A case report highlighting drug-drug interactions between 3 life-saving treatments: Feminizing hormones, antiretrovirals and antituberculosis drugs.

We here present a case providing valuable insights for clinicians who deliver care to patients identifying as transgender or nonbinary. A 30-year-old trans woman presented to sexual health services requesting a routine sexual health screen and was subsequently diagnosed with HIV and syphilis. She started antiretrovirals for HIV (bictegravir/tenoforvir alafenamide/emtricitabine) 12 days later and was treated with benzathine penicillin G. The patient also had a positive tuberculosis (TB) ELIspot blood test result and further investigations proved the presence of active TB in the chest with mediastinal involvement. She commenced treatment for TB with quadruple therapy, including rifampicin. Due to the clinically significant interaction between rifampicin and bictegravir, the patient's antiretroviral treatment was switched to dolutegravir 50 mg twice daily in combination with tenofovir disoproxil fumarate and emtricitabine. As the patient had transitioned from male to female and was self-medicating with oestrogen-containing feminizing hormone therapy, her hormonal treatment was optimized and blood levels of oestradiol were closely monitored and titrated to manage the drug-drug interaction between rifampicin and oestrogen to ensure the latter would be maintained within the expected therapeutic range. Our case report demonstrates the importance of combining treatment of multiple conditions under 1 team ideally integrated with gender services to prevent multiple attendances and mismanagement of feminizing hormone therapies.

Vaginal gonorrhoea in a transgender man reporting no vaginal sex.

We present a case of a transgender man symptomatic of vaginal Neisseria gonorrhoeae infection despite reporting no receptive vaginal sex in his recent history.

Infectious Proctitis due to Human Mpox.

We describe 2 cases of infectious proctitis secondary to human monkeypox in patients presenting with rectal pain. These cases highlight the importance of multidisciplinary management of monkeypox and in expanding case definitions and enabling clinical recognition in patients presenting without skin rash.

Demographic and clinical characteristics of confirmed human monkeypox virus cases in individuals attending a sexual health centre in London, UK: an observational analysis.

BACKGROUND: Historically, human monkeypox virus cases in the UK have been limited to imported infections from west Africa. Currently, the UK and several other countries are reporting a rapid increase in monkeypox cases among individuals attending sexual health clinics, with no apparent epidemiological links to endemic areas. We describe demographic and clinical characteristics of patients diagnosed with human monkeypox virus attending a sexual health centre. METHODS: In this observational analysis, we considered patients with confirmed monkeypox virus infection via PCR detection attending open-access sexual health clinics in London, UK, between May 14 and May 25, 2022. We report hospital admissions and concurrent sexually transmitted infection (STI) proportions, and describe our local response within the first 2 weeks of the outbreak. FINDINGS: Monkeypox virus infection was confirmed in 54 individuals, all identifying as men who have sex with men (MSM), with a median age of 41 years (IQR 34-45). 38 (70%) of 54 individuals were White, 26 (48%) were born in the UK, and 13 (24%) were living with HIV. 36 (67%) of 54 individuals reported fatigue or lethargy, 31 (57%) reported fever, and ten (18%) had no prodromal symptoms. All patients presented with skin lesions, of which 51 (94%) were anogenital. 37 (89%) of 54 individuals had skin lesions affecting more than one anatomical site and four (7%) had oropharyngeal lesions. 30 (55%) of 54 individuals had lymphadenopathy. One in four patients had a concurrent STI. Five (9%) of 54 individuals required admission to hospital, mainly due to pain or localised bacterial cellulitis requiring antibiotic intervention or analgesia. We recorded no fatal outcomes. INTERPRETATION: Autochthonous community monkeypox virus transmission is currently observed among MSM in the UK. We found a high proportion of concomitant STIs and frequent anogenital symptoms, suggesting transmissibility through local inoculation during close skin-to-skin or mucosal contact, during sexual activity. Additional resources are required to support sexual health and other specialist services in managing this condition. A review of the case definition and better understanding of viral transmission routes are needed to shape infection control policies, education and prevention strategies, and contact tracing. FUNDING: None.

The success of HIV combination prevention: The Dean Street model.

The 56 Dean Street combination prevention model, a strong engagement with the LGBTQI community and flexible services adapted to users' changing needs led to an 80% drop in HIV diagnoses in gay, bisexual and other men who have sex with men (GBMSM) from 2015 to 2017. We describe the service changes at 56 Dean Street since 2012 which resulted in an increase in the frequency of HIV testing, the introduction of pre-exposure prophylaxis, earlier HIV diagnosis and a shorter time to viral suppression in those living with HIV. This model could be adapted to deliver similar results in those settings of high HIV prevalence among GBMSM and where access to technological innovation in healthcare and engagement with the community can be achieved.

Safeguarding outcomes of 16 and 17-year-old service users of Sexual Health London (SHL.uk), a pan-London online sexual health service.

Guidance around how to safeguard young people using online sexual health services (e-SHSs) is limited. Sexual Health London (SHL.uk) is an e-SHS, integrated with London's sexual health clinics (SHCs), offering users aged 16 years and above sexually transmitted infection (STI) testing. For a safeguarding risk assessment, under 18s must complete a safeguarding e-triage, and any concern raised results in a 'call back' (CB) by the SHL.uk team. The safeguarding outcomes of CBs between 8 January 2018 and 18 September 2018 were reviewed; 261/454 (57.5%) users never triggered a CB on their e-triage (non-CB group) and 193/454 (42.5%) users triggered one or more CB(s) (CB group). Safeguarding concerns disclosed predominantly related to drug/alcohol use and partner's age imbalance. Successful telephonic risk assessment took place in 84.5% CB cases. Safeguarding outcomes comprised referrals to: SHC in 35.5%; child protection team in 8.5%; social services in 7%. STI positivity was 16.4% and 15.2% in the CB and non-CB groups, respectively. Although a high number of safeguarding triggers were disclosed, only a small proportion warranted referral for further support/intervention. Using e-triage with telephony support to screen and safeguard adolescents accessing an e-SHS was acceptable to users and enabled their clinical and safeguarding needs to be safely met. e-SHS integration within a network of SHCs further supported this model.

Enhanced surveillance of syphilis cases among men who have sex with men in London, October 2016-January 2017.

Syphilis rates have been increasing in men who have sex with men (MSM) in London. To describe risk behaviour and refine public health interventions, we conducted prospective enhanced surveillance of new syphilis cases in MSM attending selected London sexual health clinics (SHCs) between October 2016 and January 2017. Sexual health advisors (SHAs) completed 107 questionnaires. Eighteen per cent of respondents reported always using condoms, with lower use in HIV-positive (8%, 4/53) than HIV-negative men (33%, 14/52). Almost half of respondents reported condomless sero-discordant sex (46%, 33/72). The most frequent means of meeting new partners reported were venues (80%, 76/95), particularly bars or clubs (34%, 32/95), and apps or websites (79%, 75/95). Nearly a third of respondents reported engaging in group sex (32%, 30/95). Almost half reported drug use during sex (47%, 46/98), with HIV-positive men more likely to report use of the three main 'chemsex' drugs. The majority of respondents preferred health promotion information from SHAs (63%, 58/92) compared to other sources such as Google/Wikipedia and apps. Prevention activity should continue to focus on condomless sex, serosorting, multiple and overlapping partners, and chemsex. SHCs, particularly those serving HIV-positive men, are important sources for sexual health promotion advice.

Evolution of a pre-exposure prophylaxis (PrEP) service in a community-located sexual health clinic: concise report of the PrEPxpress.

Screening and treatment of sexually transmissible infections, including HIV, are free in the UK nations; pre-exposure prophylaxis (PrEP) became free in England in October 2017 through the PrEP Impact trial. Doctor-led PrEP clinics started at 56 Dean Street in September 2015, with the drug purchased privately at full price. The service was expanded to other staff to support initiation and monitoring of increasing numbers of attendees purchasing PrEP from online pharmacies. Nonetheless, when the clinic was given a target of 1700 for the PrEP Impact trial, it was clear this could not be achieved in a timely manner through 56 Dean Street alone. To prepare for the trial, all staff with HIV testing competencies were trained in good clinical practice and trial-specific procedures, and a patient group directive was approved to facilitate nurse prescribing and dispensing. Electronic pro formas to capture eligibility for starting or continuing PrEP were adapted for the Dean Street Express clinic, with some information collected directly from service users using touch screens. These interventions, together with an update to the 2016 information leaflet developed by the community, enabled enrolment and follow-up of 1700 participants in 4 months. PrEP advice and monitoring were easily accommodated in the 56 Dean Street sexual health service, but did require additional training and approval for nurse prescribing and dispensing drug in order to achieve the target, which still fell short of the demand.