing or treatment or pre-exposure prophylaxis (PrEP)?

Since October 2015 up to September 2016, HIV diagnoses fell by 32% compared with October 2014–September 2015 among men who have sex with men (MSM) attending selected London sexual health clinics. This coincided with high HIV testing volumes and rapid initiation of treatment on diagnosis. The fall was most apparent in new HIV testers. Intensified testing of high-risk populations, combined with immediately received anti-retroviral therapy and a pre-exposure prophylaxis (PrEP) programme, may make elimination of HIV achievable.

What is the overlap between HIV and shigellosis epidemics in England: further evidence of MSM transmission?

Background Evidence suggests that sexual transmission between men has replaced foreign travel as the predominant mode of Shigella transmission in England. However, sexuality and HIV status are not routinely recorded for laboratory-reported Shigella, and the role of HIV in the Shigella epidemic is not well understood. Methods The Modular Open Laboratory Information System containing all Shigella cases reported to Public Health England (PHE) and the PHE HIV and AIDS Reporting System holding all adults living with diagnosed HIV in England were matched using a combination of Soundex code, date of birth and gender. Results From 2004 to 2015, 88 664 patients were living with HIV, and 10 269 Shigella cases were reported in England; 9% (873/10 269) of Shigella cases were diagnosed with HIV, of which 93% (815/873) were in men. Shigella cases without reported travel history were more likely to be living with HIV than those who had travelled (14% (751/5427) vs 3% (134/4854); p<0.01). From 2004 to 2015, the incidence of Shigella in men with HIV rose from 47/100 000 to 226/100 000 (p<0.01) peaking in 2014 at 265/100 000, but remained low in women throughout the study period (0–24/100 000). Among Shigella cases without travel and with HIV, 91% (657/720) were men who have sex with men (MSM). HIV preceded Shigella diagnosis in 86% (610/720), and 65% (237/362) had an undetectable viral load (<50 copies/mL). Discussion We observed a sustained increase in the national rate of shigellosis in MSM with HIV, who may experience more serious clinical disease. Sexual history, HIV status and STI risk might require sensitive investigation in men presenting with gastroenteritis.

The people living with HIV stigma survey UK 2015: HIV-related sexual rejection and other experiences of stigma and discrimination among gay and heterosexual men

ABSTRACT We aim to understand the difference in stigma and discrimination, in particular sexual rejection, experienced between gay and heterosexual men living with HIV in the UK. The People Living with HIV StigmaSurvey UK 2015 recruited a convenience sample of persons with HIV through over 120 cross sector community organisations and 46 HIV clinics to complete an online survey. 1162 men completed the survey, 969 (83%) gay men and 193 (17%) heterosexual men, 92% were on antiretroviral therapy. Compared to heterosexual men, gay men were significantly more likely to report worrying about workplace treatment in relation to their HIV (21% vs. 11%), worrying about HIV-related sexual rejection (42% vs 21%), avoiding sex because of their HIV status (37% vs. 23%), and experiencing HIV-related sexual rejection (27% vs. 9%) in the past 12 months. In a multivariate logistic regression controlling for other sociodemographic factors, being gay was a predictor of reporting HIV-related sexual rejection in the past 12 months (aOR 2.17, CI 1.16, 4.02). Both gay and heterosexual men living with HIV experienced stigma and discrimination in the past 12 months, and this was higher for gay men in terms of HIV-related sexual rejection. Due to the high proportion of men reporting sexual rejection, greater awareness and education of the low risk of transmission of HIV among people on effective treatment is needed to reduce stigma and sexual prejudice towards people living with HIV.

Experiences of stigma and discrimination in social and healthcare settings among trans people living with HIV in the UK.

ABSTRACT The People Living with HIV StigmaSurvey UK 2015 was a community led national survey investigating experiences of people living with HIV in the UK in the past 12 months. Participants aged 18 and over were recruited through over 120 cross-sector community organisations and 46 HIV clinics to complete an anonymous online survey. Trans is an umbrella term which refers to individuals whose current gender identity is different to the gender they were assigned at birth. Trans participants self-identified via gender identity and gender at birth questions. Descriptive analyses of reported experiences in social and health care settings were conducted and multivariate logistic regression analyses were used to identify sociodemographic predictors of reporting being treated differently to non-HIV patients, and being delayed or refused healthcare treatment in the past 12 months. 31 out of 1576 participants (2%) identified as trans (19 trans women, 5 trans men, 2 gender queer/non-binary, 5 other). High levels of social stigma were reported for all participants, with trans participants significantly more likely to report worrying about verbal harassment (39% vs. 23%), and exclusion from family gatherings (23% vs. 9%) in the last 12 months, compared to cisgender participants. Furthermore, 10% of trans participants reported physical assault in the last 12 months, compared to 4% of cisgender participants. Identifying as trans was a predictor of reporting being treated differently to non-HIV patients (48% vs. 30%; aOR 2.61, CI 1.06, 6.42) and being delayed or refused healthcare (41% vs. 16%; aOR 4.58, CI 1.83, 11.44). Trans people living with HIV in the UK experience high levels of stigma and discrimination, including within healthcare settings, which is likely to impact upon health outcomes. Trans-specific education and awareness within healthcare settings could help to improve service provision for this demographic.

Towards elimination of HIV transmission, AIDS and HIV-related deaths in the UK

Our objective was to present recent trends in the UK HIV epidemic (2007–2016) and the public health response.

Injecting drug use predicts active tuberculosis in a national cohort of people living with HIV

Objectives: Tuberculosis (TB) is common in people living with HIV, leading to worse clinical outcomes including increased mortality. We investigated risk factors for developing TB following HIV diagnosis. Design: Adults aged at least 15 years first presenting to health services for HIV care in England, Wales or Northern Ireland from 2000 to 2014 were identified from national HIV surveillance data and linked to TB surveillance data. Methods: We calculated incidence rates for TB occurring more than 91 days after HIV diagnosis and investigated risk factors using multivariable Poisson regression. Results: A total of 95 003 adults diagnosed with HIV were followed for 635 591 person-years; overall incidence of TB was 344 per 100 000 person-years (95% confidence interval 330–359). TB incidence was high for people who acquired HIV through injecting drugs [PWID; men 876 (696–1104), women 605 (365–945)] and black Africans born in high TB incidence countries [644 (612–677)]. The adjusted incidence rate ratio for TB amongst PWID was 4.79 (3.35–6.85) for men and 6.18 (3.49–10.93) for women, compared with MSM. The adjusted incidence rate ratio for TB in black Africans from high-TB countries was 4.27 (3.42–5.33), compared with white UK-born individuals. Lower time-updated CD4+ cell count was associated with increased rates of TB. Conclusion: PWID had the greatest risk of TB; incidence rates were comparable with those in black Africans from high TB incidence countries. Most TB cases in PWID were UK-born, and likely acquired TB through transmission within the United Kingdom. Earlier HIV diagnosis and quicker initiation of antiretroviral therapy should reduce TB incidence in these populations.

HIV testing in persons diagnosed with hepatitis B and C

In the UK, an estimated 101 200 people are living with HIV, 13% of whom are unaware of their infection [1]. The first national guidelines for HIV testing published in 2008 recommended the universal offer of an HIV test in health care services for persons diagnosed with hepatitis B and C [2]. The latest National Institute for Health and Care Excellence (NICE) testing guidelines (released in December 2016) continue to recommend offering HIV tests to people with HIV indicator conditions, which include hepatitis B and hepatitis C, and in services treating people for hepatitis B and hepatitis C [3]. Using the Sentinel Surveillance of Blood Borne Virus Testing (SSBBV), linked to the national HIV and AIDS Reporting System (HARS), we investigated the extent to which the guidelines are being followed. HIV testing information was extracted from the SSBBV for all adults (≥ 15 years old) with a first positive test between 2010 and 2014 for hepatitis C virus (HCV) antibodies, indicative of being ever infected, or for hepatitis B virus (HBV) surface antigen. Persons tested within the SSBBV were matched, using deterministic and probabilistic methodologies, to the HARS, and persons identified as diagnosed with HIV infection prior to their hepatitis diagnosis were excluded. Persons testing HBV positive in antenatal services were also excluded, as women are routinely tested for HIV and HBV as part of the antenatal screening programme. Among persons who tested positive for HCV (32 114), 38.7% (12 429) were tested for HIV on the same day as their HCV test, 6.7% (2158) were tested in the following 6 months, and 54.6% (17 527) had no record of an HIV test during the 6-month period following their positive HCV test (Table 1). Among persons who tested positive for HBV (16 086), the corresponding figures were 34.8% (5593), 10.7% (1722) and 54.5% (8771). In persons who were HCV positive, HIV testing was less likely in older persons [adjusted odds ratio (aOR) per 10year increase 0.88; 95% confidence interval (CI) 0.86– 0.90] and in persons diagnosed in primary care (aOR: 0.6; 95% CI: 0.6–0.7) when compared with secondary care. In persons who were HBV positive, HIV testing was less likely in older persons (aOR per 10-year increase 0.94; 95% CI: 0.92–0.97), but more likely in men (aOR: 1.2;

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.