Demand for pre-exposure prophylaxis for HIV and the impact on clinical services: Scottish men who have sex with men perspectives.

There is a lack of data on ability and willingness of men who have sex with men (MSM) to self-fund HIV pre-exposure prophylaxis (PrEP). We aimed to explore how many eligible (PROUD study criteria) men may want PrEP and how many lower-risk MSM would be willing and able to self-fund this intervention. A self-completed anonymous questionnaire was distributed to MSM populations attending services. Of 377 participants, 81.5% were aware of PrEP. Fifty-three (15.5 %) were eligible, of whom 43 (81%) were very/extremely likely to want it. Of those ineligible, 229 (80%) were aware of PrEP and 106 (37.3%) were very/extremely likely to want it. Of eligible respondents 23% would be willing and able to pay at least £50 a month for PrEP. Of ineligible respondents this proportion was 21%. Our survey revealed high levels of awareness, understanding and willingness to take PrEP among MSM at high and lower risk of HIV acquisition. It indicated that over 70% of high-risk men would be unwilling or unable to self-fund PrEP, should it not be available on the NHS. For lower-risk MSM we estimated that capacity requirements for monitoring self-funded PrEP will be 50% higher than numbers eligible for PrEP. These factors will need to be taken into account when planning services.

British Association for Sexual Health and HIV Scottish investigation 2010-2011: reasons for non-attendance in individuals lost to follow-up for HIV care for more than 12 months in Scotland.

As of 31 March 2011, 6696 HIV diagnoses had ever been reported in Scotland; of these, 1791 individuals had died, 3339 were attending specialist services, but the remainder had defaulted from specialist care; an investigation into their reasons for non-attendance, and the efforts of services to re-engage, was undertaken by British Association for Sexual Health and HIV Scottish branch using a web-based survey questionnaire. Twelve of the 13 Scottish HIV services returned information for 424 of 579 eligible cases; 112 of these 424 individuals were identified as genuine non-attendees. Findings indicate that the epidemiology of these non-attendees is similar to that of the whole Scottish HIV cohort. Three-quarters of individuals failed to attend a booked appointment following their last known attendance and very few attempts to contact non-attending individuals were successful. This survey has refocused attention on those lost to follow-up, while quality of the national data-set has improved, providing a clearer epidemiological picture of people living with HIV in Scotland.

Strongyloides stercoralis: highlighting an imported case of the neglected parasite.

Travel-related strongyloidiasis is described in an HIV-infected individual who previously tested positive for schistosomiasis. This report illustrates that a positive serological result for schistosomiasis may represent a co-infection but may potentially occur as a result of cross-reactivity. Routine testing for schistosomiasis but not for strongyloidiasis in HIV-infected individuals who have spent more than one month in sub-Saharan Africa is recommended in recent UK HIV care guidelines. Therefore we recommend that further consideration should be given to routine investigations for other parasites including Strongyloides species in these circumstances.

UK national guideline on safer sex advice.

This guideline provides evidence-based guidance on the content of safer sex advice and the provision of brief behaviour change interventions deliverable in genitourinary (GU) medicine clinics. Much of the advice is applicable to other healthcare settings including general practice and clinics providing HIV care. Advice on condom use and effectiveness, oral sex and other sexual practices, testing for sexually transmitted infections (STI) and partner reduction is provided. Advice specific to the transmission of HIV infection including seroadaptive behaviours and negotiated safety is also included. An accompanying review of the evidence supporting the guideline with a complete reference list is available online. A patient information leaflet based on the advice statements developed is also available through the BASHH website.

BASHH Scotland/Scottish HIV and AIDS group national audit 2009-2010: sexual health care for people living with HIV.

A national Scottish audit of 282 patients with HIV infection attending 11 clinics showed the following levels of performance against quality improvement Scotland Sexual Health Services Standards: syphilis serology was offered in the previous six months to 55% of patients (range: 12-97% of patients in individual clinics), sexual history documented within four weeks of initial HIV diagnosis in 67% (12-100%) and offer of tests for sexually transmitted infections (STIs) documented within four weeks of HIV diagnosis in 45% (4-96%). Considerable variation in performance exists between clinics. The audit prompted interventions to further improve the sexual health care of people living with HIV infection.

How many cases of chlamydial infection would we miss by not testing partners for infection?

Quality Improvement Scotland standards for sexual health services require that 0.64 contacts per case should be verified as having attended within 90 days of the first partner notification interview. Partner delivered therapy results in more patients being treated than when patients are given information for partners but removes the possibility of further cases of Chlamydia trachomatis being diagnosed through the tracing of secondary contacts. An audit was performed to estimate the impact of removing secondary contacts on the number of chlamydial infections identified in our service. Patients who were not known to be contacts of chlamydial infection were included. One hundred and twenty-seven index cases generated 189 contacts, of which 100 were confirmed as tested and treated. Sixty-four were C. trachomatis positive, who in turn generated 36 new contacts. Fourteen of these were positive. Secondary contact tracing identified 22-28% more cases of chlamydial infection in our service than if all partners were treated without testing.

Antiretroviral treatment roll-out in a resource-constrained setting: capitalizing on nursing resources in Botswana.

PROBLEM: As programmes to deliver antiretroviral therapy (ART) are implemented in resource-constrained settings, the problem becomes not how these programmes are going to be financed but who will be responsible for delivering and sustaining them. APPROACH: Physician-led models of HIV treatment and care that have evolved in industrialized countries are not replicable in settings with a high prevalence of HIV infection and limited access to medical staff. Therefore, models of care need to make better use of available human resources. LOCAL SETTING: Using Botswana as an example, we discuss how nurses are underutilized in long-term clinical management of patients requiring ART. RELEVANT CHANGES: We argue that for ART-delivery programmes to be sustainable, nurses will need to provide a level of clinical care for patients receiving this therapy, including prescribing ART and managing common adverse effects. LESSONS LEARNED: Practicalities involved in scaling up nurse-led models of ART delivery include overcoming political and professional barriers, identifying educational requirements, agreeing on the limitations of nursing practice, developing clear referral pathways between medical and nursing personnel, and developing mechanisms to monitor and supervise practice. Operational research is required to demonstrate that such models are safe, effective and sustainable.

Audit of Postal Test Kits in Edinburgh for Chlamydia trachomatis as an alternative to genitourinary medicine clinic attendance.

Our objective was to investigate whether Postal Test Kits (PTKs) for Chlamydia trachomatis in Edinburgh offer an alternative to genitourinary (GU) medicine clinic attendance. All PTKs returned in the Edinburgh area over a six-month period from August 2005 were audited. Data on age and previous access to GU medicine services were collected. Return rates of kits from various sources were calculated. In all, 799 kits were returned with 72 (9%) chlamydia prevalence, and 10% had previously attended a GU medicine clinic. The largest proportion of kits were used by the 16-29 years old age group. Return rates of kits varied with distribution point, with only 15% returned from GU medicine. PTKs appear to be targeting an appropriate high-risk age group and a population not otherwise accessing GU medicine clinics. However, return rates are low and kits do not offer an adequate alternative to GU medicine clinics.

How many sexually transmitted infections (STIs) will we miss?--an algorithm to assess risk factors for STI.

A self-administered algorithm for the assessment of symptoms of, and risk factors for, sexually transmitted infection (STI) was developed. The algorithm was applied retrospectively to all cases of STI other than chlamydia diagnosed over a one-year period, to estimate the risk of missing STI diagnoses by its introduction. Three hundred and eighty-nine cases were identified, of whom 81 (21%) were asymptomatic. Seven asymptomatic cases had no identifiable risk factors for infection and might potentially have been offered a postal testing kit for chlamydia rather than a full STI screen. We estimate that 1.8% of STIs diagnosed in the unit might be missed by the introduction of the algorithm.

Audit of treatment and contact-tracing rates in immediate (presumptive) versus delayed (polymerase chain reaction) diagnosis of chlamydial infection.

An audit of all cases of chlamydial infection diagnosed in men at the Edinburgh genitourinary (GU) medicine clinic over a six-month period from January 2003 is reported. In all, 189 men identified as requiring treatment for possible chlamydial infection on first attendance (because of contact with a partner with chlamydia or the diagnosis of non-gonococcal urethritis [NGU] on microscopy), who later proved chlamydia-positive by polymerase chain reaction (PCR), were compared with 83 men in whom infection was identified only on receipt of a PCR result. Treatment rates were 100% in the first group and 97.6% in the second group (chi(2) 0.046, P<0.05). In men presumptively diagnosed and treated, 88.6% of contacts identified were confirmed as traced, compared with 90% confirmed as traced in the group diagnosed by PCR alone. Our audit suggests that identifying men with chlamydial NGU by routine microscopy may carry a small but significant advantage in increasing treatment rates, but makes no difference to contact-tracing success rate.

Chlamydia trachomatis infection and non-gonococcal urethritis in homosexual and heterosexual men in Edinburgh.

In 1998, when ligase chain reaction testing for chlamydial infection was introduced in our clinic in Edinburgh, routine clinic protocol included the testing of all heterosexual, but not homosexual, men for urethral chlamydial infection. We audited all new homosexual and bisexual male attendees with a diagnosis of chlamydial infection or non-gonococcal urethritis (NGU) in 1999, together with heterosexual men with the same diagnoses attending in alternate months of the same year. Urethral Chlamydia trachomatis infection was detected in 14.6% (350/2402) of heterosexual men and 2.4% (11/465) of homosexual men tested. Fifty percent of chlamydial infections were asymptomatic. In this population 44% (84/190) of NGU in heterosexual men is attributable to C. trachomatis as opposed to only 10% (6/59) of that in homosexual men. These rates of chlamydial infection differ from previous reports in Scotland and recent studies from the USA. Our clinic protocol has been revised to include routine testing for chlamydial infection in all men.

Substance use and unsafe sex amongst homosexual men in Edinburgh.

A self-reported behaviour survey using an anonymous critical incident based questionnaire was administered by trained interviewers in 1998. Five hundred and thirty-one homosexual and bisexual men were recruited from gay bars, clubs, cafes, a sauna and 'cruising ground' in central Edinburgh. The use of alcohol and recreational drugs and details of sexual activity over the preceding three months and at the last sexual encounter were recorded. Unsafe sex was defined as anal sex without the use of a condom with a partner of unknown or different HIV status. Safer sex was defined as all other types of sex, including anal sex with a condom and anal sex without a condom with a partner whose HIV status was known to be the same. Of the questionnaires completed, 506 were suitable for analysis; 29 men (6.1%) reported anal sex with a partner of unknown or different HIV status without a condom ('unsafe sex') during their last sexual encounter. A total of 53 men (10.5%) could recall an episode of unsafe sex within the last three months. Men who had used marijuana or inhaled nitrites ('poppers') less than two hours before sex, or whose sexual partners had done so, were more likely to have unsafe sex than those who had not. Although alcohol use was more likely before sex with casual partners, the use of alcohol less than 2 hours before sex was not associated with sex being unsafe.

Managing genital chlamydia trachomatis infection in Scotland: targeted opportunistic testing or a screening programme?

OBJECTIVE: To compare two models of testing for genital chlamydia trachomatis infection: opportunistic testing for genital chlamydia trachomatis at sexual health related consultations, as advocated in the SIGN guideline on Chlamydia trachomatis, or the introduction of a screening programme. DESIGN: Calculation of estimates of numbers of cases found in one Health Board Area using the two different approaches. Review of the literature on chlamydia with reference to the UK National Screening Committee criteria for appraisal of a screening programme. SETTING: Lothian Health Board Area. RESULTS: The evidence suggests that a screening programme for chlamydia has population benefits and is cost effective compared to a no-screening approach. However, current understanding of the natural history of chlamydial infection and the effect of treatment is inadequate to fully inform individual women regarding the benefit of testing. Full implementation of the SIGN guideline on Chlamydia trachomatis in Lothian would detect at least 600 new cases of chlamydia whereas a screening programme would detect over 2000 new cases in the first year. CONCLUSION: Opportunistic testing at sexual health related consultations does not equate with a screening programme. Although a screening programme would detect more cases of chlamydia trachomatis its cost effectiveness compared to opportunistic testing is unproven. Introducing a screening programme has individual psychological and broader social and ethical implications and must not occur by default.

Osteolytic bone lesions in a patient with idiopathic myelofibrosis and bronchial carcinoma.

A 59 year old man with longstanding myelofibrosis and previous splenectomy was incidently found to have a large lytic lesion in his left femur which required operative fixation. He had undergone right upper lobectomy for squamous carcinoma of the bronchus five years earlier. Histological analysis of bone reamings showed no evidence of metastatic carcinoma. Osteosclerosis is frequently noted in patients with myelofibrosis but osteolytic lesions are uncommon and may be confused with metastatic malignancy.