Pilot study of pharyngeal Chlamydia trachomatis in HIV-positive and HIV-negative men who have sex with men.

Unlike pharyngeal Neisseria gonorrhoeae, less is known about pharyngeal Chlamydia trachomatis in men who have sex with men (MSM). We reviewed cases of pharyngeal chlamydia in MSM from January to December 2019. The overall prevalence of pharyngeal chlamydia was 75/6613 (1.13%; 95% confidence interval (CI) = 0.9-1.14). The median number of sexual partners was three, four (5%) reported throat symptoms and 20 (26%) were HIV positive. Multi-site and concomitant infection was common: rectal chlamydia [39 (52%)], urethral chlamydia [12 (16%)], early syphilis [2 (3%)] and gonorrhoea [14 (19%)]. HIV-positive MSM with pharyngeal chlamydia were older (P = 0.02) and more likely to have had previous syphilis (odds ratio = 4.9; 95% CI = 1.6-14.7; P = 0.005). Further research is needed to explore the characteristics of pharyngeal chlamydia and benefits of increased screening for asymptomatic pharyngeal chlamydia in MSM.

Pharyngeal gonorrhoea in men who have sex with men.

Pharyngeal gonorrhoea is important in the transmission dynamics of gonorrhoea, and generation of antimicrobial resistance and the performing of culture remains vital. We reviewed the notes of men who have sex with men (MSM) presenting to our clinic with a positive pharyngeal NAAT for gonorrhoea between January and December 2019. There were 383 cases of NAAT-positive pharyngeal gonorrhoea, and 28 (7%, 95% CI = 5.11-10.36) reported sore throat at presentation. Pharyngeal cultures were taken from 270/383 (70%), and 73/270 (27%) were culture positive with available antimicrobial sensitivities. Overall, the presence of pharyngeal symptoms was not associated with pharyngeal chlamydia (OR = 1.6, CI = 0.19-13.32, p = 0.7), HIV status (OR = 1.1, CI = 0.47-2.57, p = 0.8), positive cultures (OR = 1.9, CI = 0.78-4.62, p = 0.2) or age (p = 0.3). Routine screening of MSM for pharyngeal gonorrhoea is important to maintain surveillance and measures need to be taken to improve pharyngeal culture sampling from MSM.

Hepatitis A susceptibility in newly attending men who have sex with men to an urban sexual health centre.

Within the UK, the majority of hepatitis A occurs in high risk groups such as men who have sex with men (MSM). It has been estimated that 70% of MSM need immunity to provide adequate herd immunity. We aimed to estimate the proportion of hepatitis A susceptibility in MSM throughout a 10-year period (2010-2019), and explore associated demographic factors. Using our Electronic Patient Record system, we extracted anonymous clinical data between for MSM at their first attendance; including hepatitis A IgG result, age, country of birth and diagnosis of an STI. Overall, 1401/6884(20%) were tested for hepatitis A IgG at their first attendance, with 626/1401 (45%, 95% CI = 42%-47%) showing susceptibility. Testing rates increased between 2010-2019 (OR = 67.79, 95%CI = 39.09-117.60, p = <0.0001); however, susceptibility remained similar (OR = 0.98, 95%CI = 0.33-2.89, p = 0.98). MSM aged 35 and under had significantly higher susceptibility vs MSM aged over 35 (OR 3.4176, 95%CI = 2.71-4.31, p = <0.0001). UK-born had significantly higher susceptibility vs non-UK born (OR 1.5, 95%CI = 1.2147-1.8618, p = 0.0002). Susceptibility of hepatitis A in MSM may be higher than necessary to control future outbreaks. It is important that effective targeting of MSM, particularly young MSM, occur at all levels of healthcare and not solely rely on opportunistic presentation at a sexual health clinic.

Healthcare charging for migrants in the UK: awareness and experience of clinicians within sexual and reproductive health and HIV.

BACKGROUND: Forced migration is at record levels, leading many European countries to seek to limit immigration or control access to public services. The UK has introduced upfront healthcare charging for overseas patients, with exceptions for certain groups and services. Confusion over these regulations amongst healthcare professionals risks care being inappropriately delayed or denied. This is pertinent within sexual and reproductive health and HIV care where sensitivity and timely management are essential. METHODS: We conducted a survey exploring clinicians' knowledge of healthcare charging regulations and terminology, their confidence and experience on this topic and their ability to evaluate case-based scenarios. RESULTS: Of 343 valid responses, 78% reported encountering refugees, asylum seekers or undocumented migrants in practice. Only 39% felt confident in their understanding of healthcare entitlements. Terminology was appropriately defined by 66%, but only 53% of case-based scenarios were answered correctly. About 71% reported needing further training in this area, and many comments indicated a desire for educational resources. CONCLUSIONS: SRH and HIV professionals demonstrated limited knowledge of healthcare charging for migrants, despite working with these groups. This could undermine their ability to deliver appropriate advice and care to these potentially vulnerable patients. Training and support for these staff is essential.

An observational study of initial HIV RNA decay following initiation of combination antiretroviral treatment during pregnancy.

BACKGROUND: In pregnancy, reduction of HIV plasma viral load (pVL) for the prevention of vertical transmission is time-constrained. The study primary objective is to investigate factors associated with faster initial HIV RNA half-life decay when combination antiretroviral treatment (cART) is initiated in pregnancy. METHODS: This was a multicentre, retrospective, observational study, conducted in south England, United Kingdom, between August 2001 and February 2018. Data were extracted from case notes of eligible women initiating cART during the index pregnancy. Anonymised data were collated and analysed centrally. Regression analyses were conducted to determine factors associated with faster HIV RNA half-life decay in the first 14 days after commencing cART (first-phase), and with achieving an undetectable maternal pVL by 36 weeks' gestation. We then assessed whether HIV- and obstetric- related parameters differed by antiretroviral third agent class and whether the proportions of women with undetectable pVL at 36 weeks' gestation and at delivery differed by antiretroviral third agent class. RESULTS: Baseline pVL was the only independent factor associated with faster first-phase HIV RNA half-life decay on commencing cART. Lower pVL on day 14 after starting cART was associated with an increased likelihood of achieving an undetectable pVL by 36 weeks' gestation. Integrase inhibitor-based cART was associated with a faster first-phase HIV RNA half-life decay on commencing cART. Overall, 73% and 85% of women had an undetectable pVL at 36 weeks' gestation and at delivery respectively, with no significant difference by antiretroviral third agent class. CONCLUSIONS: Only high baseline pVL independently contributed to a faster rate of first-phase viral half-life decay. pVL at 14 days after initiating cART allows early identification of treatment failure. In the first 14 days after initiating cART in pregnancy, integrase inhibitor-based cART reduced maternal pVL faster than protease inhibitor- and non-nucleoside reverse transcriptase-based cART. While our study findings support INSTI use when initiated in pregnancy especially when initiated at later gestations and in those with higher baseline pVL, other non-INSTI based cART with more data on safety in pregnancy also performed well.

Symptomatic secondary syphilis: empirical antimicrobial treatment or await microbiology?

Men who have sex with men (MSM) with symptomatic secondary syphilis present with characteristic symptoms of rash, fever and lymphadenopathy; due to delays in microbiology results and some patients failing to return for treatment, empirical treatment is sometimes offered. We reviewed all patients presenting with secondary syphilis diagnosed on the basis of clinical symptoms and signs and reviewed treatment. Of the 36 patients, 16 MSM (44%; 95% confidence interval (CI) 27.8-60.2%) were treated empirically, whereas treatment was delayed for 20 (56%; 95% CI 39.8-72.2%) waiting for microbiology results. Treatment delays were longer for HIV-negative than HIV-positive MSM (10 vs 5 days respectively; P = 0.01); the cumulative treatment delay was 143 days. Concerns over antimicrobial resistance and overuse of antimicrobials should drive the use of point-of-care testing for syphlis.

Why it is unethical to charge migrant women for pregnancy care in the National Health Service.

Pregnancy care is chargeable for migrants who do not have indefinite leave to remain in the UK. Women who are not 'ordinarily resident', including prospective asylum applicants, some refused asylum-seekers, unidentified victims of trafficking and undocumented people are required to pay substantial charges in order to access antenatal, intrapartum and postnatal services as well as abortion care within the National Health Service. In this paper, we consider the ethical issues generated by the exclusion of pregnancy care from the raft of services which are free to all. We argue that charging for pregnancy care amounts to sex discrimination, since without pregnancy care, sex may pose a barrier to good health. We also argue that charging for pregnancy care violates bodily autonomy, entrenches the sex asymmetry of sexual responsibility, centres the male body and produces health risks for women and neonates. We explore some of the ideological motivations for making maternity care chargeable, and suggest that its exclusion responds to xenophobic populism. We recommend that pregnancy care always be free regardless of citizenship or residence status, and briefly explore how these arguments bear on the broader moral case against chargeable healthcare for migrants.

Osteoporosis in postmenopausal women living with HIV.

The widespread availability of effective antiretroviral therapy (ART) has transformed HIV from a life-limiting condition to one with near-normal life expectancy. HIV is associated with an increased risk of osteopenia and osteoporosis, with people living with HIV (PLHIV) potentially experiencing these conditions at a younger age than their HIV-negative counterparts. The mechanisms driving bone disease in HIV are complex and include: an increased prevalence of traditional risk factors; other comorbid conditions; and HIV-associated factors such as viral effects, systemic inflammation, and ART-related factors. One-third of PLHIV in the United Kingdom are female, and increasing numbers of women living with HIV (WLHIV) are reaching menopausal age. Oestrogen decline in the context of an elevated background risk of poor bone health results in WLHIV being at greater risk of osteoporosis than women without HIV. European HIV guidelines therefore recommend routine screening of postmenopausal WLHIV using FRAX© for clinical risk factors, with or without bone mineral density scanning. Data support the use of calcium and vitamin D supplementation, and bisphosphonates in the treatment of osteoporosis in PLHIV. Additionally, some patients with confirmed osteoporosis may benefit from a switch to an ART agent with a better bone safety profile. However, there remains a notable paucity of data on HIV and menopause, including the impact of hormone replacement therapy on the bone health of WLHIV. In conclusion, it is important that clinicians are aware that postmenopausal WLHIV are a group at particular risk of bone disease, who require proactive screening and advice about preventative measures.

Men who have sex with men diagnosed with a sexually transmitted infection are significantly more likely to engage in sexualised drug use.

The sexualised use of recreational drugs (Mephedrone, GBL/GHB, Crystal Meth) generally known as 'chemsex' in men who have sex with men (MSM) is thought to be associated with sexually transmitted infection (STI) acquisition; however there is little data showing a direct relationship. We reviewed 130 randomly selected cases of MSM with an STI attending our STI service and 130 controls (MSM attending the STI service who did not have an STI) between 5 May 2015 and 2 November 2015. Reported condomless anal sex was significantly higher in cases 90/121 (74%) compared with controls 65/122 (53%); ( χ2 = 11.71, p < 0.005, OR 2.54). Recreational drug use in the cases 38/122 (31%) was significantly greater than in controls 20/125 (16%); ( χ2 = 7.88, p < 0.005, OR 2.37). This demonstrates a link between STI acquisition and recreational drug use in MSM. Harm reduction initiatives identifying and addressing party drug use can help to improve the sexual health of MSM, including reducing risk-taking behaviours.

A postal survey of data in general practice on the prevalence of Acquired Brain Injury (ABI) in patients aged 18-65 in one county in the west of Ireland.

BACKGROUND: Very little is known about the prevalence of acquired brain injury (ABI) in Ireland. ABI prevalence has previously been obtained from Belgian general practitioners using a postal survey. We attempted to ascertain the prevalence of ABI in County Mayo through a postal survey of all general practitioners in the county.The specific objectives of this project were to:1. identify whether general practitioners are a. aware of patients with ABI aged 18-65 in their practices b. able to provide prevalence data on ABI in patients aged 18-65 c. able to provide data on age, gender and patient diagnosis 2. analyse prevalence of ABI from any available data from general practitioners. METHODS: A pilot postal survey was performed initially in order to assess the feasibility of the study. It was established that general practitioners did have the necessary information required to complete the questionnaire. A main postal survey was then undertaken. A postal questionnaire was administered to all general practices in County Mayo in the west of Ireland (n = 59). The response rate was 32.2% (n = 19). RESULTS: General practitioners who replied on behalf of their practice could provide data on patient age, gender and diagnosis. In the nineteen practices, there were 57 patients with ABI. The age-specific prevalence of ABI in the area surveyed was estimated at 183.7 per 100,000. The mean patient population per practice was 2,833 (SD = 950). There were found to be significantly more patients with ABI in rural areas than urban areas (p = 0.006). There were also significant differences in the ages of patients in the different ABI categories. Patients whose ABI was of traumatic origin were significantly younger than those patients with ABI of haemorrhagic origin (p = 0.002). CONCLUSION: Although this is a small-scale study, we have ascertained that general practitioners do have data on patients with ABI. Also, some prevalence data now exist where none was available before. These can be used to form the basis of a more substantial programme of university/community partnership research which could provide medical and psychosocial benefits for people with ABI and their families.