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Phillips LT, Witney AA, Furegato M, Laing KG, Zhou L, Sadiq ST. Time Required for Nanopore Whole-Genome Sequencing of Neisseria gonorrhoeae for Identification of Phylogenetic Relationships. J Infect Dis 2023; 228:1179-1188. [PMID: 37216766 PMCID: PMC10629711 DOI: 10.1093/infdis/jiad170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 03/20/2023] [Accepted: 05/19/2023] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND Antimicrobial resistance (AMR) in Neisseria gonorrhoeae is a global health challenge. Limitations to AMR surveillance reporting, alongside reduction in culture-based susceptibility testing, has resulted in a need for rapid diagnostics and strain detection. We investigated Nanopore sequencing time, and depth, to accurately identify closely related N. gonorrhoeae isolates, compared to Illumina sequencing. METHODS N. gonorrhoeae strains collected from a London sexual health clinic were cultured and sequenced with MiSeq and MinION sequencing platforms. Accuracy was determined by comparing variant calls at 68 nucleotide positions (37 resistance-associated markers). Accuracy at varying MinION sequencing depths was determined through retrospective time-stamped read analysis. RESULTS Of 22 MinION-MiSeq pairs reaching sufficient sequencing depth, agreement of variant call positions passing quality control criteria was 185/185 (100%; 95% confidence interval [CI], 98.0%-100.0%), 502/503 (99.8%; 95% CI, 98.9%-99.9%), and 564/565 (99.8%; 95% CI, 99.0%-100.0%) at 10x, 30x, and 40x MinION depth, respectively. Isolates identified as closely related by MiSeq, within one yearly evolutionary distance of ≤5 single nucleotide polymorphisms, were accurately identified via MinION. CONCLUSIONS Nanopore sequencing shows utility as a rapid surveillance tool, identifying closely related N. gonorrhoeae strains, with just 10x sequencing depth, taking a median time of 29 minutes. This highlights its potential for tracking local transmission and AMR markers.
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Affiliation(s)
- Laura T Phillips
- Institute for Infection and Immunity, St George’s University of London, London, United Kingdom
| | - Adam A Witney
- Institute for Infection and Immunity, St George’s University of London, London, United Kingdom
| | - Martina Furegato
- Institute for Infection and Immunity, St George’s University of London, London, United Kingdom
| | - Ken G Laing
- Institute for Infection and Immunity, St George’s University of London, London, United Kingdom
| | - Liqing Zhou
- Institute for Infection and Immunity, St George’s University of London, London, United Kingdom
| | - S Tariq Sadiq
- Institute for Infection and Immunity, St George’s University of London, London, United Kingdom
- Infection Clinical Academic Group, St George's University Hospitals NHS Trust, London, United Kingdom
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Argoubi R, Reese ES, Furegato M, Medina P, Bobiak S. Advanced or metastatic biliary tract cancer in Japan: a study using the Japan Medical Data Center payer claims database. J Comp Eff Res 2023; 12:e220201. [PMID: 37256267 PMCID: PMC10402906 DOI: 10.57264/cer-2022-0201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 05/02/2023] [Indexed: 06/01/2023] Open
Abstract
Aim: Biliary tract cancers are aggressive, with poor prognosis. This study describes clinical characteristics, treatment patterns and healthcare resource utilization in patients with metastatic biliary tract cancer in Japan. Materials & methods: This cohort-based study collected data from the Japan Medical Data Center claims database (2014-2018). Results: A total of 325 patients were included; 65.2% were male and the mean age was 59.2 years. A 47.6% had an Elixhauser Comorbidity Index score ≥5. Most frequent regimens were gemcitabine + cisplatin (52.9%) for first-line therapy and tegafur + gimeracil + oteracil for second-line therapy (48.6%) and third-line therapy (27.2%). Approximately 77% of patients had ≥1 hospital admission, with a median length of 57 days. Conclusion: This study provides insights on the characteristics and burden of metastatic biliary tract cancer in Japan, highlighting high disease burden in a younger population.
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Affiliation(s)
| | - Emily S Reese
- EMD Serono Research & Development Institute, Inc, Billerica, MA 01821, USA, an affiliate of Merck KGaA
| | | | | | - Sarah Bobiak
- EMD Serono Research & Development Institute, Inc, Billerica, MA 01821, USA, an affiliate of Merck KGaA
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Umemura T, Wattanakamolkul K, Nakayama Y, Takahashi Y, Sbarigia U, KyungHwa L, Villasis-Keever A, Furegato M, Gautier L, Nowacki G, Azzi J, Wu DBC. Real-World Epidemiology, Clinical and Economic Burden of Chronic Hepatitis B in Japan: A Retrospective Study Using JMDC Claims Database. Infect Dis Ther 2023; 12:1337-1349. [PMID: 37067724 DOI: 10.1007/s40121-023-00795-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 03/24/2023] [Indexed: 04/18/2023] Open
Abstract
INTRODUCTION Chronic hepatitis B (CHB) is one of the world's major healthcare problems, especially in the Western Pacific regions. This study describes the prevalence, incidence, treatment profiles and clinical and economic burden of chronic hepatitis B patients in Japan using the Japan Medical Data Center (JMDC) Claims Database. METHODS This is a retrospective observational study. Prevalence cases were identified as patients with ≥ 1 inpatient or ≥ 2 outpatient CHB diagnoses and ≥ 2 records for hepatitis B tests or ≥ 1 prescription for CHB treatment between January 2010 and December 2019. Newly diagnosed CHB patients were defined as patients diagnosed from 2010 to 2018 with no history of the disease up to 2 years prior to the diagnosis. The index date is defined as the first CHB diagnosis day. We only used patients' data with ≥ 1-year post-index date. RESULTS We identified 13,061 CHB prevalent cases (2010-2019), yielding a crude period prevalence of 0.32%. Newly diagnosed CHB patients (n = 1973; median age 52 years) were followed for a median period of 3.1 years, during which 15% received a CHB treatment. Entecavir was the most common first treatment (66%). During this period, 3.4% of the patients developed compensated cirrhosis (CC), 1.5% decompensated cirrhosis (DC) and 3.0% hepatocellular carcinoma (HCC). Around 43.3% of CHB patients were hospitalized at least once. Hospitalizations, treatment rates, serologic testing and screening for liver diseases increased as the severity of the disease progressed. The average total healthcare cost was 870,568 JPY (7779 USD) per person per year. DC and HCC resulted in the highest management costs. CONCLUSIONS Chronic hepatitis B represents a high clinical and economic burden for patients and caregivers, given its morbidity and associated costs.
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Affiliation(s)
- Takeji Umemura
- Division of Gastroenterology, Department of Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | | | | | | | | | | | | | | | | | | | | | - David Bin-Chia Wu
- Janssen Asia Pacific, Singapore, Singapore.
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore.
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Kerry-Barnard S, Zhou L, Phillips L, Furegato M, Witney AA, Sadiq ST, Oakeshott P. Vaginal microbiota in ethnically diverse young women who did or did not develop pelvic inflammatory disease: community-based prospective study. Sex Transm Infect 2022; 98:503-509. [PMID: 35086915 PMCID: PMC9613871 DOI: 10.1136/sextrans-2021-055260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 11/26/2021] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES A lactobacilli-dominated vaginal microbiome may protect against pelvic inflammatory disease (PID), but one dominated by Gardnerella species might increase susceptibility. Not all lactobacilli are equally protective. Recent research suggests that D(-) isomer lactic acid producing lactobacilli (Lactobacillus crispatus, Lactobacillus jensenii and Lactobacillus gasseri) may protect against infection with Chlamydia trachomatis, an important cause of PID. Lactobacillus iners , which produces L(+) isomer lactic acid, may be less protective. We investigated the microbiome in stored vaginal samples from participants who did or did not develop PID during the prevention of pelvic infection (POPI) chlamydia screening trial. METHODS Long-read 16S rRNA gene nanopore sequencing was used on baseline vaginal samples (one per participant) from all 37 women who subsequently developed clinically diagnosed PID during 12-month follow-up, and 111 frequency matched controls who did not, matched on four possible risk factors for PID: age <20 versus ≥20, black ethnicity versus other ethnicity, chlamydia positive versus negative at baseline and ≥2 sexual partners in the previous year versus 0-1 partners. RESULTS Samples from 106 women (median age 19 years, 40% black ethnicity, 22% chlamydia positive, 54% reporting multiple partners) were suitable for analysis. Three main taxonomic clusters were identified dominated by L. iners, L. crispatus and Gardnerella vaginalis. There was no association between a more diverse, G. vaginalis dominated microbiome and subsequent PID, although increased Shannon diversity was associated with black ethnicity (p=0.002) and bacterial vaginosis (diagnosed by Gram stain p<0.0001). Women who developed PID had similar relative abundance of protective D(-) isomer lactic acid producing lactobacilli to women without PID, but numbers of PID cases were small. CONCLUSIONS In the first-ever community-based prospective study of PID, there was no clear association between the vaginal microbiome and subsequent development of PID. Future studies using serial samples may identify vaginal microbial communities that may predispose to PID.
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Affiliation(s)
- Sarah Kerry-Barnard
- Population Health Research Institute, St George's, University of London, London, UK
| | - Liqing Zhou
- Applied Diagnostic Research and Evaluation Unit, St George's, University of London, London, UK
| | - Laura Phillips
- Applied Diagnostic Research and Evaluation Unit, St George's, University of London, London, UK
| | - Martina Furegato
- Applied Diagnostic Research and Evaluation Unit, St George's, University of London, London, UK
| | - Adam A Witney
- Institute for Infection and Immunity, St George's, University of London, London, UK
| | - S Tariq Sadiq
- Applied Diagnostic Research and Evaluation Unit, St George's, University of London, London, UK,Clinical Academic group in Infection and Immunity, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Pippa Oakeshott
- Population Health Research Institute, St George's, University of London, London, UK
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Vikis HG, Clark O, Furegato M, Vavroch N, Purinton S, Haskell T, Boshears T. Mapping the epidemiologic characteristics of cancer patients with NTRK gene fusions: A real-world analysis of the Cerner Enviza Eletronic Health Records (EHR) database. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.e15123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e15123 Background: Fusions in neurotrophic-tropomyosin receptor kinase (NTRK) genes occur in a vast array of tumors and are among the most important genetic alterations in cancer patients. Their presence warrants the use of specific agnostic therapy (AT) with TRK inhibitors Larotrectinib (L) and Entrectinib (E). AT is associated with high levels of tumor response rate in patients showing NTRKgenetic alterations. This mutation is rare and the epidemiologic profile and clinical characteristics of NTRK positive patients are not completely clear. Methods: Our aim was to identify and describe the characteristics of patients with NTRK fusions in a large EHR database. De-identified records of NTRK positive oncologic patients were retrieved from Cerner-Enviza EHR, a healthcare provider network with 100 different providers across the USA, between November 2018 to August 2021. Data extracted were primary tumor, gender, age, and treatment received. Results: We identified 123 patients with NTRK alterations. Major primary tumor locations are described in the table. Males were 56% of the population, median age at diagnosis was 59 years, 36% of the patients were treated with E and 64% with L. Conclusions: In this sample, NTRK mutations were more common in patients with Lung Cancer and Soft Tissue tumors. The median age at diagnosis was 59 years.[Table: see text]
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Llangarí-Arizo LM, Sadiq ST, Márquez C, Cooper P, Furegato M, Zhou L, Aranha L, Mateo MM, Romero-Sandoval N. Sexually transmitted infections and factors associated with risky sexual practices among female sex workers: A cross sectional study in a large Andean city. PLoS One 2021; 16:e0250117. [PMID: 33956840 PMCID: PMC8101946 DOI: 10.1371/journal.pone.0250117] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 03/30/2021] [Indexed: 11/23/2022] Open
Abstract
Background There are limited published data on factors related to risky sexual practices (RSP) affecting sexually transmitted infections (STIs) among female sex workers (FSWs) in Ecuador. Methods Cross-sectional study of FSWs presenting for a consultation in a primary health care centre during 2017. A questionnaire was administered to collect information on RSP and potential risk factors including age, membership of an FSW association, self-report of previous STI diagnosis, previous treatment for suspected STI and temporary migration for sex work. Associations between RSP and potential risk factors were estimated by logistic regression. The proportion of STI was estimated from vaginal swabs by real-time PCR for four sexually transmitted pathogens (Neisseria gonorrhoeae, Trichomonas vaginalis, Chlamydia trachomatis, and Mycoplasma genitalium). Results Of 249 FSWs recruited, 22.5% had reported RSPs at least once during sex work. Among FSWs reporting unprotected vaginal sex in the previous three months, 25.5% had at least one other RSP type. 17.6% (95%CI 13.3–22.8) had at least one active STI. Prevalence of co-infections was 2.4% (95%CI 1.1–5.2). In multivariable analysis, RSP was associated with age (adjusted OR 1.06; 95%CI 1.02–1.10), membership of an FSWs association (aOR 3.51; 95%CI 1.60–7.72) and self-reported previous STI (aOR 3.43; 95%CI 1.28–9.17). Conclusions Among a population of female sex workers with high proportion of STIs, increasing age and belonging to an FSWs association was associated with a higher likelihood of engaging in RSP with clients. Engaging with FSWs organisations may reduce the burden of STI among sex workers.
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Affiliation(s)
- Luz Marina Llangarí-Arizo
- School of Medicine, Universidad Internacional de Ecuador, Quito, Ecuador
- Unitat de Bioestadística, Facultat de Medicina, Universitat Autónoma de Barcelona, Barcelona, Spain
- Red Internacional Grups de Recerca d’Amèrica i Àfrica Llatines – GRAAL, Barcelona, Spain
- * E-mail:
| | - S. Tariq Sadiq
- Applied Diagnostic Research and Evaluation Unit, St George’s University of London, London, United Kingdom
- Institute for Infection & Immunity, St George’s University of London, London, United Kingdom
| | - Cynthia Márquez
- School of Medicine, Universidad Internacional de Ecuador, Quito, Ecuador
| | - Philip Cooper
- School of Medicine, Universidad Internacional de Ecuador, Quito, Ecuador
- Institute for Infection & Immunity, St George’s University of London, London, United Kingdom
| | - Martina Furegato
- Applied Diagnostic Research and Evaluation Unit, St George’s University of London, London, United Kingdom
| | - Liqing Zhou
- Applied Diagnostic Research and Evaluation Unit, St George’s University of London, London, United Kingdom
- Institute for Infection & Immunity, St George’s University of London, London, United Kingdom
| | - Luisa Aranha
- Ministerio de Salud Pública de Ecuador, Quito, Ecuador
| | - Miguel Martín Mateo
- School of Medicine, Universidad Internacional de Ecuador, Quito, Ecuador
- Unitat de Bioestadística, Facultat de Medicina, Universitat Autónoma de Barcelona, Barcelona, Spain
- Red Internacional Grups de Recerca d’Amèrica i Àfrica Llatines – GRAAL, Barcelona, Spain
| | - Natalia Romero-Sandoval
- School of Medicine, Universidad Internacional de Ecuador, Quito, Ecuador
- Red Internacional Grups de Recerca d’Amèrica i Àfrica Llatines – GRAAL, Barcelona, Spain
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Blondeel K, Dias S, Furegato M, Seuc A, Gama A, Fuertes R, Mendão L, Temmerman M, Toskin I. Sexual behaviour patterns and STI risk: results of a cluster analysis among men who have sex with men in Portugal. BMJ Open 2021; 11:e033290. [PMID: 33483434 PMCID: PMC7825267 DOI: 10.1136/bmjopen-2019-033290] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES Portugal has the highest HIV incidence rate in Western Europe. The proportion assigned to sexual contact between men recently increased to more than 30% of all HIV infections. Men who have sex with men (MSM) are vulnerable to the acquisition of other sexually transmitted infections (STIs), increasing the per-contact risk of HIV infection. Building on syndemic theory, the aim of this analysis was to identify patterns of current sexual behaviour in MSM, and explore their relationship with self-reported current, past STI diagnoses and HIV positive serostatus. DESIGN A cross-sectional behavioural survey was conducted in Portugal among MSM, using a community-based participatory research approach. Hierarchical cluster analysis was used to identify patterns including behavioural and demographic factors. RESULTS The analysis resulted in six clusters. Three clusters showed higher rates of current STI diagnosis (ranging from 11.7% to 17.1%), past STI diagnosis (ranging from 25.5% to 41.5%) and HIV positive serostatus (ranging from 13.0% to 16.7%). From the three clusters scoring lower on current and past STI and HIV diagnoses, one was characterised by a high number of sexual partners (62% had more than 12 partners in the last year), a high proportion (94.6%) of frequent visits to gay venues to meet sexual partners and high alcohol use (46.1%). The other two clusters scored lower on high risk sexual behaviour. CONCLUSION Factors other than sexual behaviour appear to reinforce the vulnerability to STIs and HIV of some MSM in this study, suggesting a syndemic of STIs, HIV and other adverse conditions. More research is needed to better understand the drivers of the STI/HIV epidemic in Portuguese MSM, using a concept that goes beyond risk behaviour, to develop effective combination prevention interventions.
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Affiliation(s)
- Karel Blondeel
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, WHO, Geneve, Switzerland
- Faculty of Medicine and Health Sciences, Ghent University, Gent, Belgium
| | - Sonia Dias
- Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisboa, Portugal
- National School of Public Health, Universidade Nova de Lisboa, Lisboa, Portugal
| | - Martina Furegato
- Applied Diagnostic Research and Evaluation Unit (ADREU), University of London, St George's Molecular and Clinical Sciences Research Institute, London, UK
- Blood Safety, Hepatitis, Sexually Transmitted Infections (STI) and HIV Service, National Infection Service, Public Health England, London, UK
| | - Armando Seuc
- Instituto Nacional de Higiene Epidemiología y Microbiología, Habana, Cuba
| | - Ana Gama
- Global Health and Tropical Medicine, Instituto de Higiene e Medicina Tropical, Universidade Nova de Lisboa, Lisboa, Portugal
| | | | - Luís Mendão
- Grupo de Ativistas em Tratamentos, Lisbon, Portugal
| | - Marleen Temmerman
- Faculty of Medicine and Health Sciences, Ghent University, Gent, Belgium
| | - Igor Toskin
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, WHO, Geneve, Switzerland
- Institute for Leadership and Health Management, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moskva, Russian Federation
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Broad CE, Furegato M, Harrison MA, Pond MJ, Tan N, Okala S, Fuller SS, Harding-Esch EM, Sadiq ST. High prevalence of coinfection of azithromycin-resistant Mycoplasma genitalium with other STIs: a prospective observational study of London-based symptomatic and STI-contact clinic attendees. Sex Transm Infect 2020; 97:63-68. [PMID: 32393529 DOI: 10.1136/sextrans-2019-054356] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 03/24/2020] [Accepted: 04/14/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Azithromycin treatment of Chlamydia trachomatis (CT) may not be adequate to treat concomitant Mycoplasma genitalium (MG) infection, and particularly if MG has macrolide resistance-associated mutations (MG-MRAMs). We estimated prevalence of coinfections of CT with MG carrying MRAM, and risk factors for MG-MRAM among a sexual health clinic population. STUDY DESIGN AND SETTING Among symptomatic and STI-contact clinic attendees in London, prevalence of CT-MG coinfection and MG-MRAM were estimated using nucleic acid amplification testing and Sanger sequencing, respectively, and their associated risk factors analysed using logistic regression. RESULTS MG prevalence was 7.5% (23/307), 17.3% (30/173), and 11.4% (8/70) in females, men who have sex with women (MSW) and men who have sex with men (MSM), respectively; MG coinfection in CT-infected participants represented 28.0% (7/25), 13.5% (5/37), 0.0% (0/0), respectively. Presence of MG-MRAM was 39.1% (9/23) in female swabs, 70.0% (21/30) in MSW urine and 83.3% (5/6) in MSM rectal swabs. In multivariate analyses, coinfection with another STI was strongly associated with MG-MRAM (OR: 7.19; 95% CI: 2.4 to 21.5). CONCLUSION A significant proportion of participants in our study of symptomatic patients and STI contacts were infected with macrolide-resistant MG, suggesting that testing for MG and MRAM, for MG positives, might be clinically useful. The findings also suggest services explore potential benefits of testing CT positive samples for MG in these patient groups. Where MG testing is not available, potential high rates of MG coinfection should be borne in mind when considering azithromycin in the treatment of CT among STI contacts and symptomatic patients.
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Affiliation(s)
- Claire E Broad
- Applied Diagnostic Research and Evaluation Unit, Institute for Infection and Immunity, St George's University of London, London, UK
| | - Martina Furegato
- Applied Diagnostic Research and Evaluation Unit, Institute for Infection and Immunity, St George's University of London, London, UK.,National Infection Service, Public Health England, Colindale, London, NW9 5EQ, UK
| | - Mark A Harrison
- Applied Diagnostic Research and Evaluation Unit, Institute for Infection and Immunity, St George's University of London, London, UK
| | - Marcus J Pond
- Applied Diagnostic Research and Evaluation Unit, Institute for Infection and Immunity, St George's University of London, London, UK
| | - NgeeKeong Tan
- Southwest London Pathology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Sandra Okala
- National Infection Service, Public Health England, Colindale, London, NW9 5EQ, UK
| | - Sebastian S Fuller
- Applied Diagnostic Research and Evaluation Unit, Institute for Infection and Immunity, St George's University of London, London, UK
| | - Emma M Harding-Esch
- Applied Diagnostic Research and Evaluation Unit, Institute for Infection and Immunity, St George's University of London, London, UK.,National Infection Service, Public Health England, Colindale, London, NW9 5EQ, UK
| | - S Tariq Sadiq
- Applied Diagnostic Research and Evaluation Unit, Institute for Infection and Immunity, St George's University of London, London, UK .,National Infection Service, Public Health England, Colindale, London, NW9 5EQ, UK.,St George's University Hospitals NHS Foundation Trust, London, UK
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Harb AK, Mohammed H, Furegato M, Wayal S, Mercer CH, Hughes G. The association between region of birth and sexually transmitted infections among people of black Caribbean ethnicity attending sexual health services in England, 2015. PLoS One 2020; 15:e0228654. [PMID: 32084155 PMCID: PMC7034901 DOI: 10.1371/journal.pone.0228654] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 01/21/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND/INTRODUCTION In England, people of Black Caribbean (BC) ethnicity are disproportionately affected by sexually transmitted infections (STIs), but it is unclear whether this varies by their region of birth. AIM(S)/OBJECTIVES To examine differences in STI diagnoses among UK- and Caribbean-born BC people. METHODS Data on STI diagnoses in BC people attending specialist sexual health services (SHSs) during 2015 and living in England were obtained from the GUMCAD STI surveillance system, the national surveillance system for STIs in England. Associations between being UK- or Caribbean-born and each of several STI diagnoses were examined, using univariate and multivariable generalised estimated equations logistic regression models adjusted for sexual orientation, place of residence (London vs. non-London), HIV status, area-level deprivation, and STI diagnosis in the last year. All analyses were stratified by age (<25 vs. ≥25 years). RESULTS In 2015, 63,568 BC people made 108,881 attendances at specialist SHSs; 81.9% of these attendances were made by UK-born BCs. The median age (years) was 26 for UK-born and 35 for Caribbean-born people (p≤0.001). Chlamydia, gonorrhoea and non-specific genital infection (NSGI) were the most commonly diagnosed STIs among UK- (5.8%, 2.1% and 2.8%) and Caribbean-born people (4.5%, 1.7% and 3.5%) respectively. Among BCs aged under 25, no significant differences in STIs were found between UK- and Caribbean-born people. Among BCs aged ≥25, compared to Caribbean-born people, those who were UK-born were more likely to be diagnosed with chlamydia (AOR 1.15 [95%C.I. 1.04-1.27]); gonorrhoea (AOR 1.23 [95%C.I. 1.06-1.45]) and genital herpes (AOR 1.23 [95% C.I. 1.10-1.56]) and less likely to be diagnosed with NSGI (AOR 0.89 [95% C.I. 0.80-0.99]) and Trichomoniasis (AOR 0.84 [95% C.I. 0.71-0.99]). DISCUSSION/CONCLUSION STI diagnoses in BC people aged ≥25 attending specialist SHSs vary by region of birth. Country of birth may have an influence on social and sexual networks and therefore transmission of STIs.
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Affiliation(s)
- Ana K. Harb
- National Infection Service, Public Health England, London, United Kingdom
- * E-mail:
| | - Hamish Mohammed
- National Infection Service, Public Health England, London, United Kingdom
- Centre for Population Research in Sexual Health and HIV, University College London, London, United Kingdom
| | - Martina Furegato
- National Infection Service, Public Health England, London, United Kingdom
- The Applied Diagnostic Research and Evaluation Unit (ADREU), St George’s, University, City, London, United Kingdom
| | - Sonali Wayal
- Centre for Population Research in Sexual Health and HIV, University College London, London, United Kingdom
- National Institute for Health Research Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections, University College London, London, United Kingdom
| | - Catherine H. Mercer
- Centre for Population Research in Sexual Health and HIV, University College London, London, United Kingdom
- National Institute for Health Research Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections, University College London, London, United Kingdom
| | - Gwenda Hughes
- National Infection Service, Public Health England, London, United Kingdom
- National Institute for Health Research Health Protection Research Unit in Blood Borne and Sexually Transmitted Infections, University College London, London, United Kingdom
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10
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Harb AK, Town K, Callan E, Furegato M, Connor N, Dunbar JK. Who is coming back for more chlamydia testing within non-specialist health services and where do they go? England, 2013-2016. Public Health 2019; 180:136-140. [PMID: 31901574 DOI: 10.1016/j.puhe.2019.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 10/16/2019] [Accepted: 11/12/2019] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To investigate patient demographics and venue type preferences within community settings associated with re-attendance for chlamydia testing. STUDY DESIGN Data used for this analysis were obtained from the English National Chlamydia Screening Programme (NCSP) which focuses on prevention, control and treatment of chlamydia in sexually active under-25 year olds. A greater understanding of how young adults attend services helps to inform commissioners regarding where to focus resources within community settings. METHODS Data from the Chlamydia surveillance system (CTAD) were used to count patient attendances at non-specialist sexual health services (SHSs) among 15-24-year-olds and monitor re-attendance for chlamydia testing within and between community services between 6 and 18 months of their first visit. RESULTS From January 2013 to December 2016, 866,847 young people underwent 1,041,245 tests for chlamydia. Re-attendance for chlamydia testing was 20.1% (174,398/866,847). Re-attendance rate was 28.5% after a positive test and 19.5% after a negative test. For re-attenders, 64.2% used the same venue type for both visits. General practice (GP) and sexual and reproductive health services (SRH) were the most commonly re-attended services (31.0% and 30.6% respectively). CONCLUSIONS Only one in five re-attended for chlamydia testing. Re-attendance was associated with having a positive result, accessibility and convenience. Patients are likely to return for testing to services they know. This should be considered by commissioners implementing new re-attendance guidance based on the NCSP.
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Affiliation(s)
- A K Harb
- Blood Safety, Hepatitis, STI & HIV Division, National Infection Service, Public Health England, London, UK.
| | - K Town
- Blood Safety, Hepatitis, STI & HIV Division, National Infection Service, Public Health England, London, UK
| | - E Callan
- Blood Safety, Hepatitis, STI & HIV Division, National Infection Service, Public Health England, London, UK
| | - M Furegato
- Blood Safety, Hepatitis, STI & HIV Division, National Infection Service, Public Health England, London, UK; Applied Diagnostic Research & Evaluation Unit, St George's, University of London, London, UK
| | - N Connor
- Blood Safety, Hepatitis, STI & HIV Division, National Infection Service, Public Health England, London, UK
| | - J K Dunbar
- Blood Safety, Hepatitis, STI & HIV Division, National Infection Service, Public Health England, London, UK
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11
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Clifton S, Bolt H, Mohammed H, Town K, Furegato M, Cole M, Campbell O, Fifer H, Hughes G. Prevalence of and factors associated with MDR Neisseria gonorrhoeae in England and Wales between 2004 and 2015: analysis of annual cross-sectional surveillance surveys. J Antimicrob Chemother 2019; 73:923-932. [PMID: 29394396 DOI: 10.1093/jac/dkx520] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 12/08/2017] [Indexed: 11/14/2022] Open
Abstract
Objectives To describe trends in prevalence, susceptibility profile and risk factors for MDR Neisseria gonorrhoeae (MDR-NG) in England and Wales. Methods Isolates from 16 242 gonorrhoea episodes at sexual health clinics within the Gonococcal Resistance to Antimicrobials Surveillance Programme (GRASP) underwent antimicrobial susceptibility testing. MDR-NG was defined as resistance to ceftriaxone, cefixime or azithromycin, plus at least two of penicillin, ciprofloxacin and spectinomycin. Trends in resistance are presented for 2004-15; prevalence and logistic regression analyses for MDR-NG cover the period of the most recent treatment guideline (ceftriaxone plus azithromycin), 2011-15. Results Between 2004 and 2015, the proportion of N. gonorrhoeae isolates fully susceptible to all antimicrobial classes fell from 80% to 46%, with the proportion resistant to multiple (two or more) classes increasing from 7.3% to 17.5%. In 2011-15, 3.5% of isolates were MDR-NG, most of which were resistant to cefixime (100% in 2011, decreasing to 36.9% in 2015) and/or azithromycin (4.2% in 2011, increasing to 84.3% in 2015). After excluding azithromycin-resistant isolates, modal azithromycin MICs were higher in MDR versus non-MDR isolates (0.5 versus 0.125 mg/L), with similar results for ceftriaxone (modal MICs 0.03 versus ≤0.002 mg/L). After adjustment for confounders, MDR-NG was more common among isolates from heterosexual men, although absolute differences in prevalence were small [4.6% versus 3.3% (MSM) and 2.5% (women)]. Conclusions N. gonorrhoeae is becoming less susceptible to available antimicrobials. Since 2011, a minority of isolates were MDR-NG; however, MICs of azithromycin or ceftriaxone (first-line therapies) for many of these were elevated. These findings highlight the importance of continued antimicrobial stewardship for gonorrhoea.
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Affiliation(s)
- Soazig Clifton
- Centre for Sexual Health and HIV Research, University College London, Mortimer Market Centre, London WC1E 6JB, UK
| | - Hikaru Bolt
- Public Health England, 61 Colindale Avenue, London NW9 5EQ, UK
| | - Hamish Mohammed
- Public Health England, 61 Colindale Avenue, London NW9 5EQ, UK
| | - Katy Town
- Public Health England, 61 Colindale Avenue, London NW9 5EQ, UK
| | | | - Michelle Cole
- Public Health England, 61 Colindale Avenue, London NW9 5EQ, UK
| | - Oona Campbell
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Helen Fifer
- Public Health England, 61 Colindale Avenue, London NW9 5EQ, UK
| | - Gwenda Hughes
- Public Health England, 61 Colindale Avenue, London NW9 5EQ, UK
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12
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Smolarchuk C, Mohammed H, Furegato M, Town K, Fifer H, Wilson J, Nardone A, Lee A, Hughes G. Just Google it! Impact of media coverage of an outbreak of high-level azithromycin-resistant Neisseria gonorrhoeae on online searches, and attendances, testing and diagnoses at sexual health clinics in England between 2015 and 2016: an interrupted time series analysis using surveillance data. Sex Transm Infect 2019; 95:594-601. [PMID: 31040249 DOI: 10.1136/sextrans-2019-053986] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 03/29/2019] [Accepted: 04/02/2019] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To determine if media coverage of an outbreak of high-level azithromycin-resistant Neisseria gonorrhoeae (HL-AziR) impacted online search interest or was temporally associated with health-seeking behaviours in several English cities. METHODS A descriptive analysis of outbreak-related online media articles and relative search interest (RSI) using Google and an interrupted time series analysis using routine surveillance data from sexual health clinics (SHCs) in England (GUMCAD STI surveillance system). The main outcomes were adjusted incidence rate ratios (IRRs) of weekly attendances, gonorrhoea tests and diagnoses of gonorrhoea or 'any STI' in selected cities after media coverage of the outbreak in 2015 and 2016. RESULTS RSI for outbreak-related terms peaked during media coverage in September 2015 with smaller peaks coinciding with subsequent coverage. The greatest increase in RSI was in Leeds, which coincided with a 63% rise (n=1932; IRR 1.26, 95% CI 1.12 to 1.43) in SHC attendances by women. There was only a 7% (n=1358; IRR 1.01, 95% CI 0.91 to 1.11) increase in attendances by men. Modest increases in outcomes occurred in four other cities with a high RSI. There was no evidence of increases in outcomes in cities, other than Leeds, after subsequent media coverage of the outbreak. CONCLUSIONS National and local media coverage of the HL-AziR outbreak coincided with peak RSI for related terms, and a transient increase in attendances, gonorrhoea tests and diagnoses of gonorrhoea or 'any STI' in some cities with a high RSI. Our analysis demonstrates the potential for media coverage to influence health-seeking behaviours during high-profile STI outbreaks.
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Affiliation(s)
- Christa Smolarchuk
- Blood Safety, Hepatitis, Sexually Transmitted Infections & HIV Division, Public Health England, London, UK
| | - Hamish Mohammed
- Blood Safety, Hepatitis, Sexually Transmitted Infections & HIV Division, Public Health England, London, UK
| | - Martina Furegato
- Blood Safety, Hepatitis, Sexually Transmitted Infections & HIV Division, Public Health England, London, UK
| | - Katy Town
- Blood Safety, Hepatitis, Sexually Transmitted Infections & HIV Division, Public Health England, London, UK.,Centre for Sexual Health & HIV Research, University College London, London, UK
| | - Helen Fifer
- Bacteriology Reference Department, Public Health England Colindale, London, UK
| | - Janet Wilson
- Leeds Sexual Health, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Anthony Nardone
- Blood Safety, Hepatitis, Sexually Transmitted Infections & HIV Division, Centre for Infectious Disease Surveillance and Control, Public Health England, London, UK
| | - Andrew Lee
- Yorkshire & the Humber Health Protection Team, Public Health England, Leeds, UK
| | - Gwenda Hughes
- Blood Safety, Hepatitis, Sexually Transmitted Infections & HIV Division, Public Health England, London, UK
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13
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Mitchell HD, Desai S, Mohammed H, Ong KJ, Furegato M, Hall V, Desai M, Saunders JM, Hughes G, Field N, Gill ON. Preparing for PrEP: estimating the size of the population eligible for HIV pre-exposure prophylaxis among men who have sex with men in England. Sex Transm Infect 2019; 95:484-487. [PMID: 31010953 DOI: 10.1136/sextrans-2019-054009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 03/27/2019] [Accepted: 04/02/2019] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES The size of the population of men who have sex with men (MSM) who may be eligible for HIV pre-exposure prophylaxis (HIV-PrEP) in England remains unknown. To plan for a national PrEP implementation trial, we estimated the number of MSM attending sexual health clinics (SHCs) that may be eligible for HIV-PrEP in England. METHODS Sexually transmitted infection (STI) surveillance data from 2010 to 2015 from the GUMCAD surveillance system were used to estimate the annual number of HIV-negative MSM who may be eligible for HIV-PrEP in England. Based on national eligibility criteria, we identified HIV-negative MSM attending SHCs with a HIV-negative test in the past year and used diagnosed bacterial STI (past year) in this group as a proxy for condomless sex and eligibility for HIV-PrEP. We estimated HIV incidence per 100 person-years (py) in these groups in 2014. RESULTS During 2010-2015, the number of HIV-negative MSM attending SHCs with a HIV-negative test in the past year doubled from 14 643 to 29 023, and HIV incidence in this group was 1.9 (95% CI 1.6 to 2.2) per 100 py in 2014. In the same period, the subgroup with a bacterial STI diagnosis (past year), and therefore considered potentially eligible for HIV-PrEP in this analysis, increased from 4365 (30%) to 10 276 (35%). HIV incidence in this subgroup was 3.3 (95% CI 2.7 to 4.0) per 100 py in 2014. CONCLUSIONS In 2015, approximately 10 000 HIV-negative MSM were considered potentially eligible for HIV-PrEP based on clinic history in GUMCAD. These data were used to inform the initial recruitment target for the PrEP Impact Trial and will inform future evaluations at a population level.
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Affiliation(s)
- Holly D Mitchell
- Blood Safety, Hepatitis, Sexually Transmitted Infections (STI) and HIV Service, National Infection Service, Public Health England, London, UK
| | - Sarika Desai
- Blood Safety, Hepatitis, Sexually Transmitted Infections (STI) and HIV Service, National Infection Service, Public Health England, London, UK
| | - Hamish Mohammed
- Blood Safety, Hepatitis, Sexually Transmitted Infections (STI) and HIV Service, National Infection Service, Public Health England, London, UK
| | - Koh Jun Ong
- Blood Safety, Hepatitis, Sexually Transmitted Infections (STI) and HIV Service, National Infection Service, Public Health England, London, UK
| | - Martina Furegato
- Blood Safety, Hepatitis, Sexually Transmitted Infections (STI) and HIV Service, National Infection Service, Public Health England, London, UK
| | - Victoria Hall
- Blood Safety, Hepatitis, Sexually Transmitted Infections (STI) and HIV Service, National Infection Service, Public Health England, London, UK
| | - Monica Desai
- Blood Safety, Hepatitis, Sexually Transmitted Infections (STI) and HIV Service, National Infection Service, Public Health England, London, UK
| | - John Michael Saunders
- Blood Safety, Hepatitis, Sexually Transmitted Infections (STI) and HIV Service, National Infection Service, Public Health England, London, UK.,Centre for Clinical Research in Infection and Sexual Health, Institute for Global Health, University College London, London, UK
| | - Gwenda Hughes
- Blood Safety, Hepatitis, Sexually Transmitted Infections (STI) and HIV Service, National Infection Service, Public Health England, London, UK
| | - Nigel Field
- Blood Safety, Hepatitis, Sexually Transmitted Infections (STI) and HIV Service, National Infection Service, Public Health England, London, UK.,Centre for Molecular Epidemiology and Translational Research, Institute for Global Health, University College London, London, UK
| | - O Noel Gill
- Blood Safety, Hepatitis, Sexually Transmitted Infections (STI) and HIV Service, National Infection Service, Public Health England, London, UK
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14
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King C, Hughes G, Furegato M, Mohammed H, Were J, Copas A, Gilson R, Shahmanesh M, Mercer CH. Predicting STI Diagnoses Amongst MSM and Young People Attending Sexual Health Clinics in England: Triage Algorithm Development and Validation Using Routine Clinical Data. EClinicalMedicine 2018; 4-5:43-51. [PMID: 31193629 PMCID: PMC6537562 DOI: 10.1016/j.eclinm.2018.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 10/16/2018] [Accepted: 11/15/2018] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Sexual health (SH) services increasingly need to prioritise those at greatest risk of sexually transmitted infections (STIs). We used SH surveillance data to develop algorithms to triage individuals attending SH services within two high-risk populations: men who have sex with men (MSM) and young people (YP). METHODS Separate multivariable logistic regression models for MSM and YP were developed using surveillance data on demographics, recent sexual history, prior STI diagnoses and drug/alcohol use from five clinics in 2015-2016 to identify factors associated with new STI diagnoses. The models were prospectively applied in one SH clinic in May 2017 as an external validation. FINDINGS 9530 YP and 1448 MSM SH episodes informed model development. For YP, factors associated with new STI diagnosis (overall prevalence: 10.6%) were being of black or mixed white/black ethnicity; history of chlamydia diagnosis (previous year); and multiple partners/new partner (previous 3-months). The YPs model had reasonable performance (c-statistic: 0.703), but poor discrimination when externally validated (c-statistic: 0.539). For MSM, being of South Asian ethnicity; being born in Europe (excluding the UK); and condomless anal sex or drug use (both in previous 3-months) were associated with STI diagnosis (overall prevalence: 22.0%). The MSM model had a c-statistic of 0.676, reducing to 0.579 on validation. INTERPRETATION SH surveillance data, including limited behavioural data, enabled triage algorithms to be developed, but its implementation may be problematic due to poor external performance. This approach may be more suitable to self-triage, including online, ensuring patients are directed towards appropriate services. FUNDING NIHR HTA programme (12/191/05).
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Affiliation(s)
- Carina King
- Institute for Global Health, University College London, 30 Guilford Street, London, UK
- Corresponding author at: Institute for Global Health, 30 Guilford Street, London WC1N 1EH, UK.
| | - Gwenda Hughes
- Institute for Global Health, University College London, 30 Guilford Street, London, UK
- Department of HIV & STIs, Centre for Infectious Disease Surveillance & Control, Public Health England, 61 Colindale Avenue, London, UK
| | - Martina Furegato
- Department of HIV & STIs, Centre for Infectious Disease Surveillance & Control, Public Health England, 61 Colindale Avenue, London, UK
- Applied Diagnostic Research and Evaluation Unit, St George's University of London, Cranmer Terrace, London, UK
| | - Hamish Mohammed
- Institute for Global Health, University College London, 30 Guilford Street, London, UK
- Department of HIV & STIs, Centre for Infectious Disease Surveillance & Control, Public Health England, 61 Colindale Avenue, London, UK
| | - John Were
- Department of HIV & STIs, Centre for Infectious Disease Surveillance & Control, Public Health England, 61 Colindale Avenue, London, UK
| | - Andrew Copas
- Institute for Global Health, University College London, 30 Guilford Street, London, UK
| | - Richard Gilson
- Institute for Global Health, University College London, 30 Guilford Street, London, UK
| | - Maryam Shahmanesh
- Institute for Global Health, University College London, 30 Guilford Street, London, UK
| | - Catherine H Mercer
- Institute for Global Health, University College London, 30 Guilford Street, London, UK
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15
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Hill-Tout R, Harding-Esch EM, Pacho A, Furegato M, Fuller SS, Sadiq ST. Health-related quality of life and psychosocial impacts of a diagnosis of non-specific genital infection in symptomatic heterosexual men attending UK sexual health clinics: a feasibility study. BMJ Open 2018; 8:e018213. [PMID: 29960999 PMCID: PMC6042625 DOI: 10.1136/bmjopen-2017-018213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Non-specific genital infection (NSGI; non-Chlamydia trachomatis, non-Neisseria gonorrhoeae-associated urethritis) is a common diagnosis in symptomatic heterosexual men attending UK sexual health clinics (SHCs). but little is known about the psychosocial impact of this diagnosis. METHODS We conducted an observational study among symptomatic heterosexual men attending SHCs to evaluate the psychosocial impact of an NSGI diagnosis compared with a diagnosis of Chlamydia trachomatis (CT), Neisseria gonorrhoeae or no abnormalities detected focusing on the feasibility of our study methodology. Participants completed a computer-assisted self-interviewing (CASI) including two validated measures of psychosocial impact: the EQ-5D-5L health-related quality of life and Rosenberg Self-Esteem Scale, before diagnostic testing and 2 weeks after receiving test results (follow-up 1 (FU-1)) and a qualitative interview. We compared scores between diagnostic groups using paired t-tests, qualitative data were analysed thematically and feasibility was assessed by process analysis. RESULTS 60 men completed the baseline CASI (75% response rate). 46 (76.6%) were eligible for follow-up; 11/46 (23.9%) completed the follow-up CASI, and 3/11 (27.3%) completed the qualitative interview. 81.7% of all participants left CASI feedback at baseline: 73.5% reported the questionnaire as 'fine' or 'very good'. Qualitative interview participants reported the study was acceptable. Compared with baseline, among patients completing FU-1, only patients with a diagnosis of NSGI (p<0.05) or CT (p<0.05) showed increased EQ-5D-5L Index, whereas patients with a diagnosis of NSGI (p=0.05) showed decreased mean Rosenberg Self-Esteem Scale score. CONCLUSIONS Although most participants indicated study acceptability at baseline, and we employed measures to increase retention (CASI questionnaires, reminder messages and a focus on men's health), we experienced high loss to follow-up. We found that heterosexual men attending SHCs with symptoms of urethritis experience both positive and negative psychosocial impacts following their clinic attendance, which warrants further investigation.
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Affiliation(s)
- Rachel Hill-Tout
- St Georges University Hospitals NHS Foundation Trust, London, UK
- Public Health England, London, UK
| | - Emma M Harding-Esch
- Public Health England, London, UK
- Applied Diagnostic Research and Evaluation Unit, Institute for Infection & Immunity St George's, University of London, London, UK
| | - Agata Pacho
- Applied Diagnostic Research and Evaluation Unit, Institute for Infection & Immunity St George's, University of London, London, UK
| | - Martina Furegato
- Public Health England, London, UK
- Applied Diagnostic Research and Evaluation Unit, Institute for Infection & Immunity St George's, University of London, London, UK
| | - Sebastian S Fuller
- Applied Diagnostic Research and Evaluation Unit, Institute for Infection & Immunity St George's, University of London, London, UK
| | - Syed Tariq Sadiq
- St Georges University Hospitals NHS Foundation Trust, London, UK
- Public Health England, London, UK
- Applied Diagnostic Research and Evaluation Unit, Institute for Infection & Immunity St George's, University of London, London, UK
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16
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Furegato M, Fifer H, Mohammed H, Simms I, Vanta P, Webb S, Foster K, Kingston M, Charlett A, Vishram B, Reynolds C, Gill N, Hughes G. Factors associated with four atypical cases of congenital syphilis in England, 2016 to 2017: an ecological analysis. ACTA ACUST UNITED AC 2018; 22. [PMID: 29233254 PMCID: PMC5727590 DOI: 10.2807/1560-7917.es.2017.22.49.17-00750] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Four isolated cases of congenital syphilis born to mothers who screened syphilis negative in the first trimester were identified between March 2016 and January 2017 compared with three cases between 2010 and 2015. The mothers were United Kingdom-born and had no syphilis risk factors. Cases occurred in areas with recent increases in sexually-transmitted syphilis among women and men who have sex with men, some behaviourally bisexual, which may have facilitated bridging between sexual networks.
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Affiliation(s)
- Martina Furegato
- HIV & STI Department, Public Health England, Colindale, London, United Kingdom
| | - Helen Fifer
- Bacteriology Reference Department, National Infection Service, Public Health England, Colindale, London, United Kingdom
| | - Hamish Mohammed
- HIV & STI Department, Public Health England, Colindale, London, United Kingdom
| | - Ian Simms
- HIV & STI Department, Public Health England, Colindale, London, United Kingdom
| | - Paul Vanta
- HIV & STI Department, Public Health England, Colindale, London, United Kingdom
| | - Sharon Webb
- NHS Infectious Diseases in Pregnancy Screening Programme, PHE Screening, London, United Kingdom
| | - Kirsty Foster
- HIV & STI Department, Public Health England, Colindale, London, United Kingdom
| | - Margaret Kingston
- The Northern Integrated Contraception, Sexual Health & HIV Service, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - André Charlett
- Statistics, Modelling and Economics Department, National Infection Service, Public Health England, Colindale, London, United Kingdom
| | - Bhavita Vishram
- NHS Blood & Transplant/PHE Epidemiology Unit, Public Health England, Colindale, London, United Kingdom
| | - Claire Reynolds
- NHS Blood & Transplant/PHE Epidemiology Unit, Public Health England, Colindale, London, United Kingdom
| | - Noel Gill
- HIV & STI Department, Public Health England, Colindale, London, United Kingdom
| | - Gwenda Hughes
- HIV & STI Department, Public Health England, Colindale, London, United Kingdom
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17
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Mohammed H, Blomquist P, Ogaz D, Duffell S, Furegato M, Checchi M, Irvine N, Wallace LA, Thomas DR, Nardone A, Dunbar JK, Hughes G. 100 years of STIs in the UK: a review of national surveillance data. Sex Transm Infect 2018; 94:553-558. [DOI: 10.1136/sextrans-2017-053273] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 03/02/2018] [Accepted: 03/24/2018] [Indexed: 11/04/2022] Open
Abstract
ObjectivesThe 1916 Royal Commission on Venereal Diseases was established in response to epidemics of syphilis and gonorrhoea in the UK. In the 100 years since the Venereal Diseases Act (1917), the UK has experienced substantial scientific, economic and demographic changes. We describe historical and recent trends in STIs in the UK.MethodsWe analysed surveillance data derived from STI clinics’ statistical returns from 1917 to 2016.ResultsSince 1918, gonorrhoea and syphilis diagnoses have fluctuated, reflecting social, economic and technological trends. Following spikes after World Wars I and II, rates declined before re-emerging during the 1960s. At that time, syphilis was more common in men, suggestive of transmission within the men who have sex with men (MSM) population. Behaviour change following the emergence of HIV/AIDS in the 1980s is thought to have facilitated a precipitous decline in diagnoses of both STIs in the mid-1980s. Since the early 2000s, gonorrhoea and syphilis have re-emerged as major public health concerns due to increased transmission among MSM and the spread of antimicrobial-resistant gonorrhoea. Chlamydia and genital warts are now the most commonly diagnosed STIs in the UK and have been the focus of public health interventions, including the national human papillomavirus vaccination programme, which has led to substantial declines in genital warts in young people, and the National Chlamydia Screening Programme in England. Since the 1980s, MSM, black ethnic minorities and young people have experienced the highest STI rates.ConclusionAlthough diagnoses have fluctuated over the last century, STIs continue to be an important public health concern, often affecting more marginalised groups in society. Prevention must remain a public health priority and, as we enter a new era of sexual healthcare provision including online services, priority must be placed on maintaining prompt access for those at greatest risk of STIs.
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18
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Clifton S, Town K, Furegato M, Cole M, Mohammed H, Woodhall SC, Kevin Dunbar J, Fifer H, Hughes G. Is previous azithromycin treatment associated with azithromycin resistance in Neisseria gonorrhoeae? A cross-sectional study using national surveillance data in England. Sex Transm Infect 2018; 94:421-426. [PMID: 29511067 DOI: 10.1136/sextrans-2017-053461] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Revised: 01/10/2018] [Accepted: 01/15/2018] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVES It has been suggested that treatment of STIs with azithromycin may facilitate development of azithromycin resistance in Neisseria gonorrhoeae (NG) by exposing the organism to suboptimal doses. We investigated whether treatment history for non-rectal Chlamydia trachomatis (CT), non-gonococcal urethritis (NGU) or NG (proxies for azithromycin exposure) in sexual health (GUM) services was associated with susceptibility of NG to azithromycin. METHODS Azithromycin susceptibility data from the Gonococcal Resistance to Antimicrobials Surveillance Programme (GRASP 2013-2015, n=4606) and additional high-level azithromycin-resistant isolates (HL-AziR) identified by the Public Health England reference laboratory (2013-2016, n=54) were matched to electronic patient records in the national GUMCAD STI surveillance dataset (2012-2016). Descriptive and regression analyses were conducted to examine associations between history of previous CT/NGU/NG and subsequent susceptibility of NG to azithromycin. RESULTS Modal azithromycin minimum inhibitory concentration (MIC) was 0.25 mg/L (one dilution below the resistance breakpoint) in those with and without history of previous CT/NGU/NG (previous 1 month/6 months). There were no differences in MIC distribution by history of CT/NGU (P=0.98) or NG (P=0.85) in the previous 1 month/6 months or in the odds of having an elevated azithromycin MIC (>0.25 mg/L) (Adjusted OR for CT/NGU 0.97 (95% CI 0.76 to 1.25); adjusted OR for NG 0.82 (95% CI: 0.65 to 1.04)) compared with those with no CT/NGU/NG in the previous 6 months. Among patients with HL-AziR NG, 3 (4%) were treated for CT/NGU and 2 (3%) for NG in the previous 6 months, compared with 6% and 8%, respectively for all GRASP patients. CONCLUSIONS We found no evidence of an association between previous treatment for CT/NGU or NG in GUM services and subsequent presentation with an azithromycin-resistant strain. As many CT diagnoses occur in non-GUM settings, further research is needed to determine whether azithromycin-resistant NG is associated with azithromycin exposure in other settings and for other conditions.
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Affiliation(s)
- Soazig Clifton
- Centre for Population Research in Sexual Health and HIV, Institute for Global Health, University College London, London, UK
| | - Katy Town
- National Infection Service, Public Health England, London, UK
| | | | - Michelle Cole
- National Infection Service, Public Health England, London, UK
| | - Hamish Mohammed
- National Infection Service, Public Health England, London, UK
| | | | - J Kevin Dunbar
- National Infection Service, Public Health England, London, UK
| | - Helen Fifer
- National Infection Service, Public Health England, London, UK
| | - Gwenda Hughes
- National Infection Service, Public Health England, London, UK
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Hibbert M, Wolton A, Crenna-Jennings W, Benton L, Kirwan P, Lut I, Okala S, Ross M, Furegato M, Nambiar K, Douglas N, Roche J, Jeffries J, Reeves I, Nelson M, Weerawardhana C, Jamal Z, Hudson A, Delpech V. Experiences of stigma and discrimination in social and healthcare settings among trans people living with HIV in the UK. AIDS Care 2018; 30:836-843. [PMID: 29409344 DOI: 10.1080/09540121.2018.1436687] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The People Living with HIV StigmaSurvey UK 2015 was a community led national survey investigating experiences of people living with HIV in the UK in the past 12 months. Participants aged 18 and over were recruited through over 120 cross-sector community organisations and 46 HIV clinics to complete an anonymous online survey. Trans is an umbrella term which refers to individuals whose current gender identity is different to the gender they were assigned at birth. Trans participants self-identified via gender identity and gender at birth questions. Descriptive analyses of reported experiences in social and health care settings were conducted and multivariate logistic regression analyses were used to identify sociodemographic predictors of reporting being treated differently to non-HIV patients, and being delayed or refused healthcare treatment in the past 12 months. 31 out of 1576 participants (2%) identified as trans (19 trans women, 5 trans men, 2 gender queer/non-binary, 5 other). High levels of social stigma were reported for all participants, with trans participants significantly more likely to report worrying about verbal harassment (39% vs. 23%), and exclusion from family gatherings (23% vs. 9%) in the last 12 months, compared to cisgender participants. Furthermore, 10% of trans participants reported physical assault in the last 12 months, compared to 4% of cisgender participants. Identifying as trans was a predictor of reporting being treated differently to non-HIV patients (48% vs. 30%; aOR 2.61, CI 1.06, 6.42) and being delayed or refused healthcare (41% vs. 16%; aOR 4.58, CI 1.83, 11.44). Trans people living with HIV in the UK experience high levels of stigma and discrimination, including within healthcare settings, which is likely to impact upon health outcomes. Trans-specific education and awareness within healthcare settings could help to improve service provision for this demographic.
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Affiliation(s)
- M Hibbert
- a HIV & STI Department , Public Health England , London , UK
| | - A Wolton
- b StigmaIndexUK, FPA , London , UK.,c CliniQ , London , UK.,d Chelsea & Westminster Hospital , London , UK
| | | | | | - P Kirwan
- a HIV & STI Department , Public Health England , London , UK
| | | | - S Okala
- a HIV & STI Department , Public Health England , London , UK
| | - M Ross
- b StigmaIndexUK, FPA , London , UK.,c CliniQ , London , UK
| | - M Furegato
- a HIV & STI Department , Public Health England , London , UK
| | - K Nambiar
- f Brighton and Sussex University NHS Trust , Brighton , UK
| | - N Douglas
- g Policy Innovation Research Unit , London School of Hygiene and Tropical Medicine , London , UK
| | | | | | - I Reeves
- h Homerton University Hospital , London , UK
| | - M Nelson
- d Chelsea & Westminster Hospital , London , UK
| | | | | | - A Hudson
- b StigmaIndexUK, FPA , London , UK.,e FPA , London , UK
| | - V Delpech
- a HIV & STI Department , Public Health England , London , UK
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20
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Brown AE, Mohammed H, Ogaz D, Kirwan PD, Yung M, Nash SG, Furegato M, Hughes G, Connor N, Delpech VC, Gill ON. Fall in new HIV diagnoses among men who have sex with men (MSM) at selected London sexual health clinics since early 2015: testing or treatment or pre-exposure prophylaxis (PrEP)? ACTA ACUST UNITED AC 2017; 22:30553. [PMID: 28662762 PMCID: PMC5490453 DOI: 10.2807/1560-7917.es.2017.22.25.30553] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 06/20/2017] [Indexed: 11/27/2022]
Abstract
Since October 2015 up to September 2016, HIV diagnoses fell by 32% compared with October 2014–September 2015 among men who have sex with men (MSM) attending selected London sexual health clinics. This coincided with high HIV testing volumes and rapid initiation of treatment on diagnosis. The fall was most apparent in new HIV testers. Intensified testing of high-risk populations, combined with immediately received anti-retroviral therapy and a pre-exposure prophylaxis (PrEP) programme, may make elimination of HIV achievable.
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Affiliation(s)
- Alison E Brown
- HIV & STI Department, Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, London, United Kingdom.,These authors contributed equally to this work and share first authorship
| | - Hamish Mohammed
- HIV & STI Department, Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, London, United Kingdom.,These authors contributed equally to this work and share first authorship
| | - Dana Ogaz
- HIV & STI Department, Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, London, United Kingdom
| | - Peter D Kirwan
- HIV & STI Department, Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, London, United Kingdom
| | - Mandy Yung
- HIV & STI Department, Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, London, United Kingdom
| | - Sophie G Nash
- HIV & STI Department, Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, London, United Kingdom
| | - Martina Furegato
- HIV & STI Department, Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, London, United Kingdom
| | - Gwenda Hughes
- HIV & STI Department, Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, London, United Kingdom
| | - Nicky Connor
- HIV & STI Department, Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, London, United Kingdom
| | - Valerie C Delpech
- HIV & STI Department, Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, London, United Kingdom
| | - O Noel Gill
- HIV & STI Department, Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, London, United Kingdom
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21
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Mirandola M, Gios L, Joanna Davis R, Furegato M, Breveglieri M, Folch C, Staneková D, Nita I, Stehlíková D. Socio-demographic factors predicting HIV test seeking behaviour among MSM in 6 EU cities. Eur J Public Health 2017; 27:313-318. [PMID: 27615734 DOI: 10.1093/eurpub/ckw144] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background HIV testing is generally accepted as being the lynchpin of a prevention strategy to tackle the HIV epidemic among MSM. However, few studies have analysed in detail the factors that influence HIV test seeking behaviour. Methods The objective of this article is to analyse the relationship between HIV test seeking behaviour and individual, social and demographic factors in a sample of MSM recruited though a multi-centre bio-behavioural cross-sectional study. A multi-level analysis was conducted to identify factors associated with HIV test seeking behaviour. Results A total of 2400 men were included in the sample. Age, self-reported sexual orientation, residence, household composition, educational status and perceived homonegativity all seem to impact on test seeking behaviour. Conclusions The results suggest the need for more targeted testing promotion strategies among MSM that take structural and environmental factors into consideration, as part of a comprehensive public health strategy to address the HIV epidemic.
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Affiliation(s)
- Massimo Mirandola
- CReMPE - Regional Coordination Centre for European Project Management Veneto Region - Department of Health, Verona University Hospital, Verona, Italy.,Infectious Diseases Section, Department of Pathology, Verona University Hospital - Veneto Region, Verona, Italy
| | - Lorenzo Gios
- CReMPE - Regional Coordination Centre for European Project Management Veneto Region - Department of Health, Verona University Hospital, Verona, Italy
| | - Ruth Joanna Davis
- CReMPE - Regional Coordination Centre for European Project Management Veneto Region - Department of Health, Verona University Hospital, Verona, Italy
| | - Martina Furegato
- CReMPE - Regional Coordination Centre for European Project Management Veneto Region - Department of Health, Verona University Hospital, Verona, Italy
| | - Michele Breveglieri
- CReMPE - Regional Coordination Centre for European Project Management Veneto Region - Department of Health, Verona University Hospital, Verona, Italy
| | - Cinta Folch
- Centre for Epidemiological Studies on HIV/STI in Catalonia (CEEISCAT), Agencia de Salut Publica de Catalunya (ASPC), Hospital Universitari Germans Trias i Pujol, Barcelona, Spain.,CIBER Epidemiología y Salud Pública (CIBERESP), Spain
| | - Danica Staneková
- NRC for HIV/AIDS, Slovak Medical University, Bratislava, Slovak Republic
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22
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Furegato M, Mitchell H, Ogaz D, Woodhall S, Connor N, Hughes G, Nardone A, Mohammed H. The role of frequent HIV testing in diagnosing HIV in men who have sex with men. HIV Med 2017; 19:118-122. [PMID: 28984407 DOI: 10.1111/hiv.12558] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVES In the UK, quarterly HIV testing is recommended for high-risk men who have sex with men (MSM). In this manuscript we determined the risk of being newly diagnosed with HIV in MSM by their HIV testing history, considering both the frequency and periodicity of testing. METHODS Data on HIV incidence in MSM attending a sexual health clinic (SHC) in England in 2013-2014 with testing history (previous 2 years) were obtained from GUMCAD, the national sexually transmitted infection (STI) surveillance system in England. HIV testing patterns among MSM were defined using the frequency and periodicity of testing, based on 3 month intervals, in the year preceding the first attendance during the study period. Cox proportional hazards regression was used to determine the association between HIV testing pattern and time to HIV diagnosis with and without adjustment for demographic confounders. Analyses were stratified by risk stratum, with 'high risk' defined as a history of a bacterial STI in the past year. Adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs) are reported. RESULTS Among the 37 702 HIV-negative MSM attending an SHC in 2013-2014, 1105 (3%) were diagnosed with HIV infection within 1 year of their first attendance. The probability of HIV diagnosis was highest in MSM who were tested quarterly compared with those who were not tested in the past year (aHR 2.51; 95% CI 1.33-4.74); this increased 1.8-fold among high-risk MSM (aHR 4.48; 95% CI 0.97-21.17). CONCLUSIONS The probability of subsequent HIV diagnosis was greatest in high-risk MSM who were tested most frequently. Quarterly HIV testing increased the likelihood of identifying undiagnosed HIV infection and should remain a continued recommendation for high-risk MSM.
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Affiliation(s)
- M Furegato
- National Infection Service, Public Health England, London, UK
| | - H Mitchell
- National Infection Service, Public Health England, London, UK
| | - D Ogaz
- National Infection Service, Public Health England, London, UK
| | - S Woodhall
- National Infection Service, Public Health England, London, UK
| | - N Connor
- National Infection Service, Public Health England, London, UK
| | - G Hughes
- National Infection Service, Public Health England, London, UK
| | - A Nardone
- National Infection Service, Public Health England, London, UK
| | - H Mohammed
- National Infection Service, Public Health England, London, UK
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23
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Wayal S, Hughes G, Sonnenberg P, Mohammed H, Copas AJ, Gerressu M, Tanton C, Furegato M, Mercer CH. Ethnic variations in sexual behaviours and sexual health markers: findings from the third British National Survey of Sexual Attitudes and Lifestyles (Natsal-3). Lancet Public Health 2017; 2:e458-e472. [PMID: 29057382 PMCID: PMC5639148 DOI: 10.1016/s2468-2667(17)30159-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Sexual health entails the absence of disease and the ability to lead a pleasurable and safe sex life. In Britain, ethnic inequalities in diagnoses of sexually transmitted infections (STI) persist; however, the reasons for these inequalities, and ethnic variations in other markers of sexual health, remain poorly understood. We investigated ethnic differences in hypothesised explanatory factors such as socioeconomic factors, substance use, depression, and sexual behaviours, and whether they explained ethnic variations in sexual health markers (reported STI diagnoses, attendance at sexual health clinics, use of emergency contraception, and sexual function). METHODS We analysed probability survey data from Britain's third National Survey of Sexual Attitudes and Lifestyles (Natsal-3; n=15 162, conducted in 2010-12). Reflecting Britain's current ethnic composition, we included in our analysis participants who identified in 2011 as belonging to one of the following seven largest ethnic groups: white British, black Caribbean, black African, Indian, Pakistani, white other, and mixed ethnicity. We calculated age-standardised estimates and age-adjusted odds ratios for all explanatory factors and sexual health markers for all these ethnic groups with white British as the reference category. We used multivariable regression to examine the extent to which adjusting for explanatory factors explained ethnic variations in sexual health markers. FINDINGS We included 14 563 (96·0%) of the 15 162 participants surveyed in Natsal-3. Greater proportions of black Caribbean, black African, and Pakistani people lived in deprived areas than those of other ethnic groups (36·9-55·3% vs 16·4-29·4%). Recreational drug use was highest among white other and mixed ethnicity groups (25·6-27·7% in men and 10·3-12·9% in women in the white other and mixed ethnicity groups vs 4·1-15·6% in men and 1·0-11·2% in women of other ethnicities). Compared with white British men, the proportions of black Caribbean and black African men reporting being sexually competent at sexual debut were lower (32·9% for black Caribbean and 21·9% for black African vs 47·4% for white British) and the number of partners in the past 5 years was greater (median 2 [IQR 1-4] for black Caribbean and 2 [1-5] for black African vs 1 [1-2] for white British), and although black Caribbean and black African men reported greater proportions of concurrent partnerships (26·5% for black Caribbean and 38·9% for black African vs 14·8% for white British), these differences were not significant after adjusting for age. Compared with white British women, the proportions of black African and mixed ethnicity women reporting being sexually competent were lower (18·0% for black African and 35·3% for mixed ethnicity vs 47·9% for white British), and mixed ethnicity women reported larger numbers of partners in the past 5 years (median 1 [IQR 1-4] vs 1 [1-2]) and greater concurrency (14·3% vs 8·0%). Reporting STI diagnoses was higher in black Caribbean men (8·7%) and mixed ethnicity women (6·7%) than white British participants (3·6% in men and 3·2% in women). Use of emergency contraception was most commonly reported among black Caribbean women (30·7%). Low sexual function was most common among women of white other ethnicity (30·1%). Adjustment for explanatory factors only partly explained inequalities among some ethnic groups relative to white British ethnicity but did not eliminate ethnic differences in these markers. INTERPRETATION Ethnic inequalities in sexual health markers exist, and they were not fully explained by differences in their broader determinants. Holistic interventions addressing modifiable risk factors and targeting ethnic groups at risk of poor sexual health are needed. FUNDING Medical Research Council, the Wellcome Trust, the Economic and Social Research Council, UK Department of Health, and The National Institute for Health Research.
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Affiliation(s)
- Sonali Wayal
- Institute for Global Health, University College London (UCL), London, UK
- HIV & STI Department, Public Health England, Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, London, UK
- The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections at UCL in partnership with Public Health England (PHE) and in collaboration with the London School of Hygiene & Tropical Medicine, London, UK
| | - Gwenda Hughes
- Institute for Global Health, University College London (UCL), London, UK
- HIV & STI Department, Public Health England, Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, London, UK
- The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections at UCL in partnership with Public Health England (PHE) and in collaboration with the London School of Hygiene & Tropical Medicine, London, UK
| | - Pam Sonnenberg
- Institute for Global Health, University College London (UCL), London, UK
| | - Hamish Mohammed
- Institute for Global Health, University College London (UCL), London, UK
- HIV & STI Department, Public Health England, Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, London, UK
| | - Andrew J Copas
- Institute for Global Health, University College London (UCL), London, UK
| | - Makeda Gerressu
- Institute for Global Health, University College London (UCL), London, UK
| | - Clare Tanton
- Institute for Global Health, University College London (UCL), London, UK
| | - Martina Furegato
- HIV & STI Department, Public Health England, Centre for Infectious Disease Surveillance and Control (CIDSC), Public Health England, London, UK
| | - Catherine H Mercer
- Institute for Global Health, University College London (UCL), London, UK
- The National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Blood Borne and Sexually Transmitted Infections at UCL in partnership with Public Health England (PHE) and in collaboration with the London School of Hygiene & Tropical Medicine, London, UK
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24
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Foley E, Furegato M, Hughes G, Board C, Hayden V, Prescott T, Shone E, Patel R. Inequalities in access to genitourinary medicine clinics in the UK: results from a mystery shopper survey. Sex Transm Infect 2017; 93:472-475. [PMID: 28377420 DOI: 10.1136/sextrans-2016-052882] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 02/19/2017] [Accepted: 02/25/2017] [Indexed: 11/04/2022] Open
Abstract
STUDY DESIGN This study investigated whether access to genitourinary medicine (GUM) clinics meets UK-recommended standards. METHODS In January 2014 and 2015, postal questionnaires about appointment and service characteristics were sent to lead clinicians of UK GUM clinics. In February 2014 and 2015, researchers posing as symptomatic and asymptomatic 'patients' contacted clinics by telephone, requesting to be seen. Clinic and patient characteristics associated with the offer of an appointment within 48 hours were examined using unadjusted and UK country and patient gender adjusted multivariable logistic regression analyses. In March 2015, a convenience sample (one in four) of clinics was visited by researchers with the same clinical symptoms. Ability to achieve a same-day consultation and waiting time were assessed. RESULTS In 2015, 90.8% of clinics offered symptomatic 'patients' an appointment within 48 hours when contacted by telephone, compared with 95.5% in 2014 (aOR=0.46 (0.26 to 0.83); p<0.01). The decline was greatest in women (96.0% to 90.1%; p<0.05), and clinics in England (96.2% to 90.7%; p<0.01). For asymptomatic patients, the proportion offered an appointment within 48 hours increased from 50.7% in 2014 to 74.5% in 2015 (aOR=3.06 (2.23 to 4.22); p<0.001), and in both men (58.2% to 90.8%; p<0.001) and women (49.0% to 59.6%; p<0.01). In adjusted analysis, asymptomatic women were significantly less likely to be offered an appointment than asymptomatic men (aOR=0.33 (0.23 to 0.45); p value<0.001). 95% of clinics were able to see symptomatic patients attending in person. CONCLUSIONS Access to GUM services has worsened for those with symptoms suggestive of an acute STI and is significantly poorer for asymptomatic women. This evidence may support the reintroduction of process targets.
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Affiliation(s)
- Elizabeth Foley
- Department of Sexual Health, Solent NHS Trust, Royal South Hants Hospital, Southampton, UK
| | | | - Gwenda Hughes
- Department of HIV and STIs, Public Health England, London, UK
| | | | - Vanessa Hayden
- Southampton University School of Medicine, Southampton, UK
| | | | - Eleanor Shone
- Southampton University School of Medicine, Southampton, UK
| | - Rajul Patel
- Solent NHS Trust, Southampton University School of Medicine, Southampton, UK
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25
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Affiliation(s)
- Hamish Mohammed
- HIV and STI Department, National Infection Service, Public Health England, London NW9 5EQ, UK
| | - Bersabeh Sile
- HIV and STI Department, National Infection Service, Public Health England, London NW9 5EQ, UK
| | - Martina Furegato
- HIV and STI Department, National Infection Service, Public Health England, London NW9 5EQ, UK
| | - Sarah Woodhall
- HIV and STI Department, National Infection Service, Public Health England, London NW9 5EQ, UK
| | - Helen Fifer
- HIV and STI Department, National Infection Service, Public Health England, London NW9 5EQ, UK
| | - Gwenda Hughes
- HIV and STI Department, National Infection Service, Public Health England, London NW9 5EQ, UK
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26
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Mebrahtu H, Furegato M, Sile B, Were J, Mohammed H, Hughes G. Access of non-specialist sexual health services by men who have sex with men: do they differ from those attending specialist services? Sex Transm Infect 2016; 94:72-74. [PMID: 27888206 DOI: 10.1136/sextrans-2016-052755] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 09/30/2016] [Accepted: 10/29/2016] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Men who have sex with men (MSM) bear a disproportionate burden of STIs. While routine STI surveillance data suggest MSM regularly access specialist genitourinary medicine (GUM) clinics for their sexual healthcare, the extent to which MSM attend non-specialist sexual health services (SHSs) is unclear. METHODS We used data from the GUM Clinic Activity Data Set (GUMCADv2), the national STI surveillance system, to compare the characteristics, service usage and STI outcomes of MSM accessing specialist and non-specialist (non-GUM) SHSs in England in 2014. Pearson's χ2, Student's t-test and logistic regression analysis were used. RESULTS Where sexual orientation was recorded (92%), 11% (4552/41 597) of non-GUM attendances were among MSM compared with 28% (280 466/999 331) of GUM attendances (p<0.001). Compared with those attending GUM services, MSM attending non-GUM services were younger (mean age: 30.2 years vs 37.7 years; p<0.001) and were more likely to be of mixed ethnicity (4.9% vs 3.5%; p<0.001), to have had a full sexual health screen (chlamydia, gonorrhoea, syphilis and HIV tests) (48.0% vs 37.0%; p<0.001) and to be diagnosed with chlamydia (7.4% vs 4.1%; p<0.001) and gonorrhoea (8.5% vs 6.5%: p<0.001). MSM attending non-GUM services had slightly lower HIV test uptake (87.0% vs 95.0%; p=0.157) and were less likely to be diagnosed with HIV (0.5% vs 0.8%; p=0.019), compared with those attending GUM clinics. CONCLUSIONS Non-specialist SHSs play an important role in the care of MSM and should ensure services meet their needs.
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27
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Mitchell H, Furegato M, Hughes G, Field N, Nardone A. What are the characteristics of, and clinical outcomes in men who have sex with men prescribed HIV postexposure prophylaxis following sexual exposure (PEPSE) at sexual health clinics in England? Sex Transm Infect 2016; 93:207-213. [PMID: 27884964 DOI: 10.1136/sextrans-2016-052806] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 10/17/2016] [Accepted: 10/29/2016] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To explore the risk factors for, and clinical outcomes in men who have sex with men (MSM) prescribed HIV postexposure prophylaxis following sexual exposure (PEPSE) at sexual health clinics (SHCs) in England. METHODS National STI surveillance data were extracted from the genitourinary medicine clinic activity dataset (GUMCADv2) for 2011-2014. Quarterly and annual trends in the number of episodes where PEPSE was prescribed were analysed by gender and sexual risk. Risk factors associated with being prescribed PEPSE among MSM attendees were explored using univariable and multivariable logistic regression. Subsequent HIV acquisition from 4 months after initiating PEPSE was assessed using multivariable Cox proportional hazards models, stratified by clinical risk profiles. RESULTS During 2011-2014, there were 24 004 episodes where PEPSE was prescribed at SHCs, of which 69% were to MSM. The number of episodes where PEPSE was prescribed to MSM increased from 2383 in 2011 to 5944 in 2014, and from 1384 to 2226 for heterosexual men and women. 15% of MSM attendees received two or more courses of PEPSE. Compared with MSM attendees not prescribed PEPSE, MSM prescribed PEPSE were significantly more likely to have been diagnosed with a bacterial STI in the previous 12 months (adjusted OR (95% CI)-gonorrhoea: 11.6 (10.5 to 12.8); chlamydia: 5.02 (4.46 to 5.67); syphilis: 2.25 (1.73 to 2.93)), and were more likely to subsequently acquire HIV (adjusted HR (aHR) (95% CI)-single PEPSE course: 2.54 (2.19 to 2.96); two or more PEPSE courses: aHR (95% CI) 4.80 (3.69 to 6.25)). The probability of HIV diagnosis was highest in MSM prescribed PEPSE who had also been diagnosed with a bacterial STI in the previous 12 months (aHR (95% CI): 6.61 (5.19 to 8.42)). CONCLUSIONS MSM prescribed PEPSE are at high risk of subsequent HIV acquisition and our data show further risk stratification by clinical and PEPSE prescribing history is possible, which might inform clinical practice and HIV prevention initiatives in MSM.
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Affiliation(s)
- Holly Mitchell
- HIV & STI Department, National Infection Service, Public Health England, London, UK
| | - Martina Furegato
- HIV & STI Department, National Infection Service, Public Health England, London, UK
| | - Gwenda Hughes
- HIV & STI Department, National Infection Service, Public Health England, London, UK
| | - Nigel Field
- HIV & STI Department, National Infection Service, Public Health England, London, UK.,Research Department of Infection & Population Health, University College London, London, UK
| | - Anthony Nardone
- HIV & STI Department, National Infection Service, Public Health England, London, UK
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28
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Mohammed H, Dabrera G, Furegato M, Yin Z, Nardone A, Hughes G. Refusal of HIV testing among black Africans attending sexual health clinics in England, 2014: a review of surveillance data. Sex Transm Infect 2016; 93:217-220. [PMID: 27672177 DOI: 10.1136/sextrans-2016-052737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 09/01/2016] [Accepted: 09/03/2016] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Black Africans are one of the key risk groups for HIV in the UK and, among those living with HIV, an estimated 16% and 12% of black African heterosexual men and women, respectively, are undiagnosed and at risk of unknowingly transmitting HIV to their sex partners. Increased HIV test uptake is needed to address this, but there is limited information on how frequently HIV test refusal occurs among those attending sexual health clinics (SHCs). We identified factors associated with HIV test refusal among black African SHC attendees. METHODS Data on all SHC attendances in England in 2014 were obtained from the genitourinary medicine clinic activity dataset, the mandatory surveillance system for STIs. Analyses were restricted to attendances by HIV-negative black Africans, and bivariate and multivariable associations between demographic and clinical characteristics and HIV test refusal were assessed. All associations were determined using generalised estimating equations logistic regression, and adjusted ORs (aORs) with 95% CIs are reported. RESULTS Black Africans made 80 743 attendances at SHCs in 2014 and refused an HIV test on 9021 (11.2%) occasions. HIV test refusal was significantly more likely in women (aOR (95% CI) 1.54 (1.46 to 1.62) vs heterosexual men), and those living in the most deprived areas (1.44 (1.24 to 1.67)), diagnosed with a new STI (1.26 (1.18 to 1.34)) or living in London (1.06 (1.01 to 1.12)). Test refusal was significantly less likely with increasing age (0.99 (0.99 to 0.99)) and men who have sex with men (0.52 (0.43 to 0.63) vs heterosexual men), and in those tested for HIV in the past year (0.85 (0.81 to 0.89)), born outside the UK (0.73 (0.69 to 0.77)) or those attending following partner notification (0.11 (0.03 to 0.38)). CONCLUSIONS Targeted interventions are needed to improve HIV testing uptake and reduce undiagnosed HIV infection among black Africans attending SHCs, especially heterosexuals residing in deprived areas.
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Mohammed H, Were J, King C, Furegato M, Nardone A, Hughes G. Sexualised drug use in people attending sexual health clinics in England. Sex Transm Infect 2016; 92:454. [DOI: 10.1136/sextrans-2016-052740] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 06/04/2016] [Indexed: 11/03/2022] Open
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Reyes-Urueña J, Breveglieri M, Furegato M, Fernàndez-López L, Agusti C, Casabona J. Heterogeneity of community-based voluntary, counselling and testing services for HIV in Europe: the HIV-COBATEST survey. Int J STD AIDS 2016; 28:28-38. [PMID: 26672004 DOI: 10.1177/0956462415623402] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study reports the first EU-wide survey of community-based voluntary counselling and testing services (CBVCTs), with the following aims: to assess the current availability of CBVCTs and how the concept of CBVCT is understood; to describe CBVCT modalities and strategies; and to measure the use of rapid tests within CBVCTs. A cross-sectional survey was conducted in two different key informant groups: HIV/AIDS National Focal Points (NFPs) and CBVCTs from the EU and European Free Trade Association (EFTA) countries. A definition of CBVCTs was reached. Descriptive and correspondence analyses were performed. The COBATEST survey was answered by NFPs from 25 of the 32 EU/EFTA countries (response rate of 78.1%), and by 55 CBVCTs in 22 different countries. CBVCTs were functioning in nearly all the responding countries, but only 56% explicitly included them in their national strategic plans. In those that had CBVCTs, the NFPs often lacked reliable information on CBVCTs. In general, CBVCTs in Europe are focused mainly on men who have sex with men, are primarily peer-driven and highly communitarised, whereas CBVCTs targeting other at-risk populations are more medicalised. In addition, the oral test is under-used and in general test performance is highly medicalised. Results show that there is a wide heterogeneity of CBVCTs in Europe, which is varied and highly medicalised. The data provided in this study in conjunction with other deliverables produced by the COBATEST project should contribute to the development of standardised indicators to enable comparisons over time and eventually improve the effectiveness of CBVCTs across Europe.
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Affiliation(s)
- Juliana Reyes-Urueña
- 1 Centre for Epidemiological Studies on HIV/STI in Catalonia (CEEISCAT), Agencia de Salut Publica de Catalunya (ASPC), Generalitat de Catalunya, Badalona, Spain
| | - Michele Breveglieri
- 2 Service for International Social and Health Relations, Verona Local Health Authority n. 20 of the Veneto Region, Italy.,3 Arcigay Italian LGBT Association, Bologna, Italy
| | - Martina Furegato
- 2 Service for International Social and Health Relations, Verona Local Health Authority n. 20 of the Veneto Region, Italy.,4 HIV & STI Department, Centre for Infectious Disease Surveillance and Control, Public Health England, London, England
| | - Laura Fernàndez-López
- 1 Centre for Epidemiological Studies on HIV/STI in Catalonia (CEEISCAT), Agencia de Salut Publica de Catalunya (ASPC), Generalitat de Catalunya, Badalona, Spain.,5 CIBER Epidemiologia y Salud Pública (CIBERESP), Spain.,6 Sciences Research Institute of the "Germans Trias i Pujol" Foundation (IGTP), Badalona, Spain
| | - Cristina Agusti
- 1 Centre for Epidemiological Studies on HIV/STI in Catalonia (CEEISCAT), Agencia de Salut Publica de Catalunya (ASPC), Generalitat de Catalunya, Badalona, Spain.,5 CIBER Epidemiologia y Salud Pública (CIBERESP), Spain.,6 Sciences Research Institute of the "Germans Trias i Pujol" Foundation (IGTP), Badalona, Spain
| | - Jordi Casabona
- 1 Centre for Epidemiological Studies on HIV/STI in Catalonia (CEEISCAT), Agencia de Salut Publica de Catalunya (ASPC), Generalitat de Catalunya, Badalona, Spain.,5 CIBER Epidemiologia y Salud Pública (CIBERESP), Spain.,6 Sciences Research Institute of the "Germans Trias i Pujol" Foundation (IGTP), Badalona, Spain.,7 Department of Paediatrics, Obstetrics and Gynaecology, and Preventive Medicine, Universidad Autonoma de Barcelona, Bellaterra Cerdanyola, Spain
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Mohammed H, Furegato M, Hughes G. P068 Inequalities in sexually transmitted infection risk among black and minority ethnic men who have sex with men in England. Sex Transm Infect 2016. [DOI: 10.1136/sextrans-2016-052718.122] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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King C, Mercer C, Furegato M, Mohammed H, Copas A, Shahmanesh M, Gilson R, Hughes G. O037 Predicting STI risk among people attending sexual health services: Development of a triage tool targeting behavioural interventions among young people. Br J Vener Dis 2016. [DOI: 10.1136/sextrans-2016-052718.36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Beaumont E, Furegato M, Mohammed H, Hughes G. O039 Role of primary care in the diagnosis of STIs in England. Br J Vener Dis 2016. [DOI: 10.1136/sextrans-2016-052718.38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Bolt H, Town K, Kundu A, Furegato M, Mohammed H, Cole M, Fifer H, Andreasen A, Hughes G. O035 Is cefixime back? Trends in gonococcal resistance to current and previous front line therapies in England and Wales since the 2011 guideline change. Br J Vener Dis 2016. [DOI: 10.1136/sextrans-2016-052718.34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Ratna N, Furegato M, O’Brien P, Elliman A, Guthrie K. P117 Are women prescribed LARC less likely to have an abortion? Br J Vener Dis 2016. [DOI: 10.1136/sextrans-2016-052718.171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Harb A, Mohammed H, Furegato M, Hughes G. P056 Influence of country of birth on risk of STI diagnosis among black Caribbeans in England in 2014. Br J Vener Dis 2016. [DOI: 10.1136/sextrans-2016-052718.110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Gios L, Mirandola M, Toskin I, Marcus U, Dudareva-Vizule S, Sherriff N, Breveglieri M, Furegato M, Folch C, Ferrer L, Montoliu A, Nöstlinger C, Vanden Berghe W, Kühlmann-Berenzon S, Velicko I, Dias S, Suligoi B, Regine V, Stanekova D, Rosińska M, Caplinskas S, Klavs I, Alexiev I, Rafila A. Bio-behavioural HIV and STI surveillance among men who have sex with men in Europe: the Sialon II protocols. BMC Public Health 2016; 16:212. [PMID: 26935752 PMCID: PMC4776381 DOI: 10.1186/s12889-016-2783-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 01/26/2016] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Globally, the HIV epidemic continues to represent a pressing public health issue in Europe and elsewhere. There is an emerging and progressively urgent need to harmonise HIV and STI behavioural surveillance among MSM across European countries through the adoption of common indicators, as well as the development of trend analysis in order to monitor the HIV-STI epidemic over time. The Sialon II project protocols have been elaborated for the purpose of implementing a large-scale bio-behavioural survey among MSM in Europe in line with a Second Generation Surveillance System (SGSS) approach. METHODS/DESIGN Sialon II is a multi-centre biological and behavioural cross-sectional survey carried out across 13 European countries (Belgium, Bulgaria, Germany, Italy, Lithuania, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden, and the UK) in community settings. A total of 4,966 MSM were enrolled in the study (3,661 participants in the TLS survey, 1,305 participants in the RDS survey). Three distinct components are foreseen in the study protocols: first, a preliminary formative research in each participating country. Second, collection of primary data using two sampling methods designed specifically for 'hard-to-reach' populations, namely Time Location Sampling (TLS) and Respondent Driven Sampling (RDS). Third, implementation of a targeted HIV/STI prevention campaign in the broader context of the data collection. DISCUSSION Through the implementation of combined and targeted prevention complemented by meaningful surveillance among MSM, Sialon II represents a unique opportunity to pilot a bio-behavioural survey in community settings in line with the SGSS approach in a large number of EU countries. Data generated through this survey will not only provide a valuable snapshot of the HIV epidemic in MSM but will also offer an important trend analysis of the epidemiology of HIV and other STIs over time across Europe. Therefore, the Sialon II protocol and findings are likely to contribute significantly to increasing the comparability of data in EU countries through the use of common indicators and in contributing to the development of effective public health strategies and policies in areas of high need.
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Affiliation(s)
- Lorenzo Gios
- Veneto Region - Department of Health, CReMPE - Regional Coordination Centre for European Project Management, the Verona University Hospital, Verona, Italy.
| | - Massimo Mirandola
- Veneto Region - Department of Health, CReMPE - Regional Coordination Centre for European Project Management, the Verona University Hospital, Verona, Italy. .,Department of Pathology, Infectious Diseases Section, the Verona University Hospital - Veneto Region, Verona, Italy.
| | - Igor Toskin
- Department of Reproductive Health & Research, World Health Organization, Geneva, Switzerland.
| | - Ulrich Marcus
- Department for Infectious Diseases Epidemiology, Robert Koch-Institute, Berlin, Germany.
| | - Sandra Dudareva-Vizule
- Department for Infectious Diseases Epidemiology, Robert Koch-Institute, Berlin, Germany.
| | - Nigel Sherriff
- Centre for Health Research, University of Brighton, Brighton, UK.
| | - Michele Breveglieri
- Veneto Region - Department of Health, CReMPE - Regional Coordination Centre for European Project Management, the Verona University Hospital, Verona, Italy.
| | - Martina Furegato
- Veneto Region - Department of Health, CReMPE - Regional Coordination Centre for European Project Management, the Verona University Hospital, Verona, Italy.
| | - Cinta Folch
- Institut Catala d'Oncologia (ICO), Centre for Epidemiological Studies on HIV/STI in Catalonia (CEEISCAT), Agencia de Salut Publica de Catalunya (ASPC), Hospital Universitari Germans Trias i Pujol, Barcelona, Spain.
| | - Laia Ferrer
- Institut Catala d'Oncologia (ICO), Centre for Epidemiological Studies on HIV/STI in Catalonia (CEEISCAT), Agencia de Salut Publica de Catalunya (ASPC), Hospital Universitari Germans Trias i Pujol, Barcelona, Spain.
| | - Alexandra Montoliu
- Institut Catala d'Oncologia (ICO), Centre for Epidemiological Studies on HIV/STI in Catalonia (CEEISCAT), Agencia de Salut Publica de Catalunya (ASPC), Hospital Universitari Germans Trias i Pujol, Barcelona, Spain.
| | | | - Wim Vanden Berghe
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.
| | | | - Inga Velicko
- Department of Monitoring and Evaluation, Public Health Agency of Sweden, Solna, Sweden.
| | - Sónia Dias
- Institute of Hygiene and Tropical Medicine & GHTM, Universidade Nova de Lisboa, Lisbon, Portugal.
| | - Barbara Suligoi
- Centro Operativo AIDS, Dipartimento di Malattie Infettive, Parassitarie ed Immunomediate, Istituto Superiore di Sanità, Rome, Italy.
| | - Vincenza Regine
- Centro Operativo AIDS, Dipartimento di Malattie Infettive, Parassitarie ed Immunomediate, Istituto Superiore di Sanità, Rome, Italy.
| | - Danica Stanekova
- NRC for HIV/AIDS, Slovak Medical University, Bratislava, Slovak Republic.
| | - Magdalena Rosińska
- Department of Epidemiology, National Institute of Public Health, National Institute of Hygiene, Warsaw, Poland.
| | | | - Irena Klavs
- National Institute of Public Health, Ljubljana, Slovenia.
| | - Ivailo Alexiev
- National Reference Laboratory of HIV, National Center of Infectious and Parasitic Diseases, Sofia, Bulgaria.
| | - Alexandru Rafila
- National Institute of Infectious Diseases Prof. Dr. Matei Bals, Bucharest, Romania
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Kramer SC, Schmidt AJ, Berg RC, Furegato M, Hospers H, Folch C, Marcus U. Factors associated with unprotected anal sex with multiple non-steady partners in the past 12 months: results from the European Men-Who-Have-Sex-With-Men Internet Survey (EMIS 2010). BMC Public Health 2016; 16:47. [PMID: 26781647 PMCID: PMC4717565 DOI: 10.1186/s12889-016-2691-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Accepted: 01/06/2016] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Practising unprotected anal intercourse (UAI) with high numbers of partners is associated with increased risk for acquiring and transmitting HIV and other sexually transmitted infections. Our aim was to describe factors associated with UAI with multiple partners in a large sample of MSM from 38 European countries recruited for an online survey in 2010. METHODS Data are from the European Men-Who-Have-Sex-With-Men Internet Survey (EMIS). The analysis was restricted to men who reported any anal sex with a non-steady partner in the past 12 months, and who were either never diagnosed with HIV, or who had been diagnosed with HIV more than 12 months ago, reported a detectable viral load and did not exclusively serosort (n = 91,477). Multivariable logistic regression was used to compare men reporting UAI with four or more (4+) non-steady partners to two comparison groups: a) no UAI with non-steady partners, and b) UAI with 1-3 non-steady partners. RESULTS Overall, 9.6% of the study population reported UAI with 4+ partners in the past 12 months. In both models, factors consistently associated with this behaviour were: having been diagnosed with HIV, lower educational levels, use of nitrite inhalants, drugs associated with sex and parties, or erectile dysfunction drugs in the past 4 weeks, using sex-on-site venues in the past 4 weeks, buying or selling sex in the past 12 months, having experienced physical violence due to sexual attraction to men in the past 12 months, reporting sexual happiness, being out to all or almost all of one's acquaintances, and knowing that ART reduces HIV transmissibility. CONCLUSIONS Effective antiretroviral treatment drastically reduces HIV transmission for men diagnosed with HIV, irrespective of partner numbers. Apart from reducing partner numbers or increasing condom use no other recommendations are currently in place to reduce the risk of HIV acquisition and onward transmission for HIV-negative men practicing UAI with multiple partners. A range of factors were identified as associated with UAI with four or more partners which allow the strengthening and targeting of prevention strategies to reduce HIV transmission risks resulting from condomless anal intercourse with multiple partners.
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Affiliation(s)
- Sarah C Kramer
- Department of Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany.
| | - Axel Jeremias Schmidt
- Sigma Research, Department of Social and Environmental Health Research, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, WC1H 9SH, London, UK.
| | - Rigmor C Berg
- Department of Evidence-Based Health Services, Norwegian Knowledge Center for the Health Services, Oslo, Norway.
| | - Martina Furegato
- HIV & STI Department, Centre for Infectious Disease Surveillance and Control, Public Health England, London, UK.
| | - Harm Hospers
- University College Maastricht, Maastricht University, Maastricht, The Netherlands.
| | - Cinta Folch
- Centre for Sexually Transmitted Infection and AIDS Epidemiological Studies of Catalonia (CEEISCAT), Barcelona, Spain.
| | - Ulrich Marcus
- Department of Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany.
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Mohammed H, Furegato M, Nardone A, Hughes G. P17.05 Hiv test refusals among black africans attending sexually transmitted infection clinics in england, 2013. Br J Vener Dis 2015. [DOI: 10.1136/sextrans-2015-052270.583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Harding-Esch E, Sherrard-Smith E, Fuller SS, Harb A, Furegato M, Mercer C, Sadiq ST, Howell-Jones R, Nardone A, White PJ, Gates P, Pearce A, Keane F, Colver H, Nori A, Dewsnap C, Schatzberger R, Estcourt C, Dakshina S, Lowndes CM. P08.28 Patients continue to engage in risky sexual behaviour in the time period between being tested for chlamydia and receiving test result and treatment. Br J Vener Dis 2015. [DOI: 10.1136/sextrans-2015-052270.374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Harding-Esch E, Sherrard-Smith E, Fuller SS, Harb A, Furegato M, Mercer C, Sadiq ST, Howell-Jones R, Nardone A, Gates P, Pearce A, Keane F, Colver H, Nori A, Dewsnap C, Schatzberger R, Estcourt C, Dakshina S, Dakshina C, Lowndes C. P65 Sexual behaviour in the time period between being tested for chlamydia and receiving test result and treatment. Br J Vener Dis 2015. [DOI: 10.1136/sextrans-2015-052126.108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Mitchell H, Furegato M, Hughes G, Field N, Mohammed H, Nardone A. O2 An epidemiological analysis of men who have sex with men (msm) who are prescribed hiv post-exposure prophylaxis: implications for wider pre-exposure prophylaxis policy. Br J Vener Dis 2015. [DOI: 10.1136/sextrans-2015-052126.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Furegato M, Mohammed H, Wayal S, Mercer C, Hughes G. O6 Measuring the impact of socio-economic deprivation on rates of sexually transmitted infection (STI) diagnoses among black caribbeans in england. Br J Vener Dis 2015. [DOI: 10.1136/sextrans-2015-052126.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Samuel M, Furegato M, Hughes G, Cassell J, Mohammed H. P165 Differing trajectories of sexual health clinic (SHC) attendance in men-who-have-sex-with-men (MSM) and heterosexual men: can we use these to plan services?: Abstract P165 Table 1. Br J Vener Dis 2015. [DOI: 10.1136/sextrans-2015-052126.208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Gilbart VL, Simms I, Jenkins C, Furegato M, Gobin M, Oliver I, Hart G, Gill ON, Hughes G. Sex, drugs and smart phone applications: findings from semistructured interviews with men who have sex with men diagnosed withShigella flexneri3a in England and Wales: Table 1. Sex Transm Infect 2015; 91:598-602. [DOI: 10.1136/sextrans-2015-052014] [Citation(s) in RCA: 129] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 04/11/2015] [Indexed: 11/03/2022] Open
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Malek R, Mitchell H, Furegato M, Simms I, Mohammed H, Nardone A, Hughes G. Contribution of transmission in HIV-positive men who have sex with men to evolving epidemics of sexually transmitted infections in England: an analysis using multiple data sources, 2009-2013. ACTA ACUST UNITED AC 2015; 20. [PMID: 25953130 DOI: 10.2807/1560-7917.es2015.20.15.21093] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
HIV seroadaptive behaviours may have contributed to greater sexually transmitted infection (STI) transmission in HIV-positive men who have sex with men(MSM) and to the global increase in STIs. Using multiple national surveillance data sources and population survey data, we estimated the risk of STIs in HIV-positive MSM and assessed whether transmission in HIV-positive MSM has contributed to recent STI epidemics in England. Since 2009, an increasing proportion of STIs has been diagnosed in HIV-positive MSM, and currently, the population rate of acute bacterial STIs is up to four times that of HIV-negative or undiagnosed MSM. Almost one in five of all diagnosed HIV-positive MSM in England had an acute STI diagnosed in 2013. From 2009 to 2013, the odds of being diagnosed with syphilis increased from 2.71 (95% confidence interval (CI) 2.41–3.05, p<0.001) to 4.05 (95%CI 3.70-4.45, p<0.001) in HIV-positive relative to HIV negative/undiagnosed MSM. Similar trends were seen for gonorrhoea and chlamydia. Bacterial STI re-infection rates were considerably higher in HIV-positive MSM over a five-year follow-up period, indicative of rapid transmission in more dense sexual networks.These findings strongly suggest that the sexual health of HIV-positive MSM in England is worsening, which merits augmented public health interventions and continued monitoring.
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Affiliation(s)
- R Malek
- Public Health England, London, United Kingdom
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Ferrer L, Furegato M, Foschia JP, Folch C, González V, Ramarli D, Casabona J, Mirandola M. Undiagnosed HIV infection in a population of MSM from six European cities: results from the Sialon project. Eur J Public Health 2014; 25:494-500. [PMID: 25161202 DOI: 10.1093/eurpub/cku139] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The purpose of this article is to assess the distribution of undiagnosed HIV infection in men who have sex with men (MSM) in Southern and Eastern European countries, to describe the differences in epidemiology and behaviour between undiagnosed, diagnosed HIV-positive and HIV-negative MSM and to identify factors associated with undiagnosed HIV infection in the study population. METHODS A multi-centre biological and behavioural cross-sectional study was conducted in 2008. Time-location sampling was used to recruit men attending different venues. A self-administered questionnaire was completed and oral fluid samples were collected to estimate HIV prevalence. RESULTS HIV prevalence was 17% in Barcelona, 12% in Verona, 6% in Bratislava, 5% in Ljubljana, 5% in Bucharest and 3% in Prague while undiagnosed HIV infection was 47, 62, 67, 83, 85 and 57%, respectively. Diagnosed HIV-positive men reported more casual partners than HIV-negative MSM (mean: 19 and 9, respectively) (P < 0.001), and they were more likely to self-reported condyloma in the last year than undiagnosed HIV-positive and HIV-negative men (15, 1 and 3%, respectively) (P < 0.001). Factors associated with undiagnosed HIV infection included attending sex-focused venues (OR = 2.49), reporting syphilis in the previous 12 months (OR = 2.56), using poppers at last sexual intercourse (OR = 3.36) and having had an HIV test in the previous year (OR = 2.00). CONCLUSIONS Many HIV infections remain undiagnosed, and there is evidence of the persistence of frequent risk behaviours and sexually transmitted infections (STI) despite knowledge of HIV-positive status, emphasising the need for a multidimensional approach to HIV/STI prevention. Access to HIV testing should be considered a priority in prevention programs targeted at MSM, especially in Eastern Europe.
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Affiliation(s)
- Laia Ferrer
- 1 Center for Epidemiological Studies on STI and AIDS of Catalonia (CEEISCAT), Agència Salut Pública de Catalunya (ASPC), Generalitat de Catalunya, Badalona, Spain 2 Institut d'Investigació Germans Trias i Pujol (IGTP), Badalona, Spain 3 CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Martina Furegato
- 4 Regional Center for Health Promotion, Veneto Region, Verona, Italy
| | | | - Cinta Folch
- 1 Center for Epidemiological Studies on STI and AIDS of Catalonia (CEEISCAT), Agència Salut Pública de Catalunya (ASPC), Generalitat de Catalunya, Badalona, Spain 2 Institut d'Investigació Germans Trias i Pujol (IGTP), Badalona, Spain 3 CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain 5 Departament de Pediatria, d'Obstetrícia i Ginecologia i de Medicina Preventiva i de Salut Pública, Facultat de Medicina, Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
| | - Victoria González
- 1 Center for Epidemiological Studies on STI and AIDS of Catalonia (CEEISCAT), Agència Salut Pública de Catalunya (ASPC), Generalitat de Catalunya, Badalona, Spain 2 Institut d'Investigació Germans Trias i Pujol (IGTP), Badalona, Spain 3 CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain 6 Microbiology Service, Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Dunia Ramarli
- 7 Immunology Section, Verona University Hospital, Verona, Italy
| | - Jordi Casabona
- 1 Center for Epidemiological Studies on STI and AIDS of Catalonia (CEEISCAT), Agència Salut Pública de Catalunya (ASPC), Generalitat de Catalunya, Badalona, Spain 2 Institut d'Investigació Germans Trias i Pujol (IGTP), Badalona, Spain 3 CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain 5 Departament de Pediatria, d'Obstetrícia i Ginecologia i de Medicina Preventiva i de Salut Pública, Facultat de Medicina, Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
| | - Massimo Mirandola
- 8 Infectious Diseases Section, Department of Pathology, Verona University Hospital, Verona, Italy
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Prati G, Breveglieri M, Lelleri R, Furegato M, Gios L, Pietrantoni L. Psychosocial correlates of HIV testing among men who have sex with men in Italy: a cross-sectional study. Int J STD AIDS 2013; 25:496-503. [DOI: 10.1177/0956462413515193] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Accepted: 10/14/2013] [Indexed: 11/17/2022]
Abstract
The objective of this study was to understand the psychosocial correlates of men having sex with men (MSM) who have never been tested (never testers), MSM who have been tested in the last 12 months (recent testers), and MSM who have been tested before (remote testers). A sample of 14,409 Italian HIV-negative adult MSM was recruited via instant messages to the members of five international commercial websites and through clickable banner advertisements on different websites. The most important correlates of never testers compared to recent testers were younger age, sexual orientation concealment, unawareness of free HIV services, having had a partner of unknown serostatus, and lower levels of HIV testing self-efficacy (i.e. the belief in one’s own ability to get a test for HIV). The most important correlates of remote testers compared to recent testers were older age, homosexual orientation, having had a partner of unknown serostatus, unawareness of free HIV services, and lower level of HIV testing self-efficacy. There are different psychosocial correlates of MSM based on HIV testing history. Based on the findings of this study, prevention efforts should be directed toward increasing awareness about the availability of HIV testing services and HIV testing self-efficacy among MSM.
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Affiliation(s)
- Gabriele Prati
- Department of Psychology, University of Bologna, Bologna, Italy
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Ross MW, Berg RC, Schmidt AJ, Hospers HJ, Breveglieri M, Furegato M, Weatherburn P. Internalised homonegativity predicts HIV-associated risk behavior in European men who have sex with men in a 38-country cross-sectional study: some public health implications of homophobia. BMJ Open 2013; 3:bmjopen-2012-001928. [PMID: 23386580 PMCID: PMC3586183 DOI: 10.1136/bmjopen-2012-001928] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES Internalised homonegativity (IH) is hypothesised to be associated with HIV risk behaviour and HIV testing in men who have sex with men (MSM). We sought to determine the social and individual variables associated with IH and the associations between IH and HIV-related behaviours. DESIGN AND SETTING We examined IH and its predictors as part of a larger Internet-delivered, cross-sectional study on HIV and health in MSM in 38 European countries. PARTICIPANTS 181 495 MSM, IH data analysis subsample 144 177. All participants were male, over the age of consent for homosexual activity in their country of domicile, and have had at least one homosexual contact in the past 6 months. METHODOLOGY An anonymous Internet-based questionnaire was disseminated in 25 languages through MSM social media, websites and organisations and responses saved to a UK-based server. IH was measured using a standardised, cross-culturally appropriate scale. RESULTS Three clusters of European countries based on the level of experienced discrimination emerged. IH was predicted by country LGB (lesbian, gay and bisexual) legal climate, Gini coefficient and size of place of settlement. Lower IH was associated with degree the respondent was 'out' as gay to others and older age. 'Outness' was associated with ever having an HIV test and age, education and number of gay friends, while IH (controlling for the number of non-steady unprotected sex partners and perceived lack of control over safe sex) was associated with condom use for anal intercourse. CONCLUSIONS IH is associated with LGB legal climate, economic development indices and urbanisation. It is also associated with 'outness' and with HIV risk and preventive behaviours including HIV testing, perceived control over sexual risk and condom use. Homonegative climate is associated with IH and higher levels of HIV-associated risk in MSM. Reducing IH through attention to LGB human rights may be appropriate HIV reduction intervention for MSM.
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Affiliation(s)
- Michael W Ross
- School of Public Health, University of Texas, Houston, Texas, USA
- Faculty of Health and Society, Malmö University, Sweden
| | - Rigmor C Berg
- Norwegian Knowledge Center for the Health Services, Oslo, Norway
| | - Axel J Schmidt
- London School of Hygiene & Tropical Medicine, London, UK
| | - Harm J Hospers
- University College Maastricht, Maastricht University, Maastricht, The Netherlands
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Mazzardis S, Vieno A, Furegato M, Santinello M, Mirandola M. [Decrease in early adolescent illegal substance use in the Veneto region]. Epidemiol Psichiatr Soc 2010; 19:80-85. [PMID: 20486427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
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