Sarika Desai

HIV incidence in men who have sex with men in England and Wales 2001–10: a nationwide population study

Summary Background Control of HIV transmission could be achievable through an expansion of HIV testing of at-risk populations together with ready access and adherence to antiretroviral therapy. To examine whether increases in testing rates and antiretroviral therapy coverage correspond to the control of HIV transmission, we estimated HIV incidence in men who have sex with men (MSM) in England and Wales since 2001. Methods A CD4-staged back-calculation model of HIV incidence was used to disentangle the competing contributions of time-varying rates of diagnosis and HIV incidence to observed HIV diagnoses. Estimated trends in time to diagnosis, incidence, and undiagnosed infection in MSM were interpreted against a backdrop of increased HIV testing rates and antiretroviral-therapy coverage over the period 2001–10. Findings The observed 3·7 fold expansion in HIV testing in MSM was mirrored by a decline in the estimated mean time-to-diagnosis interval from 4·0 years (95% credible interval [CrI] 3·8–4·2) in 2001 to 3·2 years (2·6–3·8) by the end of 2010. However, neither HIV incidence (2300–2500 annual infections) nor the number of undiagnosed HIV infections (7370, 95% CrI 6990–7800, in 2001, and 7690, 5460–10 580, in 2010) changed throughout the decade, despite an increase in antiretroviral uptake from 69% in 2001 to 80% in 2010. Interpretation CD4 cell counts at HIV diagnosis are fundamental to the production of robust estimates of incidence based on HIV diagnosis data. Improved frequency and targeting of HIV testing, as well as the introduction of ART at higher CD4 counts than is currently recommended, could begin a decline in HIV transmission among MSM in England and Wales. Funding UK Medical Research Council, UK Health Protection Agency.

Epidemiology of, and behavioural risk factors for, sexually transmitted human papillomavirus infection in men and women in Britain

Objectives Persistent infection with high-risk sexually transmitted human papillomaviruses (HR-HPVs) can lead to development of cervical and other cancers, while low-risk types (low-risk HPV) may cause genital warts. We explored the epidemiology of different HPV types in men and women and their association with demographic and behavioural variables. Methods We analysed data collected for the British National Survey of Sexual Attitudes and Lifestyles, a cross-sectional survey undertaken in 1999–2001. Half of all sexually experienced male and female respondents aged 18–44 years were invited to provide a urine sample. We tested 3123 stored urine samples using an in-house Luminex-based HPV genotyping system. Results HPV DNA was detected in 29.0% (95% CI 26.7% to 31.3%) of samples from women and 17.4% (95% CI 15.1% to 19.8%) from men. Any of 13 HR-HPV types was detected in 15.9% (95% CI 14.1% to 17.8%) of women and 9.6% (95% CI 8.0% to 11.6%) of men. HPV types 16/18 were found in 5.5% (95% CI 4.5% to 6.8%) of women and 3.0% (95% CI 2.1% to 4.3%) of men; and types 6/11 in 4.7% (95% CI 1.8% to 5.9%) of women and 2.2% (95% CI 1.5% to 3.1%) of men. In multivariate analysis, HR-HPV was associated with new partner numbers, in women with younger age, single status and partner concurrency, and in men with number of partners without using condom(s) and age at first intercourse. Conclusions HPV DNA was detectable in urine of a high proportion of the sexually active British population. In both genders, HR-HPV was strongly associated with risky sexual behaviour. The minority of HPV infections were of vaccine types. It is important to monitor HPV prevalence and type distribution following the introduction of vaccination of girls.

Genital warts and cost of care in England

Objectives To estimate the total number of cases of, and cost of care for, genital warts (GWs) in England, to inform economic evaluations of human papillomavirus vaccination. Methods The number of GW cases seen in general practices (GPs) and in genitourinary medicine (GUM) clinics was estimated using the General Practice Research Database and the GUM Clinic Activity Dataset. The overlap in care of cases in the two settings was estimated. The calculated costs of care in GP and hospitals were added to the costs of care in GUM clinics (estimated elsewhere) to estimate the cost of care for GWs in England. Results In England, in 2008, GP and GUM saw 80 531 new (157/100 000 population) and 68 259 recurrent (133/100 000 population) episodes, giving a total of 148 790 episodes of care of GWs (289/100 000 population). Seventy-three per cent of cases were seen only in GUM clinics, 22% were seen by a GP before being referred to GUM, and 5% by GPs only. Hospital care was given in 1.3% of cases and contributed 8% of the costs. The average cost of care per episode was £113, and the estimated annual cost of care in England was £16.8 million. Conclusions This study provides a fairly comprehensive measure of GW frequency and care in England. GWs exert a considerable impact on health services, a large proportion of which could be prevented through immunisation using the quadrivalent human papillomavirus vaccine.

Prevalence of human papillomavirus antibodies in males and females in England.

Background: Most studies of human papillomavirus (HPV) epidemiology have employed DNA testing, which measures current infections. Serum antibodies offer a longer-term marker of infection in individuals who seroconvert and can therefore provide additional information about the exposure of populations to HPV. Methods: Sera from a population-based sample of males and females aged 10 to 49 years, in England, were tested for type-specific HPV antibodies using a multiplexed competitive Luminex assay and previously defined cutoffs of 20, 16, 20, and 24 mMU mL−1 for HPV 6, 11, 16, and 18, respectively. Seropositivity and geometric mean titers of seropositives were analyzed by HPV type, gender, and age. Catalytic models were developed to explore potential effects of antibody waning over time and changing risk of infection by age-cohort. Results: Seroprevalence for HPV 6, 11, 16, and 18 was 16.4%, 5.7%, 14.7%, and 6.3%, respectively, among females and 7.6%, 2.2%, 5.0%, and 2.0%, respectively, among males. Seroprevalence in females was significantly higher than males (P < 0.001 for all types) and showed a decline in older ages that was not seen in males. There was no evidence of declining antibody titers with increasing age. Model results suggest that cohort effects mediated through changes in sexual behavior better explain the observed trend in seroprevalence than waning antibodies over time. Conclusions: Preimmunization HPV seroprevalence in England shows similar trends to reports from other developed countries. We find the lower seroprevalence in older females probably reflects changes in sexual behavior over the last few decades. This study provides baseline data to monitor the impact of the immunization programme.

Human papillomavirus vaccine coverage

1 Bach PB. Gardasil: from bench, to bedside, to blunder. Lancet 2010; 375: 963–64. 2 Department of Health. Annual HPV vaccine uptake in England: 2008/09. http://www.dh. gov.uk/prod_consum_dh/groups/dh_ digitalassets/@dh/@en/@ps/documents/ digitalasset/dh_111676.pdf (accessed March 29, 2010). 3 Centers for Disease Control and Prevention. Vaccination coverage among adolescents aged 13–17 years—United States, 2007. Morb Mortal Wkly Rep 2008; 57: 1100–03. 4 Roberts SA, Brabin L, Stretch R, et al. Human papillomavirus vaccination and social inequality: results from a prospective cohort study. Epidemiol Infect 2010; 25: 1–6. 5 NHS Cervical screening programme. Cervical screening programme 2008–09 data tables. http://www.ic.nhs.uk/statistics-and-datacollections/screening/cervical-screening/ cervical-screening-programme-england2008-09 (accessed March 29, 2010). 100

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.

O13 HIV incidence in an open national cohort of MSM attending GUM clinics in England

Background Endemic HIV transmission in men who have sex with men (MSM) is a major concern in England. Since 2008, a new national anonymised genitourinary medicine (GUM) clinic reporting system provides follow-up data on clinic attendees. Objective To calculate HIV seroconversion rates and identify predictors of acquisition in MSM clinic attendees to inform the development of further HIV prevention initiatives. Methods National cohort of MSM who tested HIV negative at a GUM clinic in England in 2009 and had a follow-up test within 1 year were included in these analyses. HIV seroconversion rates (per 100 person-years (py)) with 95% CI were calculated by subgroups and risk markers. HR with 95% CI are reported for significant (p<0.05) predictors of HIV seroconversion identified using Cox regression analyses. Population attributable risk was calculated to estimate the importance of each predictor for HIV infection. Results Among the 15 500 men who attended in 2009, there were 277 seroconversions, giving an overall incidence of 2.7/100 py (95% CI 2.4 to 3.1). Incidence was higher among MSM aged 35–49 years (3.4/100 py), of black ethnicity (4.1/100 py) and with a previous gonorrhoea or chlamydia infection (8.6/100 py and 9/100 py, respectively). In multivariable analysis, risk of acquiring HIV was higher among MSM with a previous gonorrhoea (HR: 2.4, 95% CI 1.4 to 4.1) or chlamydia infection (HR: 3.0, 95% CI 2.0 to 4.7) or who received treatment as a STI contact (HR: 1.8, 95% CI 1.1 to 2.9). Age predicted HIV acquisition in 30% of new infections and clinical risk markers from the previous year another 10%. Conclusions Annual HIV incidence among MSM re-attending GUM clinics is very high at almost 3%. None of the clinical risk factors were important predictors of HIV acquisition. Therefore more discriminatory behavioural information is required to identify MSM at higher risk of HIV and facilitate better triaging of HIV prevention measures in GUM clinics.

The geographic relationship between sexual health deprivation and the Index of Multiple Deprivation 2010: a comparison of two indices

OBJECTIVES To construct an Index of Sexual Health Deprivation (ISHD), examine its sensitivity, investigate the association between the ISHD and the Index of Multiple Deprivation 2010 (IMD2010), and interpret the observed geographic variation. METHODS The modified IMD method was informed by the IMD2010. Thirteen profiles relating to sexual health were selected and grouped into four domains. The observed profile values for each primary care trust (PCT) were smoothed and converted to a normal distribution before principal component analysis. Loadings were used to calculate profile weights. Domain scores were calculated by combining weighted profiles, which were combined to create the ISHD. A Bayesian approach acted as a comparator for the ISHD. RESULTS Substantial variation in sexual health deprivation was seen across strategic health authorities (SHA). The London SHA had the highest proportion of PCTs (61%) among the most deprived quartile, followed by North-West SHA (29%). More than half of PCTs in East of England (71%), South Central (56%) and South-West (50%) SHAs fell into the least deprived quartile. No PCTs within the East of England, South Central and South-West SHAs were in the most deprived quartile. Only 57% of PCTs were attributed to the same quartile of the ISHD as the IMD2010. The modified IMD method and the Bayesian approach produced consistent results. CONCLUSIONS The ISHD provides a robust picture of the geography of sexual health and shows a weak association with the IMD2010. It can be used to guide public health action to reduce the geographical gradient in sexual health inequality.

Linkage to HIV care following diagnosis in the WHO European Region: A systematic review and meta-analysis, 2006-2017

Background Timely linkage to care after HIV diagnosis is crucial as delayed access can result in poor patient outcomes. The aim of this systematic review was to synthesise the evidence to achieve a better understanding of what proportion of patients are linked to care and what factors impact linkage. Methods Systematic searches were run in six databases up to the end of February 2017. The grey literature was also reviewed. Inclusion criteria were: sample size ≥50 people (aged ≥15), from the WHO European Region, published 2006–2017 and in English. Linkage to care was defined as a patient seen for HIV care after diagnosis. Study selection, data extraction and quality assurance were performed by two independent reviewers. Random-effects meta-analysis was carried out to summarise linkage to care within three months of diagnosis. Results Twenty-four studies were included; 22 presented linkage to care data and seven examined factors for linkage. Linkage among 89,006 people in 19 countries was captured. Meta-analysis, restricted to 12 studies and measuring prompt linkage within three months, gave a pooled estimate of 85% (95% CI: 75%-93%). Prompt linkage was higher in studies including only people in care (94%; 95% CI: 91%-97%) than in those of all new diagnoses (71%; 95% CI: 50%-87%). Heterogeneity was high across and within strata (>99%). Factors associated with delaying or not linking to care included: acquiring HIV through heterosexual contact/injecting drug use, younger age at diagnosis, lower levels of education, feeling well at diagnosis and diagnosis outside an STI clinic. Conclusion Overall, linkage to care was high, though estimates were lower in studies with a high proportion of people who inject drugs. The high heterogeneity between studies made it challenging to synthesise findings. Studies should adopt a standardised definition with a three month cut-off to measure prompt linkage to care to ensure comparability.

P5.15 Preparing for prep: estimating the need for hiv pre-exposure prophylaxis among men who have sex with men using sexual health surveillance data in england

Introduction To inform public health planning for a large-scale PrEP trial in England, we estimated the need for HIV pre-exposure prophylaxis (PrEP) among men who have sex with men (MSM) attending sexual health clinics. Methods National STI surveillance data from the genitourinary medicine clinic activity dataset (GUMCADv2) were used to estimate the annual number of HIV-negative MSM who had a HIV test in the past year (which will be a criterion for accessing PrEP in England), for 2010–2015. To estimate the number and proportion of all MSM needing PrEP, we used bacterial STI diagnosis in the past year as a proxy for high-risk behaviour, and estimated HIV incidence (per 100 person-years) in both groups. We used these data to understand the likely geographical distribution of MSM who might need PrEP within the 152 English counties. Results The number of HIV-negative MSM attending sexual health clinics increased by 68% from 69 392 in 2010 to 1 16 546 in 2015, and the number of HIV-negative MSM with a prior HIV test nearly doubled from 14 643 to 29 023 in the same period. Among HIV-negative MSM with a prior HIV test, the number with a recorded bacterial STI (past year) increased from 4365 (30%) in 2010 to 10,276 (35%) in 2015 (33% on average). HIV incidence among MSM with a prior HIV test was 1.9 (95% CI 1.6–2.2) per 100py compared to 3.3 (2.7–4.0) per 100py in MSM with a prior HIV test and history of bacterial STI. The number of MSM in need of PrEP (according to bacterial STI history) was 200 men in 4% (6/152) of counties. Conclusion We estimated that the need for PrEP among MSM in England in 2015 might be around 10 000 individuals with an annual HIV incidence of 3%. Need for PrEP was highly concentrated; in most English counties, the number of MSM with a prior HIV test was small, and only 33% of these men might be clinically assessed as eligible for PrEP. These data illustrate how the population need for PrEP might be estimated in advance of a national trial, and will inform future evaluations at a population level.