Rebecca Metcalfe

Don't ask, sometimes tell. A survey of men who have sex with men sexual orientation disclosure in general practice.

Despite advances in lesbian, gay, bisexual and transgender equality in recent years, some men who have sex with men remain at increased risk of ill-health. Positive interventions in primary care include psychological support and strategies for risk reduction. It is important that men who have sex with men can disclose sexual orientation in primary care. To quantify disclosure of sexual orientation by men who have sex with men attending general practice and identify barriers to disclosure we surveyed a group of Scottish men. A questionnaire was distributed by voluntary organisations and the National Health Service in the West of Scotland, to rural and urban populations. Two hundred and four gave evaluable responses, with all ages represented. A total of 199 (98%) were registered with a General Practitioner and 167 (83%) attended in the previous year. A total of 81 (40%) stated staff were aware of their sexual orientation. A total of 93/121 (75%) men who have sex with men whose GP was unaware stated this was because they had never been asked. A total of 36/81(44%) men who have sex with men rated support from practices since disclosure as ‘excellent’ and qualitative responses were positive. It is reassuring that almost all respondents were registered with GPs and attending primary care services. However, only 40% had disclosed sexual orientation. This was not because of fear of negative impact on care but because men who have sex with men felt it was irrelevant to their attendance. GPs appear to be reluctant to raise the issue of sexual orientation without prompting.

Gaining Insights from Candida Biofilm Heterogeneity: One Size Does Not Fit All

Despite their clinical significance and substantial human health burden, fungal infections remain relatively under-appreciated. The widespread overuse of antibiotics and the increasing requirement for indwelling medical devices provides an opportunistic potential for the overgrowth and colonization of pathogenic Candida species on both biological and inert substrates. Indeed, it is now widely recognized that biofilms are a highly important part of their virulence repertoire. Candida albicans is regarded as the primary fungal biofilm forming species, yet there is also increasing interest and growing body of evidence for non-Candida albicans species (NCAS) biofilms, and interkingdom biofilm interactions. C. albicans biofilms are heterogeneous structures by definition, existing as three-dimensional populations of yeast, pseudo-hyphae, and hyphae, embedded within a self-produced extracellular matrix. Classical molecular approaches, driven by extensive studies of laboratory strains and mutants, have enhanced our knowledge and understanding of how these complex communities develop, thrive, and cause host-mediated damage. Yet our clinical observations tell a different story, with differential patient responses potentially due to inherent biological heterogeneity from specific clinical isolates associated with their infections. This review explores some of the recent advances made in an attempt to explore the importance of working with clinical isolates, and what this has taught us.

Biofilms Formed by Isolates from Recurrent Vulvovaginal Candidiasis Patients Are Heterogeneous and Insensitive to Fluconazole

ABSTRACT Vulvovaginal candidiasis (VVC) is a global health problem affecting ∼75% of women at least once in their lifetime. Here we examined the epidemiology of VVC in a patient cohort to identify the causative organisms associated with VVC. Biofilm-forming capacity and antifungal sensitivity profiles were also assessed. We report a shifting prevalence of Candida species with heterogeneous biofilm-forming capacity, which is associated with altered antifungal drug sensitivity.

Has the introduction of HIV pre-exposure prophylaxis had an impact on HIV post-exposure prophylaxis for sexual exposure prescriptions in men who have sex with men in the UK’s largest health board?

In April 2017, the Scottish Medicine Consortium approved emtricitabine/tenofovir disoproxil for use as HIV pre-exposure prophylaxis (PrEP), in combination with safer sex practices.1 National Health Service (NHS) Greater Glasgow and Clyde (GG&C) provides healthcare to >1.2 million people, with a prevalence of HIV in men who have sex with men (MSM) of 5.4%.2 HIV post-exposure prophylaxis for sexual exposure (PEPSE) is available at Sexual Health services …

P052 Using modern technology to improve the management of initial presentation of herpes simplex virus infection – communication with patients and delivering pcr results

Introduction The first presentation of Herpes Simplex Virus (HSV) may be distressing, with severe symptoms and associated stigma pertaining to the diagnosis. Initial audit confirmed clinic staff were inconsistent with how the initial clinical diagnosis was relayed to patients, the amount of information given and how follow up and PCR test results would be provided. Best practice dictates that detailed information and uncertainties around diagnosis should be communicated. Methods Staff training was delivered using workshop style sessions and local protocol changed to highlight ‘10 key points’ to be communicated. An SMS used to deliver positive HSV PCR results was changed to include a bitlink to clinic website ‘Genital Herpes’ page and link to BASHH patient information leaflet. The automated results line was changed for PCR negative results, providing information for follow up if symptoms remained. A GP letter was created for PCR positives. Results Audit cycles were comparable in gender, age distribution, HSV type and PCR negativity rate. There was a significant improvement in the number of patients who received written information (p=0.0043), discussion on PCR sensitivity (p<0.0001), discussion on disclosure (p<0.0001) and significant reduction positive PCR results with no record of result being given (p=0.0091). There number of patients requiring follow up appointment for same episode of HSV did not change. Discussion Using modern technology can improve communication of important information to the patient and ensure the patient receives the result appropriately. Altering electronic resources can give more information and provide a back up when the diagnosis is unclear.

P153 Using information technology to improve linkage into sexual health care in patients receiving hiv post exposure prophylaxis for sexual exposure (PEPSE) in emergency departments

Introduction HIV PEPSE should be commenced within 72 hours (ideally 24) after possible exposure to HIV. Patient education on PEPSE includes advice on attendance at Emergency Department (ED) if outside opening hours of local sexual health services (SHS). Our healthboard serves a population of 1.2 million with four EDs. An initial four month audit revealed 12 patients who received a 5-day starter pack of PEPSE at ED and no communication between departments; patients were told to self-refer to SHS. We recognised there was no robust mechanism to ensure these high risk patients were not lost to follow up (LTFU). HIV testing at baseline was also poor in this setting, highlighting importance of linkage into SHS. Methods HIV PEPSE 5 day pack leaflets were altered to ask the dispensing clinican to refer patient via secure email or telephone message to the sexual health advisers. Results Prospective four month re-audit revealed 19 patients attended ED for PEPSE and all subsequently attended SHS for follow up(100%). 12/19(63%) were referred by email, 6/19(32%) via answering machine, 1/19(5%) self referred. 11/19(60%) reported unprotected receptive anal intercourse with someone from a high risk group. Discussion Following implementation of the email/telephone referral intervention, we found an increased number of patients received HIV PEPSE from EDs in the health board area and all were successfully linked into sexual health services. We cannot be sure that this increase is due to the prevention of patients being LTFU; other reasons include an increased awareness of PEPSE and where to obtain.

HIV diagnosis in older adults

It is recognised that those diagnosed with HIV infection over the age of 50 have higher rates of morbidity and mortality. Little is known about how clinical presentation at diagnosis of HIV varies within this group. We sought to compare clinical presentation and markers of outcome among those diagnosed with HIV aged 60 and over vs. those diagnosed aged 50–59, over a ten-year period. The results showed that 84/111 were diagnosed with HIV aged 50–59 and 27/111 aged ≥60. Ethnicity and HIV risk factors were similar between groups, and most infections were sexually acquired with 7.4% of those aged ≥60 suspected to have a recent infection. Median CD4 cell count at presentation was significantly lower in the ≥60 age group (111 vs. 249; p < 0.001), and the proportion with a CD4 cell count <50 was also significantly lower in this population (33% vs. 15%; p = 0.04). In keeping with this, the frequency of AIDS-defining illness at diagnosis was higher in the ≥60 group (38% vs. 4%; p < 0.001). Co-morbidities were found in both groups, and 38% of those aged ≥60 at diagnosis were known to have since died compared to 4% of those aged 50–59 at diagnosis (p ≤ 0.01). Those aged ≥60 had lower CD4 cell counts at diagnosis and more AIDS-defining illnesses, highlighting the increased risk of poor outcomes in this group. The majority of infections were sexually acquired. More work is needed to understand survival in adults diagnosed with HIV at an older age and to consider those over 60 as a specific population worthy of further research.

An observational study of the impact of the 2014 XX Commonwealth Games on the sexual and reproductive health services in Glasgow, Scotland

Background: Large sporting events have raised concerns about the effect on the sexual and reproductive health (SRH) of visiting and resident populations to the host city and increased demand on SRH services. However, there is little evidence to support these concerns. The aim of this study is to investigate if the 2014 XX Commonwealth Games had an effect on the service demands of a Glasgow city-wide integrated SRH service. Methods: Electronic patient records, city-wide pharmacy data and case note review was used to assess aspects of SRH; this included overall attendance at integrated services, clinic and community emergency contraception prescriptions, victims of sexual assault, acute sexually transmissible infections (STIs), post exposure prophylaxis after sexual exposure (PEPSE) prescriptions, condom distribution and termination of pregnancy. Results: There was a significant decrease in core sexual health attendances, total acute STIs and emergency hormonal contraception prescriptions. There was no change in PEPSE prescriptions or the number of reported sexual assaults throughout the city. Conclusions: This study found no evidence that the 2014 XX Commonwealth Games placed any increased demand on the local SRH services, and showed no increase in STIs, emergency hormonal contraception prescriptions or sexual assaults. These findings will help service planning in host cities hosting future large sporting events.

A limp with an unusual cause.

A 41 year old Ghanaian man resident in the United Kingdom presented with a five hour history of pain and swelling of the right ankle, left wrist, and right middle finger. He felt generally unwell but had no other specific symptoms on systemic inquiry. He had just returned from a two week visit to Ghana. There was no medical history of note, he was taking no regular drugs, and he had no known drug allergies. The appropriate travel prophylaxis had been adhered to. He had had unprotected intercourse with a new female partner about 10 days ago. On examination, his temperature was 37.8°C. There was evidence of synovitis (joint swelling, redness, tenderness, and reduced range of movement) of the right ankle, left wrist, and the proximal interphalangeal joint of the middle finger of his right hand. Initial investigations confirmed that his neutrophil count, C reactive protein concentration, and erythrocyte sedimentation rate were raised. Radiographs of the affected joints showed soft tissue swelling but were otherwise normal. The pain did not ease with oral non-steroidal anti-inflammatory drugs and he was admitted to hospital. ### 1. What is the differential diagnosis? #### Answer The main differential diagnosis is between polyarticular septic arthritis and reactive arthritis. Other possibilities include seronegative inflammatory arthritis, connective tissue disorder, and polyarticular gout. #### Discussion Septic arthritis may be polyarticular, although this is less common than monoarticular septic presentations. Polyarticular septic arthritis is caused by the haematogenous spread of organisms to affected joints. Most cases are caused by Staphylococcus aureus or Streptococcus spp. Less common causes are Gram negative organisms such as Escherichia coli and Neisseria gonorrhoeae .1 2 Risk factors for septic arthritis include local factors such as pre-existing joint …